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70 Sequence types of Staphylococcus epidermidis associated with prosthetic joint infections are not present in the laminar flow during prosthetic joint surgery(Emeli Månsson)
71 Genotypic relatedness between clinical and environmental isolates of Staphylococcus pettenkoferi(Emeli Månsson)
72 Jämförelse av fem olika metoder för påvisande av toxinproducerande C. difficile(Emeli Månsson)
74 Assessing cervical intraepithelial neoplasia as an indicator disease for HIV in a low endemic setting: a population-based register study(Christina Carlander)
75 Suppressive art associated with effective treatment of cervical precancer(Christina Carlander)
76 High incidence of high-grade cervical neoplasia among HIV-infected immigrants: a population based cohort study (Christina Carlander)
78 PCR with electrospray ionization-mass spectrometry on bronchoalveolar lavage for detection of invasive mold infections in hematological patients(Anders Krifors)
79 Rätt val av trumhinnerör minskar komplikationsrisken(Johan Knutsson)
80 Infektionsfokus och etiologi vid neutropen feber i Västmanland(Torbjörn Larsson)
81 Erfarenheter från 5 års användande av Xpert MTB/RIF i Västmanland(Ingrid Selmeryd)
82 Staphylococcus aureus bacteremia in patients with cardiac implantable electronic devices (Jonas Selmeryd)
83 Risk factors for severe malaria in travellers and migrants(Andreas Wångdahl)
Postrar 70 – 83
Sequence types of Staphylococcus epidermidis associated with prosthetic joint infections are not present in the laminar flow during prosthetic joint surgery
Conclusion: Micrococcus luteus and coagulase-‐nega-ve staphylococci cons-tuted the majority of iden-fied microorganisms in the laminar air flow in the opera-ng room during prosthe-c joint surgery. ST2 and ST215 of S. epidermidis were not found to be present in the laminar air flow and other
routes of transmission of these healthcare-‐associated strains thus seems more probable.
E.Månsson 1,2, B.Hellmark 3, M.Sundqvist 3, B.Söderquist 1,3 1. Örebro University, Sweden 2. Center of clinical research, Västmanland county hospital, Sweden 3. Dept of microbiology, Örebro university hospital, Sweden
Introduction
Materials and Methods
Correspondence
ResultsStaphylococcus epidermidis is a ubiquitous skin commensal, but also a common cause of prosthe-c joint infec-ons (PJIs). Molecular characteriza-on of S. epidermidis has indicated that pa-ents acquire specific healthcare-‐associated, mul--‐drug resistant strains (ST2 and ST215) that cause PJIs and that these differs from commensal isolates. Our aim was to inves-gate if such strains could be iden-fied in the laminar air flow (LAF) in the opera-ng room during prosthe-c joint surgery. !
Air sampling was performed with ac-ve technique (Sartorius MD8 AirScan) during 17 hip/knee arthroplas-es at Västmanlands sjukhus, Västerås, Sweden from November 2010 to January 2011. A filter was placed in the LAF in close proximity to the wound and was replaced acer each m3 air sampled (= every 10 min). Filters were immediately placed on Mueller Hinton agar and incubated overnight. The CFU per filter was calculated and isolates were subsequently stored at –70°C. Species iden-fica-on was performed using MALDI-‐TOF MS (Bruker Daltonics). When no reliable result was obtained, extrac-on was performed and MALDI-‐TOF MS was repeated. Isolates iden-fied as S. epidermidis was further characterized by mul- locus sequence typing (MLST) and an-bio-c suscep-bility tes-ng using EUCAST methodology.
Sequence types and antibiotic susceptibility patterns for S. epidermidis (n=32)
732042086867
54617054754754754754713013032454822754913027855055154722754754754722755054552
Cefoxi-n
Fucidic
acid
Clindam
ycin
Erythrom
ycin
Genta
micin
Norflo
xacin
TMP-‐S
MX
Rifam
picin
ST
Red = isolate resistant. Black = MecA posi-ve
MALDI-‐TOF analysis of n=735 isolatesMicrococcus sp. 303Coagulase nega-ve staphylococci 217Corynebact sp. 37Staphylococcus sp. 29Kocuria sp. 17Dietzia sp 9Stenotrophomonas maltophilia 7Brevibacterium sp 5Arthrobacter sp 5Dermacoccus sp 5Miscellanous 33No reliable ID 68
MALDI-‐TOF MS resulted in accurate species-‐level iden-fica-on (score ≥ 2,0) of 543/735 isolates (74%). In addi-on, 124 isolates were iden-fied to genus level.
All but one S. epidermidis (n=32) isolate were sensi-ve to cefoxi-n. MLST of S. epidermidis demonstrated 18 different sequence types, but no ST2 or ST215.
Emeli Månsson (MD): emeli.mansson@ltv.se
A BC RF
Gel-like image
CONCLUSION
S. pettenkoferi should most often be regarded as a contamination in blood
cultures. Isolates obtained from the air of the operation room and blood culture
isolates are genetically related, implicating a common origin, probably human
skin flora. The significance of this species in clinical samples must be judged
together with clinical information.
Genotypic relatedness between clinical and environmental isolates of Staphylococcus pettenkoferi
Emeli Månsson1,2, Bengt Hellmark1, Martin Sundqvist1, Bo Söderquist1
1) School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden; 2) Centre for Clinical Research, Uppsala University, County Hospital, Västerås, Sweden.
BACKGROUND
Staphylococcus pettenkoferi was first proposed as
a novel staphylococcal species in 2002. Species
identification of S. pettenkoferi in clinical practice
has become straightforward with MALDI-TOF MS,
and hence reporting of this novel staphylococcal
species is believed to increase. Case reports of S. pettenkoferi infections include osteomyelitis, blood
stream infections in immunocompromised hosts and
bursitis, but little is known about the ecological niche
of S. pettenkoferi. We investigated the genotypic relatedness and
antibiotic susceptibility profiles of 25 isolates of S. pettenkoferi, collected from blood cultures and intra-
operative air sampling, to further characterize this
species.
