The dynamic relationship between antibiotic use and the incidence of vancomycin-resistant Enterococcus: time-series modelling of 7-year surveillance data in a tertiary-care hospital.

The role of antibiotics in the epidemiology of vancomycin-resistant Enterococcus (VRE) has been studied extensively, but controversies remain as to which, and to what extent, antibiotics facilitate the emergence and dissemination of VRE in hospitals. Aggregate data on the use of several antibiotic classes in terms of defined daily doses (DDD) per 100 patient-days (PD), and VRE incidence rates in terms of clinical isolates per 1000 PD, were evaluated during a 7-year period at a tertiary-care hospital. Time-series analysis (autoregressive integrated moving average (ARIMA) and transfer function models) was used to quantify the temporal effect of antibiotic use on VRE incidence and estimate effect-delays. The incidence rate of VRE observed in a specific bimester was found to be a function of its value during the preceding bimester and of prior changes in the volume of use of four antibiotic classes. In particular, an increase of one DDD/100 PD in the use of glycopeptides, fluoroquinolones, extended-spectrum cephalosporins and beta-lactam-beta-lactamase inhibitor combinations resulted, independently, in average changes of +0.024, +0.015, + 0.020 and -0.010 isolates per 1000 PD in the incidence of VRE, with average delays of 2, 4, 2 and 6 months, respectively, which explained 56% of the observed variation in VRE rates over time. Efforts to reduce VRE cross-transmission should be supplemented by targeted antibiotic control policies. The use of glycopeptides, broad-spectrum cephalosporins and fluoroquinolones in high amounts should be the targets of such policies. Penicillin-beta-lactamase inhibitor combinations might be suitable substitutes for extended-spectrum cephalosporins.

Murine typhus in Cyprus: 21 paediatric cases.

The aim of this article is to present the manifestations of Rickettsia typhi infection in childhood. Twenty-one children under 15 years of age were hospitalised in the Department of Paediatrics of the Archbishop Makarios Hospital in Nicosia, Cyprus, from 2000 to 2006 with Rickettsia typhi infection. Ten of them were boys and 11 were girls. The median age was eight years (range four to 13 years). The most common clinical features were fever (100%) and rash (57%). Lymphadenopathy, usually cervical, was also a frequent finding (37%). Severe headache was rather infrequent (29%). Splenomegaly or hepatomegaly were less frequent findings (24% and 10%, respectively). Mild elevation of liver enzymes (AST and ALT elevated >1-fold in 81% and 75%, respectively) was the most frequent laboratory finding. Thrombocytopenia (28%) and leucopenia (17%) were less frequent. Nearly half of the patients (10/21) came from four neighbouring villages, where most residents work in agriculture. All of the children were treated with appropriate antibiotic regimens and had complete recovery. Rickettsia typhi infection should be considered in the differential diagnosis of children who present during the summer or early autumn months with prolonged fever and rash with or without lymphadenopathy.

Faunistic study of sandflies in Greece.

A faunistic study of phlebotomine sandflies was carried out on the mainland and on four islands in Greece between 1999 and 2004. Sandflies were collected in 18 areas, and the population structure was observed and recorded. A total of 10 species were identified; their distribution is presented here. Of these, the species Phlebotomus neglectus Tonnoir and P. perfiliewi Parrot (Diptera: Psychodidae), epidemiologically the most important vectors of leishmaniases and sandfly fever in Greece, were shown to be present in the main endemic foci of the country.

Toxoplasmosis in pregnant women in Crete.

In Greece there are no official recommendations concerning the management of pregnant women for the prevention of congenital toxoplasmosis. A protocol for monitoring pregnant women was designed in order to differentiate between acute and latent toxoplasmosis and was tested successfully for 7 years. The maternofetal transmission rate in Crete was assessed and a map showing seroprevalence of pregnant women in all prefectures of Greece was prepared. The high seroprevalence of Toxoplasma gondii in Greece (up to 46% in some areas) may be explained by: (a) the presence of a great number of stray cats; (b) the Greek diet consisting of large amounts of raw, wild vegetables and salads that could easily be contaminated with oocysts; (c) the high consumption of meat, smoked pork and sausages, well-documented sources of T. gondii infection. T. gondii genotypes were characterized, directly from clinical samples, after PCR-RFLP on the SAG2 gene and sequence analysis at the restriction sites. They belonged to all 3 clonal lineages.

