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The genes coding for 4 aminoglycoside-modifying enzymes AAC(6′)-APH(2″), APH(3′), ANT(4′) and ANT(6) were determined in 44 Slovak clinical isolates of Enterococcus faecalis with high-level resistance to gentamicin (HLGR, collection 1) and 48 E. faecalis isolates with resistance to amikacin (AR, collection 2). The occurrence of spotted genes was (collection 1 vs. collection 2): aac(6′)-aph(2″) 81.8 vs. 8.3 %, ant(4′) 52.3 vs. 81.3 %, aph(3′) 50 vs. 56.3 % and ant(6) 6.8 vs. 4.2 %, the most frequent combinations of genes in the HLGR collection were aac(6′)-aph(2″)+ant(4′) and aac(6′)-aph(2″)+aph(3′). In contrast, the aph(3′)+ant(4′) gene profile was predominant in AR isolates. None of the isolates contained all four AGME genes simultaneously. [ABSTRACT FROM AUTHOR]

Susceptibility of 75 clinical isolates of Enterobacteriaceae to 15 aminoglycosides, beta-lactams and fluoroquinolones was studied. The isolates originated from 3 wards (Pathological neonates, Surgical ICU, and Pediatric cardiology) of the Children's University Hospital in Bratislava, Slovakia. The isolates were collected from patients in April and November 1999 and June 2001. All isolates were resistant to gentamicin, tobramycin, and ampicillin. The majority of isolates were resistant to netilmicin, amikacin, cephalosporins, and azthreonam, but they were susceptible to meropenem and fluoroquinolones. The prevailing number of isolates produced 2 to 4 aminoglycoside-modifying enzymes. All isolates produced beta-lactamases and 80% produced extended-spectrum beta-lactamases (ESBL). Plasmid analysis revealed in the majority of isolates, originating from all 3 wards, a 116 kb plasmid throughout the entire period of study. Restriction analysis suggested a dissemination and persistence of a single nosocomial plasmid at all 3 units of the large pediatric hospital in Bratislava. [ABSTRACT FROM AUTHOR]

This study prospectively investigated all 157 cases of Acinetobacter baumannii bacteremia occurring in major university hospitals or tertiary care institutions in Slovakia during 1999 in order to determine the antimicrobial susceptibility, risk factors and outcome. Resistance to meropenem was 7.4, gentamicin 35.6, amikacin 26.5, cefepime 20.4 and ciprofloxacin 32.7%, but was only 17.3% to cefoperazone/sulbactam or ampicillin/sulbactam. Antimicrobial susceptibility of A. baumanii was lowest among isolates from cancer patients (ceftazidime 58%, piperacillin/tazobactam 52% and azthreonam 48%; p ≤ 0.01-0.001). In univariate analysis, several risk factors, such as wound infection (p ≤ 0.01) and ventilatory support (p ≤ 0.0001), were significantly related to A. baumannii bacteremia in surgical patients. Neutropenia (p ≤ 0.0001), antineoplastic chemotherapy (p ≤ 0.0001) and prior antibiotic therapy (p ≤ 0.0006) were significant risk factors for A. baumannii bacteremia in cancer patients. In addition, ventilatory support and surgery (p ≤ 0.0001) and prior antibiotic therapy (p ≤ 0.01) were significantly related to A. baumannii bacteremia in children. Colonization at other body sites (p ≤ 0.05), diabetes mellitus (p ≤ 0.04) and decubital ulcers/burns (p ≤ 0.002) as underlying disease were significantly related to death due to A. baumannii bacteremia. In a multiple logistic regression model, decubital ulcers/burns as underlying disease (p ≤ 0.0006; relative risk 5.08) and nosocomial pneumonia (p ≤ 0.045; relative risk 5.08) were independent predictors of mortality. Mortality was similar between cancer and surgical patients but significantly lower in children vs. adults (p ≤ 0.009). [ABSTRACT FROM AUTHOR]

Occurrence and transferability of β-lactam resistance in 30 multi-resistant Escherichia coli, Klebsiella spp., Enterobacter spp., Pantoea agglomerans, Citrobacter freundii and Serratia marcescens strains isolated from children between 0 and 3 years of age is presented. The strains were resistant to ampicillin (30), cefoxitin (22), cefotaxime (30), ceftriaxone (30), ceftazidime (30) and aztreonam (28), but susceptible to cefepime (30) and imipenem (26). Twenty-eight of 30 isolates possessed a transferable resistance confirmed by conjugation and isolation of 79–89-kb plasmids. The β-lactam resistance was due to production of β-lactamases and ceftazidime proved to be stronger β-lactamase inductor than ceftriaxone. Twenty-five clinical isolates expressed transferable extended spectrum β-lactamases, and chromosomally encoded AmpC β-lactamase. [ABSTRACT FROM AUTHOR]

