Poul Kjældgaard

National Surveillance of Fungemia in Denmark (2004 to 2009)

ABSTRACT A 6-year nationwide study of fungemia in Denmark was performed using data from an active fungemia surveillance program and from laboratory information systems in nonparticipating regions. A total of 2,820 episodes of fungemia were recorded. The incidence increased from 2004 to 2007 (7.7 to 9.6/100,000) and decreased slightly from 2008 to 2009 (8.7 to 8.6/100,000). The highest incidences were seen at the extremes of age (i.e., 11.3 and 37.1/100,000 for those <1 and 70 to 79 years old, respectively). The rate was higher for males than for females (10.1 versus 7.6/100,000, P = 0.003), with the largest difference observed for patients >50 years of age. The species distribution varied significantly by both age and gender. Candida species accounted for 98% of the pathogens, and C. albicans was predominant, although the proportion decreased (64.4% to 53.2%, P < 0.0001). C. glabrata ranked second, and the proportion increased (16.5% to 25.9%, P = 0.003). C. glabrata was more common in adults and females than in children and males, whereas C. tropicalis was more common in males (P = 0.020). C. krusei was a rare isolate (4.1%) except at one university hospital. Acquired resistance to amphotericin and echinocandins was rare. However, resistance to fluconazole (MIC of >4 μg/ml) occurred in C. albicans (7/1,183 [0.6%]), C. dubliniensis (2/65 [3.1%]), C. parapsilosis (5/83 [6.0%]), and C. tropicalis (7/104 [6.7%]). Overall, 70.8% of fungemia isolates were fully fluconazole susceptible, but the proportion decreased (79.7% to 68.9%, P = 0.02). The study confirmed an incidence rate of fungemia in Denmark three times higher than those in other Nordic countries and identified marked differences related to age and gender. Decreased susceptibility to fluconazole was frequent and increasing.

Epidemiological changes with potential implication for antifungal prescription recommendations for fungaemia: data from a nationwide fungaemia surveillance programme

Significant changes in the management of fungaemia have occurred over the last decade with increased use of fluconazole prophylaxis, of empirical treatment and of echinocandins as first-line agents for documented disease. These changes may impact the epidemiology of fungaemia. We present nationwide data for Denmark from 2010 to 2011. A total of 1081 isolates from 1047 episodes were recorded in 995 patients. The numbers of patients, episodes and recovered isolates increased by 13.1%, 14.5% and 14.1%, respectively, from 2010 to 2011. The incidence rate was significantly higher in 2011 (10.05/100 000) than in 2010 (8.82/100 000), but remained constant in the age groups 0-79 years. The incidence rate was highest at the extremes of age and in males. Candida albicans accounted for 52.1% but declined during 2004-11 (p 0.0155). Candida glabrata accounted for 28% and increased during 2004-2011 (p <0.0001). Candida krusei, Candida tropicalis and Candida parapsilosis remained rare (3.3-4.2%). The species distribution changed with increasing age (fewer C. parapsilosis and more C. glabrata) and by study centre. Overall, the susceptibility rates were: amphotericin B 97.3%, anidulafungin 93.8%, fluconazole 66.7%, itraconazole 69.6%, posaconazole 64.2% and voriconazole 85.0%. Acquired echinocandin resistance was molecularly confirmed in three isolates. The use of systemic antifungals doubled over the last decade (2002-2011) (from 717 000 to 1 450 000 defined daily doses/year) of which the vast majority (96.9%) were azoles. The incidence of fungaemia continues to increase in Denmark and is associated with a decreasing proportion being susceptible to fluconazole. Changes in demography, higher incidence in the elderly and higher antifungal consumption can at least in part explain the changes.

Streptococcus suis: Meningitis, spondylodiscitis and bacteraemia with a serotype 14 strain

Meningitis and spondylodiscitis caused by Streptococcus suis is a rare disease which is contracted by occupational exposure to pigs. We report a 54-y-old pig-farm worker with S. suis meningitis and septicaemia complicated with thoracal and lumbar spine spondylodiscitis. The S. suis strain involved in this case report was identified as serotype 14, which has only been described in 2 previous cases. It is important to report infection with S. suis as a work accident for compensation if the patient has been occupationally exposed to pigs.

Phenotypical properties of Enterobacter agglomerans (Pantoea agglomerans) from human, animal and plant sources

Clinical, animal and plant isolates, representing different geographical areas, were identified as Enterobacter agglomerans (Pantoea agglomerans) using a quantitative bacterial dot method for DNA‐DNA hybridization. The phenotypical properties of the 65 strains were investigated by conventional test methods. No strain decarboxylated ornithine. Twenty‐two strains, mainly plant isolates, showed delayed acid production from α‐methyl‐glycoside, a trait which may have ecological significance. With regard to these two properties, our results differed from the description of Pantoea agglomerans given by Gavini et al. (6); further investigations will clarify these differences. Three non‐pigmented, maltose‐negative and salicin‐negative variants were derived from yellow pigmented, maltose‐positive, salicin‐positive strains.