Mediterranean spotted fever in crete, Greece: clinical and therapeutic data of 15 consecutive patients.

The clinical, epidemiological, and therapeutic aspects of 15 patients with Mediterranean spotted fever (MSF), admitted to the Internal Medicine Department of the General Hospital of Sitia (southeastern Crete, Greece) between December 2000 and July 2003, were studied. Diagnosis was made on the basis of clinical signs and symptoms and was confirmed by serology. Of the patients studied, 67% were men and 33% women, with a median age of 52 years (range of 23-76 years). Ten cases (67%) were diagnosed between May and July. Of all the patients, 93% had a history of contact with animals, mainly with sheep (11 patients, 73%), while 53% of them had a history of tick-bite (33%), or reported the presence of ticks in their environment (20%). The typical eschar lesion (tache noir) at the tick-bite site was present in 53% of the patients, while the rash was present in 87% of them. Laboratory findings included leukopenia (47%), thrombocytopenia (54%), elevation of transaminases (80%), hyponatremia (33%), and microscopic hematuria (80%). Four patients (27%) displayed pulmonary infiltrates on chest radiography. All patients were treated with doxycycline (200 mg daily) and recovered rapidly. Renal function deteriorated in one patient with chronic renal failure, but he recovered thereafter.

Ticks, tick-borne rickettsiae, and Coxiella burnetii in the Greek Island of Cephalonia.

Domestic animals are the hosts of several tick species and the reservoirs of some tick-borne pathogens; hence, they play an important role in the circulation of these arthropods and their pathogens in nature. They may act as vectors, but, also, as reservoirs of spotted fever group (SFG) rickettsiae, which are the causative agents of SFG rickettsioses. Q fever is a worldwide zoonosis caused by Coxiella burnetii (C. burnetii), which can be isolated from ticks. A total of 1,848 ticks (954 female, 853 male, and 41 nymph) were collected from dogs, goats, sheep, cattle, and horses in 32 different localities of the Greek island of Cephalonia. Rhipicephalus (Rh.) bursa, Rh. turanicus, Rh. sanguineus, Dermacentor marginatus (D. marginatus), Ixodes gibbosus (I. gibbosus), Haemaphysalis (Ha.) punctata, Ha. sulcata, Hyalomma (Hy.) anatolicum excavatum and Hy. marginatum marginatum were the species identified. C. burnetii and four different SFG rickettsiae, including Rickettsia (R.) conorii, R. massiliae, R. rhipicephali, and R. aeschlimannii were detected using molecular methods. Double infection with R. massiliae and C. burnetii was found in one of the positive ticks.

Epidemiological study of Q fever in humans, ruminant animals, and ticks in Cyprus using a geographical information system.

A cross-sectional study of Q fever was conducted in a representative sample of the human and animal population in Cyprus in order to assess the seroprevalence of Q fever and the prevalence of related risk factors. A total of 583 human and 974 ruminant animal serum samples were collected and tested for the detection of antibodies against Coxiella burnetii phase II antigen using an indirect immunofluorescent assay. One hundred forty-one ticks were collected from the infested animals examined; the polymerase chain reaction and the shell-vial technique were used to detect and isolate C. burnetii. Standardized questionnaires were used to obtain information concerning inhabitants and their animals. A geographical information system was used to identify high-risk regions. The prevalence of IgG antibodies against C. burnetii phase II antigen was estimated at 52.7% for humans, 48.2% for goats, 18.9% for sheep, and 24% for bovines. C. burnetii was detected in 11 (7.8%) ticks. Using the geographical information system, two villages were identified as high-risk regions on the basis of high seroprevalence rates of IgG antibodies in humans and animals. Risk factors related to Q fever seropositivity were identified by logistic regression analysis and included age, residence, occupation, use of manure in the garden, ownership of animals (especially goats), and the presence of tick-infested or aborting animals. Q fever poses an occupational hazard to humans living in close contact with sheep and/or goats. In parallel, ticks should be considered an important aspect in the epidemiology of Q fever and should be further studied to better elucidate their role.

Comparative effects of ertapenem, imipenem, and meropenem on the colonization of the gastrointestinal tract of mice by Candida albicans.

