Management of the antibiotic resistance problem – approach of the Dutch Working Party on Antibiotic Policy

Zadnjih nekoliko desetljeća svjedoci smo konstantno rastućeg problema antimikrobne rezistencije zbog kojeg je Vijeće Europske Unije donijelo rezoluciju te preporuke o razumnoj uporabi antibiotika u humanoj medicini. Naglasak u preporukama je stavljen na uspostavljanje mreže praćenja antimikrobne rezistencije te implementiranje mjera za doprinos razumnoj potrošnji antibiotika kroz razvijanje nacionalnih smjernica o upotrebi antibiotika. Uspostava interdisciplinarnog nacionalnog tijela (ICM, od engl. interdisciplinary coordinating mechanism) za koordiniranje svih aktivnosti na području rezistencije bakterija na antibiotike predložena je kao glavni instrument implementacije preporuka. Kao ICM u Nizozemskoj je osnovana Radna grupa za antimikrobnu strategiju (SWAB), a u Hrvatskoj Interdisciplinarna sekcija za kontrolu rezistencije na antibiotike (ISKRA). Dobra suradnja između SWAB-a i ISKRA-e započeta je kroz Matra (Matra Pre-Accession Programme, MPAP) projekt "Praćenje antimikrobne rezistencije u humanoj medicini" nizozemskog Ministarstva vanjskih poslova. Nizozemska je zemlja s najnižom potrošnjom antibiotika u Europi te niskim udjelom antibiotske rezistencije kod većine bakterija. Rezistencija na neke antibiotike, ipak, raste.In the past decades we are witnessing an increasing antibiotic resistance problem to which the EU Ministers of Health responded by issuing a "Council Recommendation on the prudent use of antimicrobial agents in human medicine" with the recommendation of establishing antimicrobial resistance surveillance systems and implementing measures to support the prudent use of antibiotics by setting evidence based guidelines. Intersectoral Coordinating Mechanisms (ICM) at national levels have been suggested as instruments of implementation. Consequently the Working Party on Antibiotic Policy (SWAB) was founded in the Netherlands, and the Interdisciplinary Section for Antibiotic Resistance Control (ISKRA) in Croatia. Good colaboration between the SWAB and the ISKRA started through the Matra Pre-Accession Programme (MPAP) project "Antimicrobial resistance surveillance in human medicine" of the Dutch Ministry of Foreign Affairs. The Netherlands is the country with the lowest antibiotic consumption in Europe and with low antibiotic resistance rates in the majority of pathogens. However, resistance to some antibiotics is rising

The rise and fall of resistant bacteria

Problem rezistencije bakterija na antibiotike jedan je od vodećih problema današnje medicine. Hrvatska sistematski prati stope rezistencije u najčešćih patogena od 1996. g. te je u ovom radu analizirano kretanje stopa rezistencije u Hrvatskoj u razdoblju od 2000. do 2014. g. Trideset pet hrvatskih mikrobioloških laboratorija (pokrivenost populacije >90 %) slalo je podatke o osjetljivosti kliničkih izolata (ponavljani izolati su isključivani) u Referentni centar Ministarstva zdravlja za praćenje rezistencije gdje su podaci agregirani i analizirani. Otpornost streptokoka grupe A na makrolide pokazuje lagani trend pada. Smanjena osjetljivost pneumokoka na penicilin pokazuje manje oscilacije bez izraženog trenda. Rezistencija na vankomicin je prisutna u E. faecium s trendom porasta u zadnje dvije godine. Rezistencija na cefalosporine 3. generacije i kinolone je u E. coli u blagom, ali stalnom porastu, a u K. pneumoniae je znatno viša, ali ne pokazuje porast zadnjih godina. Rezistencija na karbapeneme je u P. aeruginosa u blagom porastu, a u A. baumannii je naglo porasla od 2008. g. Hrvatska ima dobro organiziranu mrežu za praćenje rezistencije i poznavanje stopa rezistencije je važan prvi korak u kontroli širenja rezistencije. U kontroli širenja rezistencije također je bitno jačati ulogu timova za kontrolu bolničkih infekcija te prepustiti antimikrobnu terapiju timovima za rukovođenje antimikrobnom terapijom.Antimicrobial resistance (AMR) is one of the leading problems in modern medicine. Antibiotic resistance surveillance in Croatia was set up in 1996 and antibiotic resistance rates in most frequent bacterial pathogens were analysed for the period 2000 till 2014. Thirty five Croatian microbiology laboratories (population coverage >90 %) have sent antibiotic sensitivity data for clinical isolates (copy isolates were excluded) to the Ministry of Health Reference Center for Antibiotic Resistance Surveillance where these data were aggregated and analysed. Macrolide resistance in group Astreptococci shows a mild decreasing trend. Penicillin non-susceptibility in pneumococci demonstrates slight oscillations without any trend. Vancomycin resistance was recorded in Enterococcus faecium with increasing trend in the last two years. Resistance to 3rd generation cephalosporins and quinolones is slightly but constantly increasing in E. coli and in K. pneumoniae, although significantly higher, it does not demonstrate increase in the last few years. Carbapenem resistance is slightly increasing in P. aeruginosa and has abruptly increased in A. baumannii since 2008. Croatia has a well organized antibiotic resistance surveillance network and knowing local resistance rates is an important first step in controlling antibiotic resistance. For successful AMR control it is also very important to strengthen the role of infection control teams and to establish antibiotic stewardship teams