Utilization of blood cultures in Danish hospitals: a population-based descriptive analysis

This national population-based study was conducted as part of the development of a national automated surveillance system for hospital-acquired bacteraemia and ascertains the utilization of blood cultures (BCs). A primary objective was to understand how local differences may affect interpretation of nationwide surveillance for bacteraemia. From the Danish Microbiology Database, we retrieved all BCs taken between 2010 and 2013 and linked these to admission data from the National Patient Registry. In total, 4 587 295 admissions were registered, and in 11%, at least one BC was taken. Almost 50% of BCs were taken at admission. The chance of having a BC taken declined over the next days but increased after 4 days of admission. Data linkage identified 876 290 days on which at least one BC was taken; 6.4% yielded positive results. Ten species, Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Enterococcus faecium, Enterococcus faecalis, Pseudomonas aeruginosa, Candida albicans, Enterobacter cloacae and Klebsiella oxytoca, accounted for 74.7% of agents for this purpose classified as pathogenic. An increase in BCs and positive BCs was observed over time, particularly among older patients. BCs showed a seasonal pattern overall and for S. pneumoniae particularly. A predominance of male patients was seen for bacteraemias due to S. aureus, E. faecium and K. pneumoniae. Minor differences in BCs and positive BCs between departments of clinical microbiology underpin the rationale of a future automated surveillance for bacteraemia. The study also provides important knowledge for interpretation of surveillance of invasive infections more generally.

Phage-typing of coagulase-negative staphylococci. Factors influencing typability

Factors influencing the phage‐typability of coagulase‐negative Micrococcaceae have been studied in 2,778 clinical isolates comprising A) 209 consecutive isolates from one laboratory, B) 2,107 clinical strains submitted for phage‐typing for epidemiological reasons, and C) 462 strains representing all isolates of presumed clinical significance found in two laboratories during one month. The reproducibility was acceptable at duplicate repeated typing of the same strains as well as by typing epidemiologically‐related pairs of strains from the same patient. Strains of Staphylococcus haemolyticus were seldom typable, whereas strains of S. epidermidis and S. hominis had a higher typability. Methicillin‐resistant strains and other multiple‐resistant strains were rarely typable (11–13%). The typability was higher among susceptible strains (36%) and strains resistant to penicillin only (43–50%). The typability of strains of the same species and antibiotic‐resistance pattern differed between hospitals compared and decreased markedly over the years for multiple‐resistant S. epidermidis isolates.

MRSA screening in emergency department detects a minority of MRSA carriers.

INTRODUCTION Methicillin-resistant Staphylococcus areus (MRSA) is an emerging problem. The Danish Health and Medicines Authority (HMA) has developed a question-based screening tool to identify patients with MRSA. The tool has three parts: questions on general risk situations, special risk situations and individual risk factors. The emergency departments (ED) play a key role in the prevention of in-hospital spreading of MRSA. The aim of the present study was to estimate the prevalence of MRSA among all admitted ED patients to assess how many patients should be swab-tested for MRSA and isolated and to evaluate the ability of the HMA screening tool to detect MRSA. METHODS Patients who were more than ten years old answered all the HMA questions on general and specific risk situations and individual risk factors for MRSA, and a swab was obtained for MRSA culture. RESULTS A total of 1,945 patients were admitted and 73% participated. Indications for swab testing for MRSA were present in 8%. The general risk situation questions identified 3% for isolation due to suspicion of MRSA. A total of 11 patients had a positive MRSA swab culture (0.9%). Among the isolated patients, 3% had MRSA, 97% would have been isolated unnecessarily, while 91% of the MRSA patients would not have been isolated. The general risk situation questions had a sensitivity of 18-27% and the whole questionnaire had a sensitivity of 55% for the detection of MRSA patients. CONCLUSIONS The majority of MRSA carriers who are acutely admitted to the ED will remain undetected. FUNDING Hospital of Southern Jutland. TRIAL REGISTRATION not relevant.

Detection of Staphyiococcal Toxic Shock Syndrome Toxin 1 by a Latex Agglutination Kit

A commercial reversed passive latex agglutination kit (Oxoid), that detects toxic shock syndrome toxin 1 (TSST-1), was evaluated for its ability to support the clinical diagnosis of toxic shock syndrome (TSS) by detecting the presence of TSST-1 producing Staphylococcus aureus. 15/16 isolates from patients with TSS were positive, while 4/50 vaginal isolates from patients without TSS were positive. The kit can be recommended as it was easy to handle, and gave results identical with those obtained by a standard assay.

Mixed bacterial meningitis in an adult caused by Haemophilus influenzae and Streptococcus pneumoniae

A case of mixed bacterial meningitis with Haemophilus influenzae and Streptococcus pneumoniae is reported in a 26‐year‐old woman without demonstrable predisposing conditions, who recovered after treatment with ampicillin, without sequelae.

Active surveillance of Methicillin-resistant Staphylococcus aureus in an emergency department: Comparing BD MAX StaphSR kit with the routine MRSA identification method

Methods Prospective observational study performed at the ED. Nasal and throat swab specimens from all patients > 10 years who were admitted to the ED from 01.09.2013 to 30.11.2013, were examined. The swabs were, immediately after sampling, incubated in 6% NaCl broth for at least 16 hours and further cultivated on MRSA-chromeand Columbia-agar. 150 ml of the incubated broth was used as sample material for StaphSR.