We evaluated the effect of three carbapenems on gut colonization of mice by Candida albicans. A total of 150 Crl:CD1 (ICR) BR mice were fed chow containing C. albicans or regular chow. Both groups were subsequently treated either with one carbapenem or with normal saline for 10 days. Stool cultures to determine colonization by C. albicans were performed immediately before, at the end, and one week after the end of treatment. Candida-colonized mice that received carbapenems had substantially higher C. albicans concentrations than control animals fed C. albicans, especially if they received ertapenem. Mice fed regular chow and treated with the study antibiotics or saline did not have Candida in their stools. Candida was not detected in the internal organs of any group of mice.

Effects of vancomycin, teicoplanin, linezolid, quinupristin-dalfopristin, and telithromycin on murine gut colonization by Candida albicans.

Crl:CDI(ICR) BR adult mice were fed chow containing Candida albicans or regular chow. Both groups were subsequently given either antibiotics acting mainly against Gram-positive organisms or normal saline for 10 days. Stool cultures were performed before, at the end, and one week after discontinuation of treatment to determine the effects on the stool yeast concentration. Candida colonized mice treated with vancomycin, teicoplanin, linezolid, quinupristin-dalfopristin or telithromycin had higher colony counts of yeast in their stools than control Candida fed mice treated with saline. This increase was not statistically significant. Mice fed regular chow treated with the study drugs or saline did not have any yeasts in their stools. Dissemination of Candida was not observed in the visceral organs of any mouse.

Serotype distribution and antimicrobial resistance of Salmonella enterica from patients with gastroenteritis in Crete, Greece.

The aim of the present study was to determine the serotype distribution and the evolution of antimicrobial resistance among Salmonella enterica strains isolated from patients with diarrhea in Crete, Greece, during a 5-year period (2000-2004). Among the 401 S. enterica isolates recovered, serotype Enteritidis was the most prevalent (66.6%), followed by serotype Typhimurium (14.2%). The rates of resistance to ampicillin, amoxicillin-clavulanic acid, gentamicin, chloramphenicol, tetracycline, nalidixic acid and trimethoprim-sulfamethoxazole were 8.5, 7, 0.7, 5.4, 14.2, 2.7 and 2.7%, respectively. A marked decrease in resistance was observed during the study period. Resistance and multidrug resistance was most common in serotype Typhimurium. The extended-spectrum beta-lactamase production observed in one strain of S. enterica serotype Virchow and the reduced ciprofloxacin susceptibility detected in 2.7% of the isolates studied are causes of concern.

The epidemiology of onychomycoses in Crete, Greece, between 1992 and 2001.

BACKGROUND: Onychomycosis represents the most frequently encountered nail disease, which is difficult to eradicate with drug treatment. Epidemiological studies concerning onychomycosis have been performed in many countries worldwide. Differences in the incidence of onychomycosis have been reported not only for various geographical areas, but also for different regions of the same country. OBJECTIVE: This survey was undertaken to determine the epidemiology of onychomycosis in the population of Crete, Greece. METHODS: In a prospective study, the fingernails and toenails of all new patients presenting to the outpatient Dermatology Department of the University Hospital of Crete were examined by certified dermatologists. If they appeared abnormal, nail material was obtained for mycologic examination. RESULTS: A total of 23,477 patients were examined during the study period (1992-2001). Of them, 19,556 (83.3%) participated in the investigation. Clinical abnormal nails were observed in 2098 (10.7%) patients, 36.7% males and 63.3% females. Mycologically confirmed onychomycosis was detected in 511 (24.3%). Toenail onychomycosis was found in 283 (55.4%) patients, fingernail onychomycosis in 210 (41%), and both toenail and fingernail onychomycosis in 18 (3.6%). In the toenail infections, dermatophytes were most frequently isolated (52%), followed by yeasts (24.7%) and moulds (15.5%); 7.8% of the infections were mixed. In the fingernail infections, yeasts were most often isolated (82.9%), followed by dermatophytes (10%), and moulds (1.9%); 5.2% of the infections were mixed. CONCLUSION: Because the pattern of onychomycoses in a country is changing with time, epidemiological studies are necessary for determining the prevalence and the causative agents of the infection.