MATERIALS & METHODS
The clinical isolates (n=16) originated from blood
cultures at the Departments of Clinical Microbiology
in Växjö and Örebro (Sweden), and from the
worldwide SENTRY Antimicrobial Surveillance
Program (JMI Laboratories). The microbiological
relevance of the isolates was determined as significant
if S. pettenkoferi was isolated from ≥ 2 blood culture
bottles. The environmental isolates were collected by
active air sampling during prosthetic joint surgery at
the Department of Orthopaedics, Västerås (Sweden).
Species identification of clinical and
environmental isolates was performed using MALDI-
Fig 1. DiversiLab rep-PCR profiles of 26 S. pettenkoferi isolates. Profiles and corresponding dendrogram obtained using Kullback-Leibner method for correlation analysis. The similarity line (95%) is presented as a light grey vertical line. Each color represents a single pattern (indistinguishable profiles).
RESULTS
Key
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
50 60 70 80 90 100
% similarity
Pattern Alternate id
1 Vasteras 17:2
1 Vasteras 17:1
8 CCUG51270
3 JMI 16
3 JMI 15
4 Vaxjo 9
4 Vaxjo 6
9 Vaxjo 2
10 Vasteras 18:1
12 Vaxjo 3
11 Vaxjo 8
13 Vaxjo 5
14 Vaxjo 12
15 Vaxjo 13
5 Vaxjo 1
5 Vaxjo 11
6 Vasteras 17:5
6 Vasteras 17:3
16 Vaxjo 4
7 Vasteras 17:6
7 Vasteras 17:7
7 Vasteras 17:8
7 Vaxjo 10
17 Vasteras 17:4
18 Orebro 14
19 Vaxjo 7
Source
Air
Air
Ref. strain
Blood culture
Blood culture
Blood culture
Blood culture
Blood culture
Air
Blood culture
Blood culture
Blood culture
Blood culture
Blood culture
Blood culture
Blood culture
Air
Air
Blood culture
Air
Air
Air
Blood culture
Air
Blood culture
Blood culture
Fig 2. Scatter plot of 26 S. pettenkoferi isolates. Each isolate is represented by its number corresponding to the DL profile, as presented in Fig. 1 (“key”). Color represents different origin of isolates (blue = air sampling, green = blood culture, pink = reference strain).
SCATTERPLOT. Gridline spacing: 5 % similarity.
Source: Air Blood culture Ref. strain
TOF MS (Bruker Daltonics) and verified by rpoB gene sequencing. Repetitive-sequence-based PCR was
performed using the DiversiLab Staphylococcus DNA
fingerprinting kit (bioMérieux) with the inclusion
of reference strain CCUG 51270 T. Antibiotic
susceptibility testing was performed with EUCAST-
methodology. In addition all isolates were tested for
presence of the mecA gene using a real-time PCR
system (Light Cycler 2.0)
Only two of the clinical isolates were isolated from
2 blood culture bottles, and hence regarded as
clinically significant findings; Vaxjo_9 and Orebro_14.
Repetitive-sequence-based PCR demonstrated close
relatedness of these isolates to both non-significant
blood culture isolates and to environmental isolates
(Fig. 1 and Fig. 2). Antibiotic susceptibility testing
demonstrated over-all low level of antimicrobial
resistance. The mecA gene was present in two out of
three cefoxitin-resistant isolates.
CORRESPONDENCE emeli.mansson@ltv.se
CL
UST
ER
A
CL
UST
ER
B
26 9
14
1 3
1 1 12
1 0
Cluste r B
23 22 2 5 16
21 7
Clus ter A
20 6
24 19 1 8 17 4 1 2 3
8
15 5
Material och metod27 fecesprov från 26 patienter med frågeställning Clostridium difficile anlayseradesmed:• ImmunoCard (immunkromatografisktsnabbtest från Meridian Diagnostics)
• PREMIER Cl difficile Toxins A&B (EIA frånMeridian Diagnostics)
• GeneXpert, Xpert C.difficile (realtids-PCR från Cepheid)
• C.DIFF CHEK –60 (glutamatdehydrogenas, GDH, EIA från TechLab)
• Odling på CCFA med efterföljande toxintest (PREMIER Cl difficile Toxins A&B)
Prov:
ImmunoCard
(Meridian Diagnostics)
GeneXpert, Xpert
C.difficile (Cepheid)
PREMIER Toxins A&B
(Meridian Diagnostics)
C. DIFF CHEK-60
(Techlab)
Odling
(CCFA)
PREMIER
Toxins A&B
(Meridian
Diagnostics)
1 neg neg neg neg
2 neg neg pos pos
3 neg neg neg neg
4 neg neg neg neg
5 neg neg neg neg
6 neg neg neg neg
7 neg neg neg neg
8 neg neg neg neg växt neg
9 neg neg neg neg växt neg
10 neg neg neg neg
11 pos pos pos pos växt pos
12 neg neg neg pos
13 neg neg neg neg
14 neg neg neg pos växt neg
15 pos pos neg pos växt pos
16 pos pos pos pos växt pos
17 neg neg pos pos växt neg
18 neg neg pos pos
19 neg pos pos pos växt pos
20 pos pos pos pos växt pos
21 neg neg pos neg
22 pos pos pos pos växt pos
23 neg neg pos neg
24 pos pos pos pos växt ej utförd
25 pos pos pos pos växt pos
26 neg pos pos pos växt pos
27 pos pos pos pos växt pos
Cut off 0,150 Cut off 0,08
neg
neg
neg
neg
neg
neg
neg
neg
neg
neg
neg
neg
neg
1,192
0,083
3,014 3,035
0,496 3,347
0,246 0,315
0,989 3,176
2,849 3,052
0,746 0,005
2,291 3,062
0,280 0,014
1,758 2,991
2,780 3,083
0,331 3,013
2,851 3,328
3,135
2,615 3,081
0,138
0,461 0,106
Jämförelse av fem olika metoder för påvisande av toxinproducerande C. difficile
Emeli Månsson, Infektionskliniken Västerås, Magnus Thore Mikrobiologen Västerås och Smittskyddsinstitutet
BakgrundVid mikrobiologiska laboratoriet i Västerås analyseras fecesprov med frågeställning Clostridium difficile med ELISA toxintest samt odling på CCFA. Vid akuta frågeställningar främst helgtid finns snabbtest tillgängligt.