Introduction: Melanized or dematiaceous fungi are associated with a wide variety of infectious syndromes. Cladophialophora bantiana is one of the most common and dangerous neurotropic fungi, able to cause brain abscess and disseminated infection., Case Presentation: We report a new case of phaeohyphomycosis brain abscesses caused by C. bantiana in Slovakia. The patient was a 63-year-old man having undergone heart transplantation, with dyspnoea, left-sided bronchopneumonia and fevers. CT (computed tomography) and MRI (magnetic resonance imaging) of the brain revealed numerous abscesses. Bacterial infection was proven by neither the growth of bacteria in culture nor the presence of bacterial antigens. Direct microscopy of the pus from the brain abscess showed Gram-positive hyphae. The isolate was finally identified as C. bantiana based on morphological and physiological features, and on DNA sequence analysis., Conclusion: In spite of appropriate therapy, neurological complications and accelerated respiratory insufficiency resulted in the patient's death. Concerning clinical manifestation of the brain phaeohyphomycosis that can sometimes be a problem to distinguish from malignancy, physicians should also assume infection caused by this serious pathogen.

A case report of ventriculoperitoneal shunt infection caused by Candida lusitaniae in a 6-year-old patient with cerebral astrocytoma and obstructive hydrocephalus is presented briefly with emphasis on the course of antifungal treatment. Seven isolates recovered subsequently from the cerebrospinal fluid were studied retrospectively. To confirm identity, isolates were typed using pulsed-field gel electrophoresis and melting curve of random amplified polymorphic DNA (McRAPD). Further, the ability to form biofilm and its susceptibility to systemic antifungals were evaluated. Using McRAPD, identity of C. lusitaniae isolates showing slight microevolutionary changes in karyotypes was undoubtedly confirmed; successful application of numerical interpretation of McRAPD for typing is demonstrated here for the first time. The strain was also recognized as a strong biofilm producer. Moreover, minimum biofilm inhibitory concentrations were very high, in contrast to low antifungal minimum inhibitory concentrations of isolates. It can be concluded that McRAPD seems to be a simple and reliable method not only for identification but also for typing of yeasts. A ventriculoperitoneal shunt colonized by C. lusitaniae was revealed as the source of this nosocomial infection, and the ability of the strain to form biofilm on its surface likely caused treatment failure.

Risk factors, mortality and antimicrobial susceptibility of Pseudomonas aeruginosa bacteremias isolated from 148 patients from all University Hospitals in Slovakia were analyzed. Only 1.2% of 169 strains of P. aeruginosa were resistant to meropenem, 4.1% to piperacillin/tazobactam, 7.7% to ceftazidime as well as cefepime and 12% to amikacin. More than 30% of P. aeruginosa were resistant to ciprofloxacin. Our analysis of risk factors for antimicrobial resistance to the particular antimicrobials, indicated no difference in risk factors and outcome in cases infected with P. aeruginosa bacteremias resistant to amikacin, piperacillin/tazobactam or ceftazidime in comparison to episodes caused by P. aeruginosa due to susceptible isolates. When comparing risk factors for P. aeruginosa bacteremia in children vs. adults, cancer vs. non-cancer patients, several differences in risk factors were observed. Neither antimicrobial resistance to amikacin, ceftazidime or piperacillin/tazobactam, nor appropriateness of therapy according to two separate analyses were associated with better outcome.

