Anders Ternhag

Short- and Long-term Effects of Bacterial Gastrointestinal Infections

Bacterial gastrointestinal infections are associated with short- and long-term complications from several organ systems.

A Meta-Analysis on the Effects of Antibiotic Treatment on Duration of Symptoms Caused by Infection with Campylobacter Species

Eleven randomized, controlled trials of antibiotic treatment versus placebo in patients with Campylobacter species infection were pooled in a meta-analysis. Antibiotic treatment shortened the duration of intestinal symptoms by 1.32 days (95% confidence interval, 0.64-1.99; P<.0001). Because of problems with drug resistance, a restrictive attitude towards the administration of antibiotics in uncomplicated cases is advised.

A Nationwide Cohort Study of Mortality Risk and Long-Term Prognosis in Infective Endocarditis in Sweden

Objectives: Infective endocarditis (IE) remains a serious disease with substantial mortality. In this study we investigated the incidence of IE, as well as its associated short and long term mortality rates. Methods The IE cases were identified in the Swedish national inpatient register using ICD-10 codes, and then linked to the population register in order to identify deaths in the cohort. Crude mortality rates among IE patients were obtained for different time intervals. These rates were directly standardized using sex- and age-matched mortality in the general population. Results The cohort consisted of 7603 individuals and 7817 episodes of IE during 1997–2007. The 30 days all-cause crude mortality rate was 10.4% and the standardized mortality ratio (SMR) was 33.7 (95% confidence interval [CI]: 31.0–36.6). Excluding the first year of follow-up, the long term mortality (1–5 years) showed an increased SMR of 2.2 (95% CI: 2.0–2.3) compared to the general population. Significantly higher SMR was found for cases of IE younger than 65 years of age with a 1–5 year SMR of 6.3, and intravenous drug-users with a SMR of 19.1. Native valve IE cases, in which surgery was performed had lower crude mortality rates and Mantel-Haenzel odds ratios of less than one compared to those with medical therapy alone during 30-day and 5-years follow-up. Conclusions The 30-days crude mortality rate for IE was 10.4% and long-term relative mortality risk remains increased even up to 5 years of follow-up, therefore a close monitoring of these patients would be of value.

Rational use of aminoglycosides - Review and recommendations by the Swedish Reference Group for Antibiotics (SRGA)

Abstract The Swedish Reference Group for Antibiotics (SRGA) has carried out a risk–benefit analysis of aminoglycoside treatment based on clinical efficacy, antibacterial spectrum, and synergistic effect with beta-lactam antibiotics, endotoxin release, toxicity, and side effects. In addition, SRGA has considered optimal dosage schedules and advice on serum concentration monitoring, with respect to variability in volume of drug distribution and renal clearance. SRGA recommends that aminoglycoside therapy should be considered in the following situations: (1) progressive severe sepsis and septic shock, in combination with broad-spectrum beta-lactam antibiotics, (2) sepsis without shock, in combination with broad-spectrum beta-lactam antibiotics if the infection is suspected to be caused by multi-resistant Gram-negative pathogens, (3) pyelonephritis, in combination with a beta-lactam or quinolone until culture and susceptibility results are obtained, or as monotherapy if a serious allergy to beta-lactam or quinolone antibiotics exists, (4) serious infections caused by multi-resistant Gram-negative bacteria when other alternatives are lacking, and (5) endocarditis caused by difficult-to-treat pathogens when monotherapy with beta-lactam antibiotics is not sufficient. Amikacin is generally more active against extended-spectrum beta-lactamase (ESBL)-producing and quinolone-resistant Escherichia coli than other aminoglycosides, making it a better option in cases of suspected infection caused by multidrug-resistant Enterobacteriaceae. Based on their resistance data, local drug committees should decide on the choice of first-line aminoglycoside. Unfortunately, aminoglycoside use is rarely followed up with audiometry, and in Sweden we currently have no systematic surveillance of adverse events after aminoglycoside treatment. We recommend routine assessment of adverse effects, including hearing loss and impairment of renal function, if possible at the start and after treatment with aminoglycosides, and that these data should be included in hospital patient safety surveillance and national quality registries.