Behandlande läkare upplever att det ibland krävs många fecesprov innan toxinproducerande Clostridium difficile kan påvisas. Det finns även ett önskemål om ett snabbtest med högre diagnostisk träffsäkerhet.
Syftet med denna undersökning var att som ett pilotprojekt jämföra befintlig metodik med en ny kommersiell PCR-metod för påvisande av toxingener och en ELISA test för påvisning av Clostridium difficile antigen.
Resultat och diskussionRealtids-PCR är en enkel och snabb metod som förefaller ha mycket god sensitivitet och specificitet (100% överensstämmelse med odling och toxintest). GDH-ELISA förefaller också ha hög sensitivitet, dock var två fecesprovnegativa i GDH-ELISA där växt påvisades på CCFA. Snabbtestet förefaller ha god specificitet men något sämre sensitivitet (samtliga fecesprov som utföll positiva i snabbtest (n=8) var även positiva i PCR och GDH-ELISA, däremot var 2/19 negativa prov senare positiva i realtids-PCR, toxin-ELISA, GDH-ELISA och odling).
SlutsatsRealtids-PCR (GeneXpert) är i denna pilotstudie tillförlitlig med resultat talande för mycket god sensitivitet och specificitet och är därmed ett alternativ vid akuta frågeställningar. Med nuvarande analysregim där Clostridium difficile inkluderas i allmän fecesodling tillför inte GDH ELISA (C. DIFF CHEK -60) något mervärde men kan teoretiskt övervägas som steg före odling. Toxin-ELISA förefaller ha specificitetsproblem som dock kan minimeras med kompletterande tester inom vissa OD-intervall. Snabbtest (ImmunoCard) har god specificitet men sämre sensitivitet.
Korrespondens: magnus.thore@smi.se
Tabell 1: 27 fecesprov analyserade med snabbtest, realtids-PCR, toxin-ELISA, GDH-ELISA och odling med efterföljande toxin-ELISA
RESULTS • The proportion of undiagnosed HIV was higher
among all women with CIN2+ than among those without CIN2+ (0.06% (95% CI 0.04-0.08) vs. 0.04% (95% CI 0.04-0.04); p = 0.017)).
• Among migrant women proportion of undiagnosed HIV was higher among those with CIN2+ than among those without (0.30% (95% CI 0.20-0.43) vs. 0.08 % (95% CI 0.07-0.10); p < 0.001) and exceeded 0.1%, suggested cost-effective for HIV-testing.
• Women with undiagnosed HIV at time of CIN2+ had a significantly lower nadir CD4+T-cell count, compared to women without CIN2+ before HIV-diagnosis.
OBJECTIVES • To analyze if the prevalence of undiagnosed HIV
among; 1) all women in Sweden, 2) migrant women in Sweden, diagnosed with CIN2+, reaches >0.1%, which has been suggested cost-effective for HIV-
testing.
METHODS • All women, born between 1940 and 1990, living in
the Counties of Stockholm and Gothenburg, Sweden, with at least one cervical cytology or histology registered in the Swedish National Cervical Screening Register (NKCx) were included.
• Data was collected from the NKCx and the Swedish National HIV register.
• The proportion of women with undiagnosed HIV among women with CIN2+ compared to women with a normal/mildly abnormal cytology/histology was assessed.
CONCLUSIONS • HIV-testing should be performed in migrant women in Europe with
unknown HIV status diagnosed with cervical intraepithelial neoplasia grade 2 or worse (CIN2+).
• HIV-testing all migrant women in Europe at time of cervical screening/gynaecologic check-up irrespective of cervical cytology results may be justified.
• HIV-testing all women in Europe diagnosed with CIN2+ may be considered. • Updated calculations of cost-effectiveness of HIV-screening in low endemic settings,
such as Europe, are needed.
Christina.Carlander@ki.se
Assessing cervical intraepithelial neoplasia as an indicator disease for HIV in a low endemic setting:
a population-based register study Christina Carlander1,2, Gaetano Marrone1, Johanna Brännström1,3, Aylin Yilmaz4, Kristina Elfgren5, Pär Sparén6, Anders Sönnerborg1, 7
1 Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden, 2 Centre for Clinical Research, Västmanland County hospital, Västerås, Sweden, 3Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden, 4Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 5 CLINTEC, Department of Obstetrics and Gynaecology, Karolinska University Hospital Huddinge, Stockholm, Sweden, 6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, 7Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
CROI 2018 657
SUPPRESSIVE ART ASSOCIATED WITH EFFECTIVE TREATMENT OF CERVICAL PRECANCER
CONCLUSIONS
• Suppressive ART and CD4 counts ≥500 are both associated with an effective treatment of CIN2+ among women living with HIV.
• An early HIV diagnosis, immediate ART and continuum of care are all essential to reach successful CIN2+ treatment.
BACKGROUND It is uncertain what effect suppressive antiretroviral therapy (HIV-RNA<50 copies/mL) has on the results of treatment of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) among women living with HIV (WLWH). AIM: To assess predictors of effective treatment of CIN2+ among women living with and without HIV DESIGN: Population-based cohort study with follow-up between 1983 and 2015. METHODS • Registry linking of the Swedish National HIV
Registry, the Swedish Population Registry and the Swedish National Cervical Screening Registry.