Urogenital tract candidiasis

Candida spp. dio je normalne mikrobiote gastrointestinalnog i urogenitalnog trakta ljudi, no u određenim uvjetima može uzrokovati infekcije - mukokutane ili diseminirane. Najčešći uzročnik je Candida albicans. Vulvovaginalna kandidijaza najčešći je oblik sluzničke kandidijaze, a njena pojava češća je uz stanja povišene razine estrogena te upotrebe antibiotika, kortikosteroida, kao i kod bolesnica oboljelih od dijabetesa ili HIV-a. Infekcijom može biti zahvaćen mokraćni mjehur, ali i bubrezi, najčešće ascendentno iz donjeg dijela mokraćnog sustava. U razdoblju od 1.1.2018. do 31.12.2019. u Mikrobiološkom laboratoriju Klinike za infektivne bolesti „Dr. Fran Mihaljević“ analizirano je 51.144 uzoraka iz urogenitalnog trakta od kojih je 17.949 (35,1%) bilo pozitivno. Od pozitivnih izolata, 1.001 izolat bila je kandida (5,6%). Kako je pojava raznih vrsta kandida u uzorcima iz urogenitalnog trakta česta, cilj ovog rada je prikazati kliničke manifestacije kandidijaze, indikacije za liječenje kao i odabir antifungika. Kandidijaza urogenitalnog trakta važan je dio svakodnevnog kliničkog rada i u hospitaliziranih i u ambulantnih bolesnika, a pažljiva interpretacija nalaza preglednog urina, urinokulture te simptoma bolesti, ako su prisutni, ključni su za razlikovanje kolonizacije od infekcije.Candida spp. is part of the normal microbiota of the human gastrointestinal and urogenital tracts, however, in some circumstances, can cause infections - mucocutaneous or disseminated. The most common causative pathogen is Candida albicans. Vulvovaginal candidiasis is the most common type of mucocutaneous candidiasis, and its occurrence is more frequent in conditions characterised by elevated levels of oestrogen, use of antibiotics, corticosteroids, as well as in patients with diabetes or HIV. The infection can also affect the bladder, but also the kidneys, most often ascending from the lower part of the urinary system. In the period between January 1, 2018 and December 31, 2019, a total of 51.144 urogenital tract samples were analysed at the Laboratory for Microbiology of the University Hospital for Infectious Diseases “Dr. Fran Mihaljević“, 17.949 of which (35,1%) were positive. Among detected isolates, candida accounted for 1.001 isolates (5,6%). Since the occurrence of various types of candida in urogenital tract is frequent, the aim of this paper was to present the clinical manifestations of candidiasis, treatment indications as well as the choice of antifungal drugs. Urogenital tract candidiasis presents an important part of everyday clinical practice in both hospitalized patients as well as in outpatients. Careful interpretation of urinalysis results, urine culture test and disease symptoms, if present, are the key factors for differentiating colonisation from infection