Objective: A multicenter study was conducted to obtain "in vitro" chloramphenicol and colistin susceptibility data on multiresistant hospital bacterial pathogens in Slovak Republic., Material and Methods: During the period of April-June 2001, 628 clinical bacterial multiresistant isolates from patients with serious infections were selected in 10 hospitals and tested to a large scale of antibiotics by means of a microdilution method. The strains expressed either a significant resistance phenotype (ESBL, MRSA, CoNMRS, MLSB/c, efflux in Ps. aeruginosa), or were resistant to one or more preparations in at least half of reliable unrelated antibiotic groups (beta-lactams, aminoglycosides, quinolons, macrolides)., Results: Both chloramphenicol and colistin retained significant "in vitro" activity against many multiresistant hospital bacterial pathogens. The highest activity of chloramphenicol was documented for isolates of Stenotrophomonas maltophilia (76,5 % susceptible, MIC50 = 4 mg/L, MIC90 = 16 mg/L) and of Staphylococcus aureus (76,2 % susceptible, MIC50 = 8 mg/L, MIC90 = 16 mg/L). In tested Pseudomonas aeruginosa (82,5 % susceptible, MIC50 = 2 mg/L, MIC90 = 16 mg/L) and Stenotrophomonas maltophilia (88,2 % susceptible, MIC50 = 1 mg/L, MIC90 = 8 mg/L) isolates colistin represented the most "in vitro" effective antibiotic. Colistin was the only "in vitro" effective antimicrobial in four of 120 multiresistant Pseudomonas aeruginosa isolates tested in our study., Conclusions: The study confirmed a good "in vitro" susceptibility of many multiresistant hospital bacterial pathogens to chloramphenicol and colistin in Slovak Republic. The clinical application of chloramphenicol and colistin might be reconsidered in infections caused by extremely resistant bacteria with prooved susceptibility to these antibiotics. It is important to consider, that the infection danger has to exceed the risk of antibiotic toxicity.

A total of 201 cases of fungaemia in children in a 12-year national survey from seven University Paediatric Clinics in Slovakia in 1990-2001 was assessed to determine risk factors, therapy and outcome, and to compare those cases with fungaemia in 130 adult cancer patients studied in a similar survey. Four univariate analyses were performed to assess differences in aetiology, antifungal susceptibility and outcome between fungaemia in neonates and paediatric intensive care unit (ICU) patients as well as between paediatric and adult cancer patients with fungaemia. There was a significant difference in aetiology and antifungal susceptibility between the subgroups of children with fungaemia: 83.3% of neonates versus 40.2% in children with cancer were due to Candida albicans. None of the non-albicans Candida spp. (NAC) in neonates but 23.5% of NAC isolates from children with cancer were resistant to fluconazole. C. albicans caused 144 (71.1%) episodes and NAC 48 (23.7%) episodes. Trichosporon beigelii, Blastoschizomyces (Trichosporon) capitatus, Rhodotorula rubra and Cryptococcus laurentii were found less frequently in neonates than in children with cancer (18.8%). There were not many differences in risk factors between paediatric fungaemia and adult cancer fungaemia except C. albicans aetiology, corticosteroid use in therapy, breakthrough fungaemia after ketoconazole prophylaxis and meningitis as a complication, which were observed significantly more frequently among children than in adults, both with cancer and fungaemia. Thirty-three of the paediatric fungaemias were breakthrough cases and appeared frequently in children with cancer. Fifty-one (25.1%) children died with fungaemia (attributable mortality) and 25 (12.7%) due to underlying disease with fungaemia; overall mortality was 37.8% and there was no significant difference in death rates between the subgroups of paediatric patients (neonates, children in ICUs and children with cancer).

Breakthrough fungaemias due to Candida albicans and Candida parapsilosis appearing during fluconazole therapy in neonates and infants were assessed for risk factors and outcome. Forty fungaemias occurred during therapy with fluconazole within a 12 year national survey and were compared with 161 cases of non-breakthrough paediatric fungaemias. The agar disc diffusion test method was used for antifungal susceptibility testing and the Vitek system for species identification. Univariate and multivariate analysis for risk factors for breakthrough fungaemia were carried out. All the fungaemias were a result of strains susceptible to fluconazole at 0.25-4 mg/L in vitro [C. albicans (85%) and C. parapsilosis (15%)]. The mean number of positive blood cultures per episode was 2.2. Sixteen children had 'early' breakthrough fungaemias (within 4-5 days) and 24 fungaemias appeared on day 6 and later. Mean fluconazole MICs in the 'early' group were 1.2, and 2.8 mg/L in the 'late' group (P < 0.03, t-test). However, no difference was observed in the average dose of fluconazole used in the two groups. Neonatal age, total parenteral nutrition, very low birth weight, before surgery, central or umbilical venous catheterization and artificial ventilation were all significantly related to breakthrough fungaemia in univariate analysis but only central or umbilical venous catheterization were significant in multivariate analysis. The outcome of breakthrough fungaemia was better overall and attributable mortalities in non-breakthrough fungaemia was significantly higher in comparison with breakthrough fungaemia.

The aim of this multicenter survey was to assess risk factors and mortality in patients with persistent fungemia (PF). Cases of persistent fungemia, defined as positive blood culture for at least 3 causative days of antifungal therapy were selected. Forty cases of persistent fungemia (lasting more than 3 days) were compared with 270 non-persistent fungemias appearing within the same period, and analyzed by univariate and multivariate analysis for risk factors and outcome. The median number of days of positive culture was 4.4 (3 - 20): 22 episodes were due to Candida albicans, 1 due to non-albicans Candida spp., 6 episodes due to non-Candida spp. Yeasts: 15 were catheter related, 16 patients had yeast-infected surgical wounds, 12 were neutropenic, 4 cases were caused by species resistant in vitro, 2 to amphotericin B (Trichosporon spp.) and 2 to fluconazole (C. laurentii, C. glabrata). Fifteen patients (37.5%) died, 7 of whom due to fungemia. Nineteen cases had one known risk factor (10 had infected wound, 4 infected vascular catheter, 3 were neutropenic and 2 had inappropriate therapy). Fourteen cases had two known risk factors (4 had wound and infected catheter, 4 neutropenia and infected catheter, 2 neutropenia and resistant organism, 4 other combinations. Two cases had 3 known risk factors and one had 4 risk factors for persistent fungemia. Artificial ventilation, C. glabrata etiology, non-Candida spp. yeasts such as Trichosporon spp. and Cryptococcus spp. and prior surgery were significantly associated with persistent fungemia in univariate, whereas only C. glabrata etiology in multivariate analysis. Breakthrough fungemia during empiric therapy with fluconazole was also observed more frequently in patients with persistent fungemia. However, there was no difference in both attributable and overall mortality between both groups.

Sixty-seven multiresistant nosocomial Acinetobacter baumannii isolates from patients hospitalized mostly in intensive care units of seven clinics in Slovak and Czech Republic were tested to determine their ability to transfer antibiotic resistance. All isolates were resistant to kanamycin, ticarcillin, cephalothin, cefotaxime, ceftazidime, aztreonam and susceptible to carbapenems, sulbactam and ampicillin/sulbactam. Sixty-five out of 67 strains transferred resistance determinants to Escherichia coli K-12 and Proteus mirabilis P-38 recipients. Analysis of selected transconjugants by an indirect selection method showed a more variable pattern of transferred resistance determinants. The clonal spread of strains transferring resistance seems to be an additional risk for occurrence of strains resistant to ceftazidime and aztreonam.

The objective of this study was to assess risk factors and the outcome of breakthrough fungaemias (BFs) occurring during fluconazole (FLU) therapy in non-cancer and non-HIV individuals. Thirty-three fungaemias occurring during therapy with FLU among a total of 310 fungaemias observed within a 10-y national survey were analysed. The agar disk diffusion method was used for antifungal susceptibility testing and the Vitek system for species identification. Univariate and multivariate analysis was performed to determine risk factors for BF. All BFs were due to species known to be susceptible to FLU: Candida albicans (25/33), C. parapsilosis (6/33) and C. guillermondii (2/33). The mean number of positive blood cultures per episode was 2.4. The MIC of Candida spp. to FLU was 0.5-8 mg/ml (all strains were susceptible in vitro). Neonatal age (< 4 weeks), very low birth weight, prior surgery, central venous catheter placement, artificial ventilation, total parenteral nutrition and C. parapsilosis were significantly related to BF in univariate analysis, but only central venous catheter placement was significantly related in multivariate analysis. However, the outcome of BFs and non-BFs was similar. All BFs occurred in non-HIV patients who were not previously treated with azoles, and were caused by in vitro FLU-susceptible species (C. albicans and C. tropicalis). Thus factors other than in vitro susceptibility play a role in BFs.

Three cases of Clavispora lusitaniae invasive fungal infections are reported. All three infections appeared in cancer patients presented with fungaemia, one additionally with meningitis. Two of them were breakthrough -- they developed during therapy with conventional amphotericin B with a dose of 0.5 mg kg(-1) day(-1) . All three were cured: two with intravenous fluconazol and one with an increasing dose (1 mg kg(-1) day(-1)) of amphotericin B. In one of two breakthrough cases the sensitivity of the strain to antifungals was tested against antifungal agents and showed in vitro resistance to amphotericin B (MIC 2 eta g ml(-1)).