The relative importance of Staphylococcus saprophyticus as a urinary tract pathogen: distribution of bacteria among urinary samples analysed during 1 year at a major Swedish laboratory

To determine the distribution of urinary tract pathogens with focus on Staphylococcus saprophyticus and analyse the seasonality, antibiotic susceptibility, and gender and age distributions in a large Swedish cohort. S. saprophyticus is considered an important causative agent of urinary tract infection (UTI) in young women, and some earlier studies have reported up to approximately 40% of UTIs in this patient group being caused by S. saprophyticus. We hypothesized that this may be true only in very specific outpatient settings. During the year 2010, 113 720 urine samples were sent for culture to the Karolinska University Hospital, from both clinics in the hospital and from primary care units. Patient age, gender and month of sampling were analysed for S. saprophyticus, Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. Species data were obtained for 42 633 (37%) of the urine samples. The most common pathogens were E. coli (57.0%), Enterococcus faecalis (6.5%), K. pneumoniae (5.9%), group B streptococci (5.7%), P. mirabilis (3.0%) and S. saprophyticus (1.8%). The majority of subjects with S. saprophyticus were women 15–29 years of age (63.8%). In this age group, S. saprophyticus constituted 12.5% of all urinary tract pathogens. S. saprophyticus is a common urinary tract pathogen in young women, but its relative importance is low compared with E. coli even in this patient group. For women in other ages and for men, growth of S. saprophyticus is a quite uncommon finding.

Antibiotic consumption and antibiotic stewardship in Swedish hospitals

Abstract Background. The aim of this paper was to describe and analyze the effect of antibiotic policy changes on antibiotic consumption in Swedish hospitals and to review antibiotic stewardship in Swedish hospitals. Results. The main findings were: 1) Antibiotic consumption has significantly increased in Swedish hospitals over the last decade. The consumption of cephalosporins has decreased, whereas that of most other drugs including piperacillin-tazobactam, carbapenems, and penicillinase-sensitive and -resistant penicillins has increased and replaced cephalosporins. 2) Invasive infections caused by ESBL-producing Escherichia coli and Klebsiella pneumoniae have increased, but the proportion of pathogens resistant to third-generation cephalosporins causing invasive infections is still very low in a European and international perspective. Furthermore, the following gaps in knowledge were identified: 1) lack of national, regional, and local data on the incidence of antibiotic resistance among bacteria causing hospital-acquired infections e.g. bloodstream infections and hospital-acquired pneumonia—data on which standard treatment guidelines should be based; 2) lack of data on the incidence of Clostridium difficile infections and the effect of change of antibiotic policies on the incidence of C. difficile infections and infections caused by antibiotic-resistant pathogens; and 3) lack of prospective surveillance programs regarding appropriate antibiotic treatment, including selection of optimal antimicrobial drug regimens, dosage, duration of therapy, and adverse ecological effects such as increases in C. difficile infections and emergence of antibiotic-resistant pathogens. Conclusions. Evidence-based actions to improve antibiotic use and to slow down the problem of antibiotic resistance need to be strengthened. The effect of such actions should be analyzed, and standard treatment guidelines should be continuously updated at national, regional, and local levels.

Salmonella-associated deaths, Sweden, 1997-2003.

We examined excess deaths after infection with Salmonella in a registry-based matched cohort study of 25,060 persons infected abroad and 5,139 infected within Sweden. The domestically infected have an increased standardized mortality ratio, whereas those who acquired Salmonella infection abroad had no excess risk of death.

The Impact of Stent Graft Material on the Inflammatory Response After EVAR

Background: Patients undergoing endovascular aneurysm repair (EVAR) due to abdominal aortic aneurysm often develop an inflammatory response, postimplantation syndrome (PIS) where fever and leukocytosis are common. Previous studies suggest that type of stent graft material (polyester or polytetrafluoroethylene [PTFE]) plays a role. Objectives: To investigate the effect of stent graft material on the inflammatory response and length of hospital stay in patients undergoing standard elective EVAR. Methods: Sixty-nine elective EVAR patients were included in this observational study. To avoid comparing patients with a different graft location and stent graft burden, 12 cases were excluded as well as cases with complication or simultaneous open surgical procedures, leaving 45 patients (32 with polyester and 13 with PTFE graft) for final analysis. Tympanic temperature, C-reactive protein (CRP), white blood cell (WBC), and procalcitonin (PCT) were measured on days −1 and +1 and +3. Duration of in-hospital stay and frequency of PIS were recorded. Results: The PIS was diagnosed in 9 (28.1%) of the 32 polyester cases and in 1 (7.7%) of the 13 cases in the PTFE group (P = .24). Median (interquartile range) in-hospital stay was 5 (5-6) days in the polyester group and 4 (4-5) days in the PTFE group (P = .009). On day +3, in the polyester group, mean CRP was 154 (95% confidence interval: 127-182) mg/L, WBC 9.5 (8.4-10.5) ×109/L, and PCT 0.17 (0.12-0.21) ng/mL. In the PTFE group, mean CRP was 70 (32-109) mg/L (P = .001), WBC 8.8 (6.4-11.1) ×109/L (P = .37), and PCT 0.09 (0.06-0.13) ng/mL (P = .009) on day +3. Conclusion: Standard EVAR with polyester stent grafts appears to result in a trend toward a more pronounced inflammatory reaction than similar EVAR using PTFE and is associated with a longer in-hospital stay.