VIROLOGIC AND EPIDEMIOLOGICAL CHARACTERISTICS OF NON-POLIO INFECTION IN CROATIA OVER A TEN-YEAR PERIOD (2000-2009)

Cilj rada bio je prikazati virološke i epidemiološke značajke non-polio enterovirusnih (NPEV) infekcija u desetogodišnjem razdoblju(2000.-2009.) u Republici Hrvatskoj. Tijekom navedenog razdoblja u Laboratoriju za enteroviruse Hrvatskog zavoda za javnozdravstvo obrađeno je 2754 kliničkih uzoraka prikupljenih od 1880 bolesnika s kliničkom slikom enterovirusne infekcije. Dijagnoza enterovirusne infekcije dokazana je izolacijom virusa u staničnoj kulturi, a virusi su tipizirani metodama neizravne imunofluorescencije i/ili testom neutralizacije. NPEV infekcija dokazana je u 394 od 1880 bolesnika (21%). Osobe muškog spola češće su obolijevale od osoba ženskog spola u omjeru 1,8:1. Broj oboljelih najveći je u dobnoj skupini predškolske i školske djece. Bolesnici u kojih su izolirani NPEV najčešće su imali dijagnozu seroznog meningitisa - 234/394 (59,4%). Infekcije su najčešće bile uzrokovane echovirusima (218/394; 55,3%), zatim coxsackie B (126/394; 32,0%) i coxsackie A (31/394; 7,9%) virusima, a rjeđe su dokazani echovirus 22 - parechovirus 1 (16/394; 4,1%) i enterovirus 71 (3/394; 0,8%). Coxsackie B5 i B4 virusi kontinuirano se detektiraju tijekom istraživanog razdoblja s učestalijom pojavom svakih 4-5 godina. Najčešći izolat echovirusa bio je echovirus 18 koji se detektira kontinuirano od 2000. do svoje epidemijske 2006. godine. Echovirus 6 i echovirus 30 također se izoliraju kontinuirano s vršnim vrijednostima 2002. i 2008., odnosno 2002., 2006. i 2008. godine.Aim: The aim of the present study was to show the virologic and epidemiological characteristics of non-polio enterovirus (NPEV) infection over a ten-year period in Croatia. Methods: During the 2000-2009 period, the Laboratory for Enteroviruses, Croatian Public Health Institute analyzed 2754 clinical samples collected from 1880 patients with a clinical picture of enteroviral infection. The diagnosis of enteroviral infection was confirmed by virus isolation in cell culture. Viruses were typed using indirect immunofluorescence and/or neutralization assay. Results: NPEV was proven in 394 (21%) of 1880 patients. Males were more commonly infected than females, at a ratio of 1.8:1, while the number of infected cases was highest among preschoolers and schoolchildren. Patients with isolated NPEV were most frequently diagnosed with aseptic meningitis (234/394; 59.4%). Infections were most commonly caused by echoviruses (218/394; 55.3%), followed by Coxsackie B (126/394; 32.0%) and Coxsackie A (31/394; 7.9%) viruses, rarely by echovirus 22 - parechovirus 1 (16/394; 4.1%) and enterovirus 71 (3/394; 0.8%). In most cases, echoviruses of the following serotypes were proven: 6, 9, 11, 13, 14, 18 and 30 (45/218, 21%; 14/218, 6.4%; 18/218, 8.3%; 15/218, 6.9%; 11/218, 5.0%; 55/218, 25.2% and 42/218, 19.3%), while serotypes 2, 3, 4, 5, 7, 12, 20, 21, 25 and 26 were evidenced in a minority of patients or individual cases. Coxsackie B5 was the predominant serotype among Coxsackie B viruses (50/126, 40%), while Coxsackie A9 was most common Coxsackie A virus (26/31, 84%). Coxsackie B5 and B4 viruses were continually detected during the study period and appeared more frequently every four to five years. The most common echovirus isolate was echovirus 18, detected continually between 2000 and the outbreak year of 2006. Echovirus 6 and echovirus 30 were also isolated continually with peaks in 2002 and 2008, or 2002, 2006 and 2008. Conclusion: The results of this study pointed to a specific pattern of the occurrence of certain NPEV serotypes in Croatia. The epidemic pattern (echovirus 18 and Coxsackie B1) was characterized by peaks with an elevated number of isolations in given years. Contrary to this, endemic viruses were isolated in similar counts every year (Coxsackie B3), or manifested milder epidemic peaks every few years (echoviruses 30 and 6, Coxsackie B4 and B5). Data on NPEV infections, given their serotype and specific pattern of occurrence, contribute significantly to prompt diagnostic, clinical and epidemiological response to NPEV infections

