Erik Svensson

Cutaneous melioidosis in a Swedish tourist after the tsunami in 2004

A tourist from Sweden developed cutaneous melioidosis after the tsunami in Thailand on 26 December 2004. Melioidosis is a severe, chronic infection which is endemic in Thailand and is caused by Burkholderia pseudomallei. Persons with traumatic injuries inflicted by the tsunami have increased risks of being infected by B. pseudomallei and melioidosis should be suspected if abscesses of the skin or inner organs develop in the months or years after the trauma.

Susceptibility of staphylococci and enterococci to antimicrobial agents at different ward levels in four north European countries

A multicentre susceptibility study was performed on staphylococci and enterococci isolated from patients at 3 different ward levels: primary care centres (PCCs), general hospital wards (GHWs) and intensive care units (ICUs), in Denmark, Finland, Norway and Sweden. There was a markedly higher incidence of resistance among CoNS in ICUs compared to GHWs and PCCs. Resistance rates were low among S. aureus isolates and no differences were found between the ward levels. Oxacillin resistance was found among 1.6% of S. aureus and 47% of CoNS isolates. 14% of CoNS and 0.9% of S. aureus isolates were glycopeptide intermediate. The prevalence of E. faecium isolates in this study differed significantly between the ward levels with the lowest prevalence found at PCCs. High level gentamicin resistant (HLGR) enterococci occurred in 11–25% of E. faecium and 6–20% of E. faecalis isolates. The HLGR rate was significantly higher among E. faecalis from hospitalized patients (GHWs and ICUs) compared to patients at PCCs. For enterococcal isolates, no other significant differences in antimicrobial resistance were found between the ward levels. All enterococci were teicoplanin susceptible, but decreased susceptibility to vancomycin was found among 2.0% and 0.6% of the E. faecium and E. faecalis isolates, respectively.

Hot tub lung: an occupational hazard

To the Editor: Hot tub baths have become increasingly common in residences as well as hotels and spa facilities. Recently, such baths have been associated with an emerging disorder known as hot tub lung (HTL). HTL is a diffuse granulomatous lung disease caused by inhalation of water aerosol containing non-tuberculous mycobacteria (NTM), in most cases belonging to the Mycobacterium avium complex [1]. Here, we report a cluster of confirmed, probable and possible HTL with occupational associations. To our knowledge, case 1 is the first confirmed case of occupational HTL in the literature. A 30-yr-old hotel technician (case 1, table 1) developed episodes of cough, dyspnoea, fever and joint pain. His condition progressed with fatigue, weight loss and increasing dyspnoea. He was hospitalised at his third emergency visit. His oxygen tension was moderately reduced (8.9 kPa). His C-reactive protein level was 16 mg·L−1. A chest radiograph was normal but computed tomography showed ground-glass opacities without signs of embolism. He was dismissed after spontaneous remission 3 days later. He continued having some fatigue and dyspnoea on exertion. Fever, accentuated dyspnoea and cough relapsed twice after returning to work. Chest radiography showed diffuse interstitial infiltration and his diffusion capacity was reduced. Lymphocytosis was found in his bronchoalveolar lavage (BAL) fluid, and transbronchial biopsies showed interstitial inflammation and granuloma. HTL was diagnosed when growth of M. avium was found in BAL fluid and it became clear that he had cleaned the hotel’s hot tub facility (facility 1) and its nylon filters with a pressure washer twice weekly. View this table: Table 1. Characterisation of a cluster of confirmed, probable and possible cases of hot tub lung related to maintenance work on hot tubs Two colleagues who had substituted for the first hotel technician at servicing the bath facility during his sick leave also fell ill with similar symptoms (cases 2 and 3, table 1). They were eventually diagnosed with probable HTL but the work-up was insufficient …

Pharmacodynamic effects of meropenem on gram-negative bacteria

The in vitro initial killing and post-antibiotic effect (PAE) of meropenem on five gramnegative reference strains were evaluated by bioluminescence assay of bacterial adenosine triphosphate (ATP) and viable count. Morphology studies were performed in parallel. Meropenem showed concentration-dependent long (2–5 h) PAEs onEnterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa andSerratia marcescens when assayed by bioluminescence and induced spheroplasts at almost all concentrations. The bioluminescence PAEs reached a maximum response at 4 × MIC. These PAEs of meropenem onEscherichia coli, Klebsiella pneumoniae andSerratia marcescens were longer than corresponding PAEs of imipenem shown in previous studies. The higher affinity of meropenem than imipenem for PBP 3 might explain the longer PAEs obtained with meropenem. However, there was only a very short PAE, no PAE or even a negative PAE when viable count was used as the initial value for the PAE calculation. A strong initial decrease in viability but a less pronounced change in intracellular ATP was registered. Since this initial change in cell numbers is the initial value for the PAE calculation, the length of PAE was highly method dependent. In summary, a strong initial killing and no PAE were shown using viable count as the initial value for the PAE calculation, but a weak initial killing and long PAEs were shown when bioluminescence was used throughout the experiments.

In vitro susceptibility of filamentous fungi to itraconazole, voriconazole and posaconazole by Clinical and Laboratory Standards Institute reference method and E-test

The use of anti‐fungal agents has increased dramatically in recent years and new drugs have been developed. Several methods are available for determinations of their specific biological activities, i.e. the standard method for minimum inhibitory concentration‐determination is described in M‐38 [Clinical and Laboratory Standards Institute document M‐38 (CLSI M‐38)]. However, alternative methods, such as the E‐test, are currently available in Mycology laboratories. The susceptibilities of clinical isolates of Aspergillus spp. (n = 29), Fusarium spp. (n = 5), zygomycetes (n = 21) and Schizophyllum (n = 1) were determined for itraconazole, voriconazole and posaconazole, using the CLSI M‐38‐A broth dilution method and also by the E‐test. A good overall agreement (83.7%) between the two methods for all drugs and organisms was observed. Analyses of voriconazole showed a better agreement (93%) between the methods than posaconazole and itraconazole (85% and 74% respectively). Aspergillus spp. were the most susceptible fungi to the anti‐fungal agents tested in this study. Posaconazole was the most active drug against filamentous fungi in vitro, followed by itraconazole and voriconazole. The latter (voriconazole) demonstrated no significant in vitro activity against zygomycetes.

Quantitative analyses of mycobacteria in water: adapting methods in clinical laboratories.

An outbreak of occupational hot tub lung necessitated quantitative analysis of mycobacteria in water samples. We combined procedures for cultivation of mycobacteria in urine and quantitative analyses of dialysis water. Whirlpool spa water samples were analyzed showing promising results. In conclusion, quantitative mycobacterial culture of water is possible by adapting methods routinely used in clinical laboratories.