Antibiotic consumption in relation to socio-demographic factors, co-morbidity, and accessibility of primary health care

Abstract Background: Differences in antibiotic consumption between individuals are not only due to differences in primary infection morbidity, other non-medical factors are important. Our objective was to investigate how socio-demographic factors, co-morbidity, and access to primary care affect antibiotic prescribing. Methods: The study population included all 2 078 481 persons in Sweden who received at least one antibiotic prescription during 2010, and an unmatched control population of 788 580 individuals. We used record linkage to obtain data on co-morbidity, various socio-demographic variables, and waiting times for doctor appointments in primary care. We used logistic regression to estimate odds ratios (ORs) for antibiotic prescription. Results: The results showed that over 20% of the population were prescribed antibiotics during 2010. Children aged 0–5 years, persons ≥ 75 years of age, those living in urban areas, and women compared with men, received many prescriptions. Co-morbidity was a strong factor that determined the number of antibiotic prescriptions: those with Charlsons index ≥ 3 had an OR of 3.03 (95% CI: 3.00–3.07) to obtain antibiotics in the adjusted analysis, compared with individuals without co-morbidity (Charlsons index 0). Short waiting times for a doctors visit in primary care were associated with a higher number of antibiotic prescriptions. Individuals born in Sweden were prescribed more antibiotics compared with those born in another country. Specifically, persons born in any of the 27 EU countries (excluding Scandinavia) had an OR of antibiotic prescription of 0.78 (95% CI: 0.77–0.78) compared with native-born individuals. Conclusions: We conclude that non-medical factors strongly influence antibiotic prescriptions.

The Role of Procalcitonin in Postimplantation Syndrome after EVAR: A Pilot Study

BACKGROUND After endovascular aortic repair (EVAR) for treatment of aortoiliac aneurysms, patients commonly develop an inflammatory reaction: Postimplantation syndrome (PIS). Clinically, it may be hard to separate PIS from an infectious complication. Procalcitonin (PCT) is a diagnostic marker for severe bacterial infections and sepsis. We hypothesize that low-PCT levels facilitate the PIS diagnosis after EVAR. METHODS Sixty-nine elective EVAR patients were included. Tympanic temperature, C-reactive protein (CRP), white blood cell count (WBC), and PCT were measured on days -1 and +1, +3 and +5. Complications, in-hospital stay, and infections were recorded. PIS was defined by a body temperature of ≥38°C and WBC ≥12,000/μL combined with no other detected complication or surgical event explaining the inflammatory response. Three cohort subgroups were compared: the noncomplication group, those with PIS, and the patients with complications or additional open surgical events. RESULTS All patients developed various extents of postoperative inflammatory responses including a rise in WBC, CRP, and/or temperature. PIS was diagnosed in 12 patients. Forty patients had no complication and seventeen suffered complications or had an additional open surgical event. All PIS patients showed low-PCT levels. On day +3, in the PIS group, median PCT was 0.22 ng/mL (95% confidence interval [CI]: 0.15-0.28), WBC 13.2 × 10(9)/L (11.4-15.6), and CRP 196 mg/L (149-243). High PCT was observed in 6 patients, out of which 4 had complications or additional open surgical procedures. CONCLUSIONS In patients with PIS after EVAR, there was a strong inflammatory reaction. In the PIS condition, PCT remains low. This pilot study shows that PCT may be useful for the PIS diagnosis.