Interspecies transmission of porcine-originated G4P[6] rotavirus A between pigs and humans: a synchronized spatiotemporal approach

As a leading viral cause of acute gastroenteritis in both humans and pigs, rotavirus A (RVA) poses a potential public health concern. Although zoonotic spillover of porcine RVA strains to humans is sporadic, it has been detected worldwide. The origin of chimeric human–animal strains of RVA is closely linked to the crucial role of mixed genotypes in driving reassortment and homologous recombination, which play a major role in shaping the genetic diversity of RVA. To better understand how genetically intertwined porcine and zoonotic human-derived G4P[6] RVA strains are, the present study employed a spatiotemporal approach to whole-genome characterization of RVA strains collected during three consecutive RVA seasons in Croatia (2018–2021). Notably, sampled children under 2 years of age and weanling piglets with diarrhea were included in the study. In addition to samples tested by real-time RT-PCR, genotyping of VP7 and VP4 gene segments was conducted. The unusual genotype combinations detected in the initial screening, including three human and three porcine G4P[6] strains, were subjected to next-generation sequencing, followed by phylogenetic analysis of all gene segments, and intragenic recombination analysis. Results showed a porcine or porcine-like origin for each of the eleven gene segments in all six RVA strains. The G4P[6] RVA strains detected in children most likely resulted from porcine-to-human interspecies transmission. Furthermore, the genetic diversity of Croatian porcine and porcine-like human G4P[6] strains was propelled by reassortment events between porcine and porcine-like human G4P[6] RVA strains, along with homologous intragenotype and intergenotype recombinations in VP4, NSP1, and NSP3 segments. Described concurrent spatiotemporal approach in investigating autochthonous human and animal RVA strains is essential in drawing relevant conclusions about their phylogeographical relationship. Therefore, continuous surveillance of RVA, following the One Health principles, may provide relevant data for assessing the impact on the protectiveness of currently available vaccines

The rise and fall of resistant bacteria

Problem rezistencije bakterija na antibiotike jedan je od vodećih problema današnje medicine. Hrvatska sistematski prati stope rezistencije u najčešćih patogena od 1996. g. te je u ovom radu analizirano kretanje stopa rezistencije u Hrvatskoj u razdoblju od 2000. do 2014. g. Trideset pet hrvatskih mikrobioloških laboratorija (pokrivenost populacije >90 %) slalo je podatke o osjetljivosti kliničkih izolata (ponavljani izolati su isključivani) u Referentni centar Ministarstva zdravlja za praćenje rezistencije gdje su podaci agregirani i analizirani. Otpornost streptokoka grupe A na makrolide pokazuje lagani trend pada. Smanjena osjetljivost pneumokoka na penicilin pokazuje manje oscilacije bez izraženog trenda. Rezistencija na vankomicin je prisutna u E. faecium s trendom porasta u zadnje dvije godine. Rezistencija na cefalosporine 3. generacije i kinolone je u E. coli u blagom, ali stalnom porastu, a u K. pneumoniae je znatno viša, ali ne pokazuje porast zadnjih godina. Rezistencija na karbapeneme je u P. aeruginosa u blagom porastu, a u A. baumannii je naglo porasla od 2008. g. Hrvatska ima dobro organiziranu mrežu za praćenje rezistencije i poznavanje stopa rezistencije je važan prvi korak u kontroli širenja rezistencije. U kontroli širenja rezistencije također je bitno jačati ulogu timova za kontrolu bolničkih infekcija te prepustiti antimikrobnu terapiju timovima za rukovođenje antimikrobnom terapijom.Antimicrobial resistance (AMR) is one of the leading problems in modern medicine. Antibiotic resistance surveillance in Croatia was set up in 1996 and antibiotic resistance rates in most frequent bacterial pathogens were analysed for the period 2000 till 2014. Thirty five Croatian microbiology laboratories (population coverage >90 %) have sent antibiotic sensitivity data for clinical isolates (copy isolates were excluded) to the Ministry of Health Reference Center for Antibiotic Resistance Surveillance where these data were aggregated and analysed. Macrolide resistance in group Astreptococci shows a mild decreasing trend. Penicillin non-susceptibility in pneumococci demonstrates slight oscillations without any trend. Vancomycin resistance was recorded in Enterococcus faecium with increasing trend in the last two years. Resistance to 3rd generation cephalosporins and quinolones is slightly but constantly increasing in E. coli and in K. pneumoniae, although significantly higher, it does not demonstrate increase in the last few years. Carbapenem resistance is slightly increasing in P. aeruginosa and has abruptly increased in A. baumannii since 2008. Croatia has a well organized antibiotic resistance surveillance network and knowing local resistance rates is an important first step in controlling antibiotic resistance. For successful AMR control it is also very important to strengthen the role of infection control teams and to establish antibiotic stewardship teams

