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During the first wave of the COVID-19 pandemic, there was a shortage of SARS-CoV-2 diagnostic tests, and testing patients with mild symptoms (low-threshold testing) was not recommended in the Netherlands. Despite these guidelines, to protect those who were most at risk, low-threshold testing was advocated and offered to the majority of long-term care institutions in the Twente region. In this manner, 144 healthcare workers and 96 residents tested SARS-CoV-2-positive and were isolated before the same service was provided nationwide by public health services. Strikingly, excess mortality rate in the Twente region 1 month after the introduction of this strategy was found to be 62%–89% lower than that in neighboring regions, which may be explained by this divergent testing strategy. In an emerging pandemic, early implementation of a liberal testing policy may be more effective than restricted testing in settings with a high death rate.

Background For eHealth technologies in general and audit and feedback (AF) systems specifically, integrating interdisciplinary theoretical underpinnings is essential, as it increases the likelihood of achieving desired outcomes by ensuring a fit among eHealth technology, stakeholders, and their context. In addition, reporting on the development and implementation process of AF systems, including substantiations of choices, enables the identification of best practices and accumulation of knowledge across studies but is often not elaborated on in publications. Objective This scoping review aims to provide insights into the development and implementation strategies for AF systems for a real-world problem that threatens modern health care—antimicrobial resistance—and provide an interdisciplinary conceptual framework that can serve as a checklist and guidance for making informed choices in the development and implementation of future AF systems. Methods A scoping review was conducted by querying PubMed, Scopus, Web of Science, IEEE Xplore Digital Library, and Embase (≥2010) for studies describing either the development or implementation process, or both, of an AF system for antimicrobial resistance or infections in hospitals. Studies reporting only on effectiveness or impact were excluded. A total of 3 independent reviewers performed the study selection, and 2 reviewers constructed the conceptual framework through the axial and selective coding of often-used theories, models, and frameworks (TMFs) from the literature on AF and eHealth development and implementation. Subsequently, the conceptual framework was used for the systematic extraction and interpretation of the studies’ descriptions of AF systems and their development and implementation. Results The search resulted in 2125 studies that were screened for eligibility, of which 12 (0.56%); 2012-2020) were included. These studies described the development and implementation processes heterogeneously in terms of study aims, study targets, target groups, methods, and theoretical underpinnings. Few studies have explicitly explained how choices for the development and implementation of AF systems were substantiated by the TMFs. The conceptual framework provided insights into what is reported on the development and implementation process and revealed underreported AF system constructs (eg, AF system design; engagement with the AF system; and comparison, goal setting, and action planning) and development and implementation (eg, champions) constructs. Conclusions This scoping review showed the current heterogeneous reporting of AF systems and their development and implementation processes and exemplified how interdisciplinary TMFs can (and should) be balanced in a conceptual framework to capture relevant AF systems and development and implementation constructs. Thereby, it provides a concrete checklist and overall guidance that supports the professionalization and harmonization of AF system development and implementation. For the development and implementation of future AF systems and other eHealth technologies, researchers and health care workers should be supported in selecting and integrating TMFs into their development and implementation process and encouraged to explicitly report on theoretical underpinnings and the substantiation of choices.

BACKGROUND: Use of single-bed rooms for control of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is under debate; the added value when applying contact precautions has not been shown. We aimed to assess whether an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae.METHODS: We did a cluster-randomised, crossover, non-inferiority study on medical and surgical wards of 16 Dutch hospitals. During two consecutive study periods, either contact precautions in a single-bed room or contact precautions in a multiple-bed room were applied as the preferred isolation strategy for patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample (index patients). Eligible index patients were aged 18 years or older, had no strict indication for barrier precautions in a single-bed room, had a culture result reported within 7 days of culture and before discharge, and had no wardmate known to be colonised or infected with an ESBL-producing Enterobacteriaceae isolate of the same bacterial species with a similar antibiogram. Hospitals were randomly assigned in a 1:1 ratio by computer to one of two sequences of isolation strategies, stratified by university or non-university hospital. Allocation was masked for laboratory technicians who assessed the outcomes but not for patients, treating doctors, and infection-control practitioners enrolling index patients. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient's isolate in at least one wardmate. The primary analysis was done in the per-protocol population, which included patients who were adherent to the assigned room type. A 10% non-inferiority margin for the risk difference was used to assess non-inferiority. This study is registered with Nederlands Trialregister, NTR2799.FINDINGS: 16 hospitals were randomised, eight to each sequence of isolation strategies. All hospitals randomised to the sequence single-bed room then multiple-bed room and five of eight hospitals randomised to the sequence multiple-bed room then single-bed room completed both study periods and were analysed. From April 24, 2011, to Feb 27, 2014, 1652 index patients and 12 875 wardmates were assessed for eligibility. Of those, 693 index patients and 9527 wardmates were enrolled and 463 index patients and 7093 wardmates were included in the per-protocol population. Transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified for 11 (4%) of 275 index patients during the single-bed room strategy period and for 14 (7%) of 188 index patients during the multiple-bed room strategy period (crude risk difference 3·4%, 90% CI -0·3 to 7·1).INTERPRETATION: For patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample, an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. Non-inferiority of the multiple-bed room strategy might change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice.FUNDING: Netherlands Organisation for Health Research and Development.

Klebsiella pneumoniae is emerging as an important nosocomial pathogen due to its rapidly increasing multidrug resistance, which has led to a renewed interest in polymyxin antibiotics, such as colistin, as antibiotics of last resort. However, heteroresistance (i.e., the presence of a subpopulation of resistant bacteria in an otherwise susceptible culture) may hamper the effectiveness of colistin treatment in patients. In a previous study, we showed that colistin resistance among extended-spectrum-beta-lactamase (ESBL)-producing K. pneumoniae isolates emerged after the introduction of selective digestive tract decontamination (SDD) in an intensive care unit (ICU). In this study, we investigated heteroresistance to colistin among ESBL-producing K. pneumoniae isolates by using population analysis profiles (PAPs). We used whole-genome sequencing (WGS) to identify the mutations that were associated with the emergence of colistin resistance in these K. pneumoniae isolates. We found five heteroresistant subpopulations, with colistin MICs ranging from 8 to 64 mg/liter, which were derived from five clonally related, colistin-susceptible clinical isolates. WGS revealed the presence of mutations in the lpxM , mgrB , phoQ , and yciM genes in colistin-resistant K. pneumoniae isolates. In two strains, mgrB was inactivated by an IS 3 -like or IS Kpn14 insertion sequence element. Complementation in trans with the wild-type mgrB gene resulted in these strains reverting to colistin susceptibility. The MICs for colistin-susceptible strains increased 2- to 4-fold in the presence of the mutated phoQ , lpxM , and yciM alleles. In conclusion, the present study indicates that heteroresistant K. pneumoniae subpopulations may be selected for upon exposure to colistin. Mutations in mgrB and phoQ have previously been associated with colistin resistance, but we provide experimental evidence for roles of mutations in the yciM and lpxM genes in the emergence of colistin resistance in K. pneumoniae .

One unreported case of extended-spectrum-beta-lactamase (ESBL)-producing Salmonella enterica serovar Typhi was identified, whole-genome sequence typed, among other analyses, and compared to other available genomes of S . Typhi. The reported strain was similar to a previously published strain harboring bla SHV-12 from the Philippines and likely part of an undetected outbreak, the first of ESBL-producing S . Typhi.

Selective decontamination of the digestive tract (SDD) selectively eradicates aerobic Gram-negative bacteria (AