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Aetiology and antifungal susceptibility of yeast bloodstream infections in a Hungarian university hospital between 1996 and 2000

The purpose of this study was to evaluate the aetiology and susceptibility of different Candida species originating from blood cultures received from different clinical wards of the University Hospital in Szeged, Hungary, from 1996 to 2000. A total of 145 episodes of fungaemia occurred in 68 patients. In 73.5% of the patients the infections were due to Candida albicans, 7.3% to C. parapsilosis, 5.9% to C krusei, 4.4% to C. tropicalis and 3% each to C. glabrata, other Candida spp. and Cryptococcus neoformans. There were no appreciable differences in the distribution of yeast species during the 5-year period: C. albicans remained the predominant species causing bloodstream infections in this hospital, similar to the results of other studies (Norway, SENTRY Program in USA, Canada and South America). Most of the Candida isolates (39.3%) were from blood cultures of patients hospitalised in surgical wards, 28.3% were from adult intensive care units (ICUs), 13.8% from paediatric ICUs, 11% from haematology and 7.6% from cardiology departments. MICs for amphotericin B, fluconazole and itraconazole were determined for 83% of the isolates. All isolates were susceptible to amphotericin B. The percentage of yeast isolates with decreased susceptibility or resistance to fluconazole was smaller (15.7%) than that for itraconazole (24%).

Successful application of the DiversiLab repetitive-sequence-based PCR typing system for confirmation of the circulation of a multiresistant Pseudomonas aeruginosa clone in different hospital wards

The applicability of the repetitive-sequence-based PCR (rep-PCR)-based DiversiLab system was tested compared with the pulsed field gel electrophoresis (PFGE) to type a phenotypically similar subset of a large collection of multiresistant Pseudomonas aeruginosa strains isolated during a 17-month period from patients treated in different wards including 4 intensive care units (ICUs). Five environmental P. aeruginosa isolates obtained from one of the ICUs were also included. The DiversiLab system and the PFGE demonstrated the genetic relationship among the isolates with the same efficacy. One of the environmental isolates had the same rep-PCR type as the circulating clone. Multilocus sequence typing of one of the clinical isolates of the circulating clone proved that it is a member of a clonal complex of P. aeruginosa that has not been previously described in clinical samples.

Genotypic and phenotypic characterisation of invasive Streptococcus pneumoniae isolates from Hungary, and coverage of the conjugate vaccines

Background and aims The 7-valent conjugate pneumococcal vaccine (Prevenar) was introduced as a recommended (but not yet obligatory) vaccine in Hungary in April 2009 and there was a sharp increase in the number of children vaccinated. Hence there is an urgent need for in-depth epidemiological data on invasive pneumococci before vaccination becomes widespread. Such a study has never been done before in Hungary. Methods 144 pneumococcal isolates, obtained from invasive infections or pneumonia, were collected from eight Hungarian diagnostic laboratories between 2000 and 2008. After confirmation of species identity, their susceptibilities to nine antibiotics were determined by Etest and agar dilution method. The serotypes and pulsed-field gel electrophoresis genotypes of the strains were also determined. Results In this cohort, most of the isolates were from patients at the extreme of life. Only 1.4% of the strains were resistant to penicillin, but nearly 40% were resistant to erythromycin (mainly due to erm(B) gene). Higher incidences of resistance were found in the very young and very old. The most prevalent serotypes in the cohort in descending order were 14, 6A, 6, 6B, 23F, 3, 19F and 11A. Conclusions Results showed a similar but not identical profile to previously examined strains causing pulmonary infections in Hungary. The serotypes could be correlated to patient groups. Furthermore, there were examples of serotype switching in strains showing identical genotype but different serotype. The study also shows a good coverage by the conjugate vaccines over the invasive pneumococcal strains in Hungary based on the detected serotypes.

Outbreak of septicaemic cases caused by Acinetobacter ursingii in a neonatal intensive care unit

Neonatal infections may be caused by various microorganisms, but as far as we are aware, Acinetobacter ursingii has not yet been reported in connection with nosocomial infections of premature infants. During 2 months, 3 premature babies were treated with nosocomial infection caused by A. ursingii at the same ward, and on the basis of molecular typing results the same strain was responsible for all of these cases. Traditional biochemical methods and automatic identification systems failed to identify this bacterium on the species level, and only 16S rDNA sequencing gave acceptable species identifications. The isolated strains proved to be susceptible to all of the tested antimicrobials, including ampicillin/sulbactam, doxycyclin, netilmicin, ciprofloxacin, piperacillin/tazobactam, ceftazidime, imipenem, meropenem, trimethoprim/sulfametoxazole, gentamicin, tobramycin, amikacin, and levofloxacin according to the CLSI standard. In spite of the environmental screening, the source of the infection could not be clarified. One of 3 neonates died, the others recovered and were discharged home after several months of hospitalization.

Early procalcitonin kinetics and appropriateness of empirical antimicrobial therapy in critically ill patients: A prospective observational study.

PURPOSE The purpose was to investigate the value of procalcitonin (PCT) kinetics in predicting the appropriateness of empirical antimicrobial treatment in critically ill patients. MATERIALS AND METHODS This prospective observational study recruited patients in whom empirical antimicrobial therapy was started for suspected infection. Biochemical and physiological parameters were measured before initiating antimicrobials (t0), 8 hourly (t8, t16, t24), and then daily (day2-6). Patients were grouped post hoc into appropriate (A) and inappropriate (IA) groups. RESULTS Of 209 patients, infection was confirmed in 67%. Procalcitonin kinetics were different between the IA (n = 33) and A groups (n = 108). In the IA group, PCT levels (median [interquartile range]) increased: t0= 2.8 (1.2-7.4), t16= 8.6 (4.8-22.1), t24= 14.5 (4.9-36.1), P< .05. In the A group, PCT peaked at t16 and started to decrease by t24: t0= 4.2 (1.9-12.8), t16= 6.99 (3.4-29.1), t24= 5.2 (2.0-16.7), P< .05. Receiver operating characteristic analysis revealed that a PCT elevation greater than or equal to 69% from t0 to t16 had an area under the curve for predicting inappropriate antimicrobial treatment of 0.73 (95% confidence interval, 0.63-0.83), P< .001; from t0 to t24, a greater than or equal to 74% increase had an area under the curve of 0.86 (0.77-0.94), P< .001. Hospital mortality was 37% in the A group and 61% in the IA group (P= .017). CONCLUSIONS Early response of PCT in the first 24 hours of commencing empirical antimicrobials in critically ill patients may help the clinician to evaluate the appropriateness of therapy.

Treatment of acute cystitis in Hungary: comparison with national guidelines and with disease-specific quality indicators

Abstract Background: The aim of this study was to compare Hungarian antibiotic use in acute cystitis with the internationally developed disease-specific quality indicators and with the national guidelines. Methods: The aggregated national-level data on systemic antibiotic use was purchased from the National Health Fund Administration. The study period was January–June 2007. Antibiotic use in acute cystitis was evaluated by means of the defined daily dose (DDD) methodology. Quality indicators of antibiotic prescribing proposed by the European Surveillance of Antimicrobial Consumption (ESAC) team were the usage rate of recommended antibacterials and the usage rate of quinolones. Adherence to the available national guidelines was determined. Results: For acute cystitis, 1.06 DDD per 1000 inhabitant-days antibiotic use was recorded. The ESAC recommended antibiotic use in cystitis (23.3%) was well below the recommended range (80–100%). The consumption of fluoroquinolones was 56.2%, which exceeded the recommended range (0–5%) more than 10 times. The adherence rate to the Hungarian guidelines ranged between 59.3% and 74.2%. Conclusions: As both investigated disease-specific quality indicators were well outside the acceptable ranges, some inappropriateness of antibiotic use in cystitis seems to be present. Adherence rates to the different national guidelines were also moderate, but due to the general recommendation of quinolones, values should be interpreted with caution. New transparent guidelines – issued by the Hungarian Society of Family Physicians – should be introduced in Hungary, recommending quinolones only for second-line therapy.

A marked shift in the serotypes of pneumococci isolated from healthy children in Szeged, Hungary, over a 6-year period.

Streptococcus pneumoniae is an important pathogen with significant morbidity and mortality rates worldwide, especially among children <5 years. Healthy carriers are the most important sources of pneumococcal infections, and the nasopharyngeal colonisation is the most prevalent among children attending communities such as day-care centres (DCCs). The conjugate pneumococcal vaccines (PCVs) were shown to have an impact on the colonisation, and so play an important role in inhibiting infections. In this study we compared the nasal carriage of healthy children attending DCCs in Szeged, Hungary in 2003/2004, when nobody was vaccinated, and in 2010, when already 1/5 of the children received PCV-7. Significant differences were observed in the serotype distribution, representing a marked shift from the previously widespread vaccine-types (mostly 6A or 14) to others (11A and 23F). The new serotypes showed higher antibiotic susceptibility. The bacterium exchange between children was clear from the pulsed-field gel electrophoresis (PFGE) patterns, and the circulation of certain international clones plays also a role in these dynamic changes.

Quantitative disparities in outpatient antibiotic exposure in a Hungarian county

OBJECTIVES Although antibiotic utilization data expressed in defined daily doses (DDDs)/1000 inhabitants/day are often available for a given period and area, the actual antibiotic exposure of the population is rarely explored. We aimed to identify the real antibiotic exposure of the inhabitants of one Hungarian county. METHODS The patient-level dispensing data for 2005 for Csongrád County were retrieved from the database of the Hungarian National Health Fund Administration. The number of antibiotic users was quantified, and differences in antibiotic use (quantity and frequency) were explored. Disparities were revealed by Lorenz curves. A new form of Lorenz curve was also introduced. The DDD values for 2005 were used. RESULTS In 2005, a total of 486 115 antibiotic prescriptions were redeemed, and 3 329 385 DDDs were dispensed to 213 748 different patients; 50.3% of the inhabitants of Csongrád County (total population 424 615) took antibiotics. The average consumption of 1-, 2-, 3-, 4- and 5-time users was 7.5, 14.6, 21.0, 26.9 and 32.2 DDDs per user, respectively. Lorenz curves (including the new form of Lorenz curve) demonstrated the existence of disparities in antibiotic use. One percent of the users with the heaviest consumption were responsible for 6.9% of the total use and redeemed antibiotic prescriptions nine times or more during 2005. CONCLUSIONS Disparities in antibiotic use were detected: half of the inhabitants were exposed to antibiotics, and among antibiotic users, the quantity of antibiotics that they redeemed displayed great variance, mainly due to differences in the prescribing frequency. Special attention should be paid to those with frequent antibiotic use (five times or more annually).

Delta Procalcitonin Is a Better Indicator of Infection Than Absolute Procalcitonin Values in Critically Ill Patients: A Prospective Observational Study

Purpose. To investigate whether absolute value of procalcitonin (PCT) or the change (delta-PCT) is better indicator of infection in intensive care patients. Materials and Methods. Post hoc analysis of a prospective observational study. Patients with suspected new-onset infection were included in whom PCT, C-reactive protein (CRP), temperature, and leukocyte (WBC) values were measured on inclusion (t 0) and data were also available from the previous day (t −1). Based on clinical and microbiological data, patients were grouped post hoc into infection- (I-) and noninfection- (NI-) groups. Results. Of the 114 patients, 85 (75%) had proven infection. PCT levels were similar at t −1: I-group (median [interquartile range]): 1.04 [0.40–3.57] versus NI-group: 0.53 [0.16–1.68], p = 0.444. By t 0 PCT levels were significantly higher in the I-group: 4.62 [1.91–12.62] versus 1.12 [0.30–1.66], p = 0.018. The area under the curve to predict infection for absolute values of PCT was 0.64 [95% CI = 0.52–0.76], p = 0.022; for percentage change: 0.77 [0.66–0.87], p < 0.001; and for delta-PCT: 0.85 [0.78–0.92], p < 0.001. The optimal cut-off value for delta-PCT to indicate infection was 0.76 ng/mL (sensitivity 80 [70–88]%, specificity 86 [68-96]%). Neither absolute values nor changes in CRP, temperature, or WBC could predict infection. Conclusions. Our results suggest that delta-PCT values are superior to absolute values in indicating infection in intensive care patients. This trial is registered with ClinicalTrials.gov identifier: NCT02311816.

An 8-Year Evaluation of Antibiotic Consumption and Antibiotic Resistance Among Streptococcus pneumoniae from In- and Out-Patients in Szeged, Hungary

Abstract At the beginning of the 1990s, the prevalence of penicillin resistance of Streptococcus pneumoniae strains in Hungary was found to be extremely high (up to 58% non-susceptible) in some studies, while in other publications the percentage of penicillin highly resistant strains was 0-2%. To see whether this was due to differences in methodology or the composition of the patient population studied, a retrospective evaluation was carried out of the penicillin, amoxicillin, ceftriaxone and macrolide resistance of all S. pneumoniae strains isolated from in- and outpatients in our laboratory between 1998 and 2005. Of the 2670 S. pneumoniae isolates only 5.58% was found to exhibit high-level resistance to penicillin, while resistance to amoxicillin, ceftriaxone and erythromycin was 2.62%, 1.12% and 42.06%, respectively. During this period 6 (3.8%) of 155 S. pneumoniae strains isolated from invasive samples displayed high-level resistance to penicillin. Earlier surveillance data on penicillin resistance of S. pneumoniae may have been biased by the age groups affected by the infection, by whether the strain was isolated from an out-patient or an in-patient, and by whether the isolates were obtained from invasive samples. Our 8-year study using the NCCLS/CLSI methodology consequently revealed a low prevalence of high-level resistance to penicillin in S. pneumoniae strains obtained both from adults and children.