• All women in Stockholm and Gothenburg counties (Sweden) living with HIV and diagnosed with CIN2+ sometime between 1983 and 2014 were identified (n=179).
• For each WLWH, two HIV-negative women resident in the same counties and matched for country of birth, diagnosed with CIN2+, were chosen as controls.
• Treatment failure was defined as the presence of
1) ASCUS+ or 2) CIN2+, at initial follow-up.
• Recurrence was defined as the presence of CIN1+ subsequent to an initial normal follow-up.
Christina Carlander (1,2), Philippe Wagner (2), Astrid van Beirs (3), Aylin Yilmaz (4), Kristina Elfgren (5), Joakim Dillner (6), Anders Sönnerborg (1,6) Pär Sparén (7)
christina.carlander@ki.se
1 Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, St1) Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden. 2) Centre for Clinical Research,Västmanland County Hospital, Västerås, Sweden. 3) Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden. 4) Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 5) CLINTEC, Department of Obstetrics and Gynaecology, Karolinska University Hospital Huddinge, Stockholm, Sweden. 6) Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden. 7) Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
All women living with HIV, born between 1942 and
1989, living in the counties of Stockholm and
Gothenburg sometime between 1983 and 2014
(n=1926)
No CIN2+ diagnosis
1983-2014 (n=1747)
Diagnosed with CIN2+ 1983-2014 (n=179)
No follow-up within one year of CIN2+
treatment (n=36)) At least one follow-up within one year of CIN2+ treatment (n=140)
Treated with hysterectomy (n=3)
Abnormal cytology/histology at first follow up (n=63)
ASCUS (n=7) CIN1 (n=26) CIN2 (n=16) CIN3 (n=14)
Normal cytology/histology at first follow-up (n=77)
No recurrence (n=64)
Recurrence (n=13) CIN1 (n=8) CIN2 (n=3) CIN3 (n=2)
Selection of study population living with HIV
RESULTS • WLWH were three times more likely to have
treatment failure (odds ratio (OR) for ASCUS+: 3.3 [95% CI 2.1-5.2] OR for CIN2+: 3.7 [95% CI 2.0-6.8]) than HIV-negative women.
• WLWH were five times more likely to recur (hazard ratio 5.0 [95% CI 2.1-11.6] than HIV-negative women.
• Suppressive ART was associated with reduced odds of treatment failure (OR for ASCUS+: 0.4 [95% CI 0.2-0.8] OR for CIN2+: 0.3 [95% CI 0.1-0.8]).
• Immunosuppression (CD4 count <200 cells/µL) associated strongly with treatment failure (compared to CD4 count ≥500: OR for ASCUS+: 8.9 [95% CI 2.9-27.7], OR for CIN2+: 8.5 [95%CI 2.3-30.7]).
High incidence of high-grade cervical neoplasia among
HIV-infected immigrants: a population based cohort study
Christina Carlander (1), Anders Sönnerborg (2), Anders Berglund (3), Katarina Westling (2), Kristina Elfgren (4), Veronica S-Johansson (2), Pär Sparén (5)
1. Center for Clinical Research, Västmanland County Hospital, 2. Department of Medicine, Karolinska Insitutet (KI), 3.Center for Clinical Research,
Uppsala University, 4. Department of Obstetrics and Gynecology, KI. 5. Department of Medical Epidemiology and Biostatistiscs, KI, Sweden
Conclusion
Our results confirm the high incidence of CIN 2+ among HIV-infected women,
increasing with immunosuppression.
In our study, HIV-infected immigrants had a higher incidence of CIN 2+ than
HIV-infected born in Sweden.
Early HIV-diagnosis and attendance to cervical screening, with special focus
on immigrants, is of crucial importance to minimize the incidence of CIN 2+.
Objectives
To assess the incidence of high-
grade cervical intraepithelial
neoplasia and invasive cervical
cancer (CIN 2+), in HIV-infected
women compared to HIV-negative
women.
Methods
A cohort of 1154 HIV-infected
women from the Swedish national
HIV register InfCare HIV and 263
262 HIV-negative controls were
frequency matched on region of
birth and age.
Data was collected between 1993
and 2011 by linking the cohort with
the Swedish National Cervical
Screening Register (NSCR),
collecting all cytological and
histological results.
Results
The cumulative incidence (CuI)
of CIN 2+ after 15 years of
follow up was 15 % for HIV-
infected and 2% for HIV-
negative.
After 10 years of follow-up HIV-
infected women born in Eastern
Europe and Asia, Subsaharan
Africa and Sweden had a CuI of
20 %, 11% and 7% respectively
E-mail: christina.carlander@ltv.se
mediabyran.kib.ki.se
PCR with electrospray ionization-mass spectrometry on bronchoalveolar lavage for detection of invasive mold infections
in hematological patients
Kontakt
Namn Anders Krifors anders.krifors@regionvastmanland.se
Anders Krifors, specialistläkare Infektionskliniken, Doktorand Karolinska Institutet
Conclusion
The PCR/ESI-MS results had a clinical impact on antifungal therapy in 12 (44%) of the patients: modification
of treatment in 6 (22%) patients and discontinuation in 6 (22%) patients. This study provides proof of
concept that routine use of a broad-spectrum PCR for molds in bronchoalveolar lavage in
immunocompromised patients is sensitive, fast, and has an impact on clinical decision-making.
Background
Invasive mold infections are life-threatening
complications in patients with hematological
malignancies, and adequate early treatment has
been shown to be essential for a successful
outcome. Identification of non-aspergillus molds,
especially molds from the order Mucorales causing
mucormycosis, is of particular concern because of
their intrinsic resistance to antifungal agents and
the often aggressive course of the infections.
Conventional microbiological methods for
diagnosing invasive pulmonary mold infections
have low sensitivity, and molecular methods are
being developed. Detection of molds using PCR
with a narrow spectrum has been reported, but
data with broad-spectrum PCR are lacking.