Resistome Analysis of Campylobacter jejuni Strains Isolated from Human Stool and Primary Sterile Samples in Croatia

Campylobacteriosis represents a global health challenge due to continuously increasing trends of antimicrobial resistance in Campylobacter jejuni. C. jejuni can sometimes cause life-threatening and severe systematic infections (bacteremia, meningitis, and other extraintestinal infections) with very few antibiotics left as treatment options. Bearing in mind that C. jejuni is the predominant species in humans, in this paper, we present a study of the C. jejuni differences in antimicrobial resistance and genotype distribution between strains isolated from stool and primary sterile sites. We compared the genomic data obtained through whole genome sequencing (WGS) and phenotypic susceptibility data of C. jejuni strains. Once antimicrobial susceptibility testing of C. jejuni strains was carried out by the broth microdilution method for six of interest, results were compared to the identified genotypic determinants derived from WGS. The high rate of resistance to fluoroquinolones presented in this study is in accordance with national surveillance data. The proportion of strains with acquired resistance was 71% for ciprofloxacin and 20% for tetracycline. When invasive isolates were analysed separately, 40% exhibited MIC values of ciprofloxacin higher than the ECOFFs, suggesting a lower flouroquinolone resistance rate in invasive isolates. All isolates demonstrated wilde-type phenotype for chloramphenicol, erythromycin, gentamicin, and ertapenem. A special focus and review in this study was performed on a group of C.jejuni strains found in primary sterile samples. Apart from demonstrating a lower resistance rate, these isolates seem genetically more uniform, showing epidemiologically more homogenous patterns, which cluster to several clonal complexes, with CC49 being the most represented clonal complex

First Report of Campylobacter jejuni Strains Belonging to ST-21 Clonal Complex Isolated from Human, Poultry and Wild Birds in Croatia: Antimicrobial Resistance and Genetic Distance

In the era of growing antimicrobial resistance, a threat affecting humans, endangering animals, as well as livelihoods and food security worldwide, we wanted to find possible explanations for its continuous spread from a new perspective. The ubiquity of resistance genes requires a One Health approach to finding the explanations for continuous AMR spread. The natural transformability of Campylobacter jejuni, its high incidence of infections, and emerging resistance worldwide inspired us to choose C. jejuni ST-21CC to be our pathogen for analyzing its contribution and connection to the cycle of AMR dissemination. ST-21CC is known as a generalist among humans and broilers, the most prevalent lineage worldwide, but it is rarely found in wild birds. Emerging in wild birds, genetic relatedness and similar resistance profiles were expected. We analyzed 23 Croatian C. jejuni strains belonging specifically to ST-21CC from humans, broilers, and wild birds. The genomic data obtained through whole genome sequencing and phenotypic susceptibility data of strains were compared. Our findings suggest high fluoroquinolone resistance in ST-21CC strains, with more diverse genetic backgrounds in wild birds. Intriguing were three isolates of ST-822 (from human and storks), sharing a similar genetic fingerprint