Method
Between February 2016 and May 2017, PCR/ESI-
MS was available as a routine diagnostic method at
Karolinska University Hospital, as one of only two
hospitals worldwide. In this study, the diagnostic
performance and utility of a broad-spectrum PCR
(broad-spectrum PCR with subsequent electrospray
ionization-mass spectrometry, PCR/ESI-MS) for
detection of molds in bronchoalveolar lavage (BAL)
in 27 hematological patients with a new pulmonary
infiltrate was analyzed.
Results
Using the revised EORTC/MSG criteria, PCR/ESI-
MS was the only positive microbiological test in
patients with proven invasive mold infection (n = 2)
and correctly identified all cases of probable
invasive pulmonary aspergillosis (n = 5). In patients
with a possible invasive mold infection (n = 5),
PCR/ESI-MS was positive in three patients.
Mucorales was identified with PCR/ESI-MS in four
patients that were all culture negative.
The PCR/ESI-MS results had a clinical impact on
antifungal therapy in 12 (44%) of the patients:
modification of treatment in 6 (22%) patients and
discontinuation in 6 (22%) patients.
Rätt val av trumhinnerör minskar komplikationsrisken
Kontaktuppgifter
Johan Knutsson, docent, överläkare, ÖNH-kliniken
johan.knutsson@regionvastmanland.se
Johan Knutsson, MD, PhD*; Claudia Priwin MD, PhD; Anne-Charlotte Hessén-Söderman MD, PhD;
Andreas Rosenblad, PhD; Magnus von Unge, MD, PhD*
*Öron-näsa-halskliniken, Västmanlands sjukhus och Centrum för Klinisk Forskning,
Region Västmanland – Uppsala Universitet
SlutsatsTrumhinnerör av silikon ger betydligt lägre risk för infektionsproblem jämfört med rör av Fluoroplast. Silikonrör av
Donaldsontyp resulterar i minst antal infektioner. Trumhinnerör av lång typ har betydligt mindre benägenhet att
stötas ut från trumhinnan än korta rör. Långa rör av Armstrong-typ sitter kvar längst av alla. Infektioner påverkar
inte risken att röret stöts ut för tidigt.
MetodVi inkluderade 400 barn i en randomiserad studie där
barnen lottades till att få en typ av rör insatt genom
ena trumhinnan och en annan typ av rör genom
andra trumhinnan. Fyra olika typer av rör användes i
studien.
Efter operationen gick barnen på kontroll hos
öronläkare var tredje månad, samt hade extra besök
vid behov, tills båda rören var utstötta och
trumhinnan läkt. Vid besöken noterade öronläkaren
om röret var kvar, om det fanns tecken till rörinfektion
samt om trumhinnan läkt när röret stötts ut.
ResultatBarnens medelålder vid operationstillfället var 35,3
månader. Det var vanligare att pojkar opererades
med trumhinnerör; 63,8 procent av studiedeltagarna
var pojkar.
• Rörinfektioner drabbade 13,8% av patienterna.
• Silikonrör resulterade i avsevärt längre tid till
första infektion.
• Det var nästan dubbelt så vanligt att ett
Fluoroplaströr drabbades av rörinfektion.
• Donaldsonrören hade den längsta tiden till första
infektionen.
• Infektioner ökade inte risken för rören att stötas ut.
• Korta rör lossnade tidigare än långa rör.
• Långa Armstrongrör satt längst.
BakgrundAtt operera in rör genom trumhinnorna är en av de
allra vanligaste operationerna som görs på barn.
Operationen görs dels om ett barn drabbas av
många akuta öroninflammationer och dels om det
samlats vätska i örat som nedsätter hörseln.
Det finns en uppsjö av olika typer av rör. Trots detta
finns det väldigt lite kunskap kring eventuella
skillnader avseende komplikationsfrekvens. Den
vanligaste komplikationen är rörinfektion vilket brukar
antibiotikabehandlas. En annan vanlig komplikation
är att röret stöts ur för tidigt vilket kan kräva att en ny
röroperation behöver göras.
SyfteStudiens syfte var att jämföra fyra olika typer av rör
avseende komplikationsfrekvens.
De fyra rörtyperna som användes i studien.
Shepard (kort, Fluoroplastic), Donaldson (kort, silikon)
Armstrong (långt, silikon), Straight tube (långt, Fluoroplastic)
Infektionsfokus och etiologi vid neutropen feber i Västmanland
Torbjörn Larsson torbjorn.c.larsson@regionvastmanland.se
Torbjörn Larsson, Infektionskliniken Västmanlands sjukhus Västerås
Handledare: Göran Åkerblom, Christina Carlander, Tomas Vikerfors
SlutsatsBland patienter med neutropen feber (NF) i Region Västmanland var lungan mest frekvent förekommande
infektionsfokus i de fall detta kunde fastställas. Andelen positiva blododlingar var hög,
kinolonresistensen relativt låg och förekomsten av ESBL-producerande E. coli förhållandevis hög jämfört
med tidigare studier. Ciprofloxacinprofylax har till synes ännu en plats i vården vid NF i Region
Västmanland men med ökande resistens kan läget snart förändras. Den kliniska presentationen vid debut
av NF lämnar viktig prognostisk information.
MetodRetrospektiv kohortstudie baserad på uppgifter från
patientjournaler, kliniskt kemiskt laboratorium och
kliniskt mikrobiologiskt laboratorium.
Studiepopulationen (n=113) inkluderade vuxna
patienter med läkemedelsorsakad neutropeni
(neutrofila <1,0 x 109/L) och samtidig feber på
Västmanlands sjukhus Västerås under perioden
1 jan 2011 till 31 dec 2012.
ResultatMajoriteten av patienterna hade hematologiska maligniteter (72 %). Infektionsfokus kunde fastställas i 2/3 av
fallen och vanligast var lungfokus (17%). Etiologin fastställdes i 45 % av fallen och via blododlingar i 34 % av
fallen. KNS och alfahemolyserande streptokocker var de vanligaste blododlingsfynden följt av E. coli, Klebsiella
och S. aureus. Två fynd av ciprofloxacinresistenta E. coli, varav en i blododling. Av nio E. coli i blodet var två
stammar ESBL-producerande. Av tre blododlingar med S. aureus var en meticillinresistent (MRSA). Mortaliteten
var högre bland de med positiva blododlingar (24%) än negativa blododlingar (11 %); p=0,04. Mortaliteten vid
gramnegativ sepsis var högre (35 %) än vid grampositiv sepsis (15 %); p=0,11. Mortaliteten var hög hos patienter
med organpåverkan (42 %) och låg hos patienter med feber utan andra infektionstecken (5 %).
BakgrundNeutropen feber (NF) är associerat med hög
mortalitet. Aktuella studier visar att andelen
gramnegativa bakteremier ökar hos patienter med
NF och likaså förekomsten av antibiotikaresistenta
bakterier, främst mot kinolonpreparat. Den
mikrobiologiska epidemiologin kring patienter med
NF i region Västmanland är inte tidigare studerad.
SyfteStudiens syfte var att kartlägga infektionsfokus,
etiologi och förekomsten av resistenta bakterier hos
patienter med NF.
Tabell 1. Studiepopulation och resultat.
* I sex fall växte två olika agens i blododlingar.
** Stenotrophomonas maltophilia, Proteus vulgaris, Listeria, Clostridium perfringens, Citrobacter
freundii, Enterobacter spp., Bacteroides fragilis, Leptotrichia buccalis, Pseudomonas aeruginosa,
obestämbar anaerob gramnegativ stav.
Samtliga Endast
feber
Feber och andra
infektionstecken
Sepsis (svår)
Antal 145 59 (41 %) 50 (34 %) 36 (25 %)
Ålder (medelvärde) 65 år (19–91) 66 år 65 år 65 år
Kvinnor 60 (53 %) - - -
Mortalitet 23 (16 %) 3 (5 %) 5 (10 %) 15 (42 %)
Antimikrobiell kemoprofylaxCiprofloxacin 48 (33 %) 16 (27 %) 22 (44 %) 10 (28 %)
PCP-profylax 23 (16 %) 10 (17 %) 8 (16 %) 5 (14 %)
Svampprofylax 83 (57 %) 27 (46 %) 30 (60 %) 26 (72 %)
Aciklovir 80 (55 %) 28 (47 %) 31 (62 %) 21 (58 %)
Bakomliggande sjukdomarHematologiska
maligniteter
104 (72 %) 38 (64 %) 38 (76 %) 28 (78 %)
Tumörsjukdomar 35 (24 %) 18 (31 %) 10 (20 %) 7 (19 %)
Icke-maligniteter 6 (4 %) 3 (5 %) 2 (4 %) 1 (3 %)
InfektionsfokusOkänt 55 (38 %) 32 (54 %) 11 (22 %) 12 (33 %)
Lungor 25 (17 %) 5 (8 %) 14 (28 %) 6 (17 %)
Blod utan annat fokus 18 (12 %) 6 (10 %) 6 (12 %) 6 (17 %)
Tarm/rektum 13 (9 %) 2 (3 %) 6 (12 %) 5 (14 %)
Urinvägar 11 (8 %) 3 (5 %) 6 (12 %) 2 (6 %)
Venös infart 11 (8 %) 1 (2 %) 6 (12 %) 4 11 %)
Svalg 7 (5 %) 7 (12 %) 0 0
Hud/mjukdelar 4 (3 %) 2 (3 %) 1 (2 %) 1 (3 %)
Tänder 1 (<1%) 1 (2 %) 0 0
Agens i blododlingarPositiva blododlingar 49* (34 %) 10 (17%) 23 (46%) 16 (44 %)
KNS 12 (8 %) 3 (5 %) 7 (14 %) 2 (6 %)
Alfa-streptokocker 11 (8 %) 3 (5 %) 5 (10 %) 3 (8 %)
E. coli 9 (6 %) 1 (2%) 5 (10 %) 3 (8 %)
Klebsiella spp. 5 (3 %) 1 (2 %) 1 (2 %) 3 (8 %)
S. aureus (1 MRSA) 3 (2 %) 0 2 (4 %) 1 (3 %)
Enterococcus faecium 3 (2 %) 0 1 (2 %) 2 (6 %)
Candida spp. 2 (1 %) 0 1 (2 %) 1 (3 %)
Övriga arter** 10 2 4 4
Empirisk antibiotikaMeropenem 123 (85 %) 53 (89%) 43 (86 %) 27 (75 %)
Piperacillin-tazobactam 18 (13 %) 6 (10 %) 5 (10 %) 7 (19 %)
Ciprofloxacin 2 (1 %) 0 2 (4 %) 0
Ingen behandling given 2 (1 %) 0 0 2 (6 %)
Erfarenheter från 5 års användande av Xpert MTB/RIF i Västmanland
Emeli Månsson emeli.mansson@regionvastmanland.se
Ingrid Selmeryd ingrid.selmeryd@regionvastmanland.se
•Ingrid Selmeryd, överläkare, Infektionsklinken Västmanlands sjukhus, Västerås
•Emeli Månsson, överläkare, Infektionskliniken Västmanlands sjukhus, Västerås
SlutsatsVi bedömer att vår region har haft stor nytta av tillgång till lokalt utförd PCR för detektion av M. tuberculosis. På 5
år har tiden till behandlingsstart förkortats med totalt 390 dygn, vilket har medfört kortare inneliggande
isoleringsvård än om vi väntat på svar från Karolinska sjukhuset, Solna (KS). Om prov- och provsvarslogistik
mellan vårdavdelning i Västerås och mikrobiologiska laboratoriet på KS förbättrades skulle dock värdet av lokal
PCR för detektion av M. tuberculosis inte vara lika stort.
Resultat
Under dessa 5 år analyserades 450 prov på
misstanke om tuberkulos med lokal PCR.
M. tuberculosis detekterades i prov från 29 patienter
(22 luftvägsprov, 2 ventrikelsköljvätska, 4
abscesspunktat, 1 empyem) (Tabell 1).
27/29 patienter bekräftades sedermera
odlingspositiva. De två odlingsnegativa patienterna
bedömdes kliniskt som otvetydig aktiv tuberkulos
(baserat på symtom, status och behandlingssvar). Av
de 29 patienterna med aktiv tuberkulos var 14
mikroskopinegativa. Prov från 6 av de 14
mikroskopinegativa patienterna var negativa i KS
PCR.
Baserat på resultat från lokal PCR kunde adekvat
behandling sättas in på dessa 29 patienter i medeltal
sex dagar tidigare (median 6, IQR 3-24) än om vi
inväntat svar från KS.
Tidsvinsten var mindre för patienter med
mikroskopipositiva luftvägsprov jämfört med icke eller
lågsmittsamma. Två patienter diagnosticerades med
misstänkt MDR-tuberkulos. Dessa patienter fick
adekvat MDR-regim 10 respektive 24 dagar tidigare
än om vi inväntat resultat från KS. Av samtliga prov
med svaret ”M. tuberculosis ej påvisad” utföll endast
ett positivt i KS PCR.
BakgrundVärdet av PCR för diagnostik av Mycobacterium
tuberculosis har ifrågasatts (1).
I Västmanland har vi sedan 2013 tillgång till lokal
PCR för detektion av M.tuberculosis samt
mutationer i rpoB-genen associerade med
rifampicinresistens (Xpert MTB/RIF, Cepheid, CA,
USA).
Analyskostnaden är 1295kr/prov. Analysen ersätter
inte ordinarie diagnostik med mikroskopi, PCR och
odling på KS.
MetodFör att utvärdera nyttan med lokal tillgång till M.
tuberculosis PCR genomfördes en retrospektiv
analys samt journalgenomgång av samtliga
analyserade prov under åren 2013-2017.
Tabell 1: Datum då svar togs emot från respektive analys och
antal dagar som patienten fick adekvat behandling innan första
svar från Karolinska sjukhuset.
Figur 1 - Tid räknat i dagar från svar på lokal PCR till första
positiva besked (mikroskopi, PCR eller odling) mottaget per telefon
eller skriftligt från Karolinska tuberkuloslaboratorium.
MaterialKS Mikroskopi*
Lokal PCR KS PCR* Odling*Vunnen behandlingstid i dagar
Kommentar
Sputum neg 130430 130508 130528 8
Bronksekret neg 130624 130710 neg 16Klinik som TB. Gott beh. svar
Bronksekret neg 130801 neg 130924 53
Sputum 140224 140220 140224 140320 4
Sputum 140521 140516 140528 140619 5 (10 för MDRbeh)
Sputum 140904 140903 140911 140915 1
Empyem neg 141205 141208 Neg 3Klinik som TB. Gott beh. svar
Sputum 150318 150312 150318 150320 6
Sputum 150430 150429 150504 160518 2
Sputum neg 150529 150611 150709 13
Sputum neg 150618 neg 150722 34
Abscesspunktat neg 151201 neg 151229 28
Sputum 160316 160311 160318 160401 5
Sputum neg 160430 Neg 160531 31
Sputum 160516 160509 160516 160531 7
Sputum 160629 160623 160630 160802 6
Abcscesspunktat 160629 160627 160707 160711 1 INHr
Abscesspunktat neg 160723 160727 160809 3
Abscesspunktat 160913 160907 160913 160922 4
Bronksekret 160927 160926 160927 161012 0Beh. insatt empiriskt efter bronkoskopi
Kräkning (VSK) 161230 161221 161230 170120 8
Sputum 170214 170213 170215 170222 1
Sputum Neg 170316 Ej tagits 170419 31
Sputum Neg 170405 170411 170505 6
VSK Neg 170427 Neg 170613 47
Sputum Neg 170503 Ej tagits 170612 40
Sputum 170628 170626 170628 170725 2
Bronksekret Neg 170818 Neg 170911 24 (MDR)
Sputum 171026 171025 171026 171103 1
*Första datum då svaret togs emot på infektionskliniken i Västerås antingen per telefon eller papper.
Staphylococcus aureus bacteremia in patients with cardiac implantable
electronic devices
Jonas Selmeryd (jonas.selmeryd@regionvastmanland.se)
Sara Pichtchoulin1; Ingrid Selmeryd2; Pär Hedberg1,3; Jonas Selmeryd1,3
1Department of Clinical Physiology , Västmanland County Hospital, Västerås, Sweden 2Department of Infectious Diseases , Västmanland County Hospital, Västerås, Sweden
3Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden
Conclusions• Subjects presenting with SAB and concomitant CIED became increasingly more common during the study period.• Subjects were older than observed in previous studies and severely comorbid. This was particularly evident among subjects dying during hospital care
and among discharged patients where the CIED was left in place.• The awareness of possible CIED infection was low and transesophageal echocardiography was rarely used which is a limitation of the present study.• The prevalence of diagnosed CIED endocarditis, as well as extraction frequency, was lower in our study compared with previous studies.• The relapse and mortality rates were, however, similar to previous studies, indicating that few cases of CIED endocarditis were missed.• The low relapse rate despite a low extraction frequency might suggest that an individual risk/benefit-analysis might be preferable to an “extraction for
all”-policy in these elderly and diseased patients.
MethodAll subjects with SAB and concomitant CIEDin Västmanland during 2010-2016 wereretrospectively reviewed. Pocket infectionswere excluded. Data on clinical course andoutcome (death or relapse in SAB within 90days of discharge) were collected.
ResultsWe identified 46 cases of SAB in patients withconcomitant CIED. Stratified by in-hospitaldeath and CIED extraction status, outcomedata, relationship between age andcomorbidity, and treatment duration areshown in Figure 1-3. The yearly frequency ofsubjects presenting with SAB andconcomitant CIED is shown in Figure 4.Comparison between our results and previousstudies on similar cohorts are shown in Table1. Characteristics of study population isshown in Supplementary Table 1.
BackgroundPrevious studies have reported a prevalenceof 34-45 % for Cardiac Implantable ElectronicDevice (CIED) associated infection amongpatients with S. aureus bacteremia (SAB).Due to poor outcome with conservativetreatment, diagnostic difficulties, and highprevalence of CIED infection with SAB, recentSwedish guidelines advocate CIED extractionin all subjects with SAB, if possible. The aimof this study was to investigate the clinicalcourse of SAB in patients with CIED.
Full study populationsSubset of subjects without clinical pocket infection
Author n Age Male sex MRSAPocket
infection Echocardiography TEECommunity acquisition Extraction
In-hospital death
All death during follow-up Relapse n
Duke based diagnosis of CIED endocarditis
Clinical diagnosis of CIED endocarditis
Chamis et.al.1 33 70 (median) 61% 55% 18% 85% 67% 48% 36% N.A. 36% 6% 27 33% N.A.Uslan et.al.2 62 72 (mean) 81% 39% 11% 77% 65% 13% N.A. 32% N.A. N.A. 55 27% N.A.Sohail et.al.3 131 73 (median) 77% 39% 0% 85% 64% 31% N.A. N.A. N.A. N.A. 131 34% N.A.Current study 46 80 (median) 63% 0% 0% 67% 11% 26% 11% 30% 41% 7% 46 N.A. 15%
In-hospital Death (n=14)
Discharged with CIED left (n=27)
Discharged with CIED extracted (n=5)
No events recorded (n=5)
Discharged from hospital (n=32)
SAB in subjects with CIED without clinical pocket infection (n=46)
No events recorded (n=19)
Death not obviously attributable to SAB (n=5)
SAB relapse (n=3)
Successfully managed SAB relapse (n=2)
Fatal SAB relapse (n=1)
Figure 1 Outcome stratified by in-hospital death and CIED extraction status Figure 2 Age and Charlson comorbidity index stratified by in-hospital death and CIED
extraction status. Boxplots with median, interquartile range, 5th percentile, and 95th
percentile indicated. Differences between groups were tested with Wilcoxon two-
sample test.
Table 1 Descriptives and outcomes in similar studies on cohorts with SAB and concomitant CIED MRSA – Methicillin resistant Staphylococcus aureus; TEE – Transesophageal echocardiography. References: 1Circulation 2001;104, 2Pacing Clin
Electrophysiol 2010;33, and 3Circ Arrhythm Electrophysiol American Heart Association, Inc.; 2015;8
Figure 3 Treatment duration in study subjects grouped by in-hospital death and CIED
extraction status. Filled staples indicate treatment duration with intravenous antibiotics
and striped boxes follow up treatment with per oral antibiotics. Time of death and
relapse of SAB within 90 days of discharge are indicated where applicable.
Figure 4 Yearly frequency of study subjects with SAB and concomitant CIED in
Västmanland.
Risk factors for severe malaria in travellers and migrants
Andreas Wångdahl andreas.wangdahl@regionvastmanland.se
Andreas Wångdahl1,2, Katja Wyss2,3, Dashti Saduddin2, Matteo Bottai4, Elsie Ydring5, Tomas Vikerfors1, Anna Färnert2,3
1. Department of Infectious Diseases, Västerås Hospital; Västerås, Sweden
2. Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet; Stockholm, Sweden
3. Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
4. Unit of Biostatistics, Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
5. Public Health Agency of Sweden, Solna, Sweden
ConclusionSevere malaria was observed in both P. falciparum and non-falciparum episodes. Several risk factors were
described, where young and older age as well as health care delay showed the strongest association to severe
malaria. Furthermore, P. falciparum episodes with parasitemia >2% started on oral treatment showed an
increased risk of developing severe malaria. Current WHO criteria for severe malaria need to be optimized to
better guide the management of malaria in travellers and migrants.
In non-falciparum, age >60y, health care delay and
endemic origin were identified as risk factors for
severe disease.
In P. falciparum episodes with parasitemia ≥2%
without severe signs at presentation, oral treatment
was associated with progress to severe malaria (OR
8.7 [95% CI 1.9-39.3]; P=0.005).
Risk factors associated with severe P. falciparum
malaria are presented in Figure 1.
BackgroundMalaria is caused by Plasmodium falciparum, P.
vivax, P. ovale, P. malariae and P. knowlesi.
Severe malaria involves dysfunction in one or
several organs and can be caused by all species.
Prompt diagnosis and effective treatment are crucial
for the outcome. Risk factors for severe malaria
needs to be acknowledged to improve management
of imported malaria.
AimThe aim was to describe clinical aspects and
outcome of imported malaria and to assess factors
that affect disease severity in different parasite
species.
MethodRetrospective review of medical records including
2793/3260 (85.7%) of all malaria episodes in
Sweden notified to the National Surveillance
Database between 1 January 1995 and 31
December 2015. Demographic, epidemiological and
clinical data were collected and analyzed using
multivariable logistic regression.
ResultsSevere malaria according to WHO 2015 criteria was
found in P. falciparum (9.4%), P. vivax (7.7%), P.
ovale (5.3%), P. malariae (3.3%) and mixed P.
falciparum episodes (21.1%).
Figure 3. P. falciparum parasitemia in episodes deteriorating to
severe malaria after initiation of oral treatment.
Figure 2. Adjusted odds ratio for severe P. falciparum malaria in
travellers and migrants in Sweden.
Figure 1. Causative species of severe malaria in travellers and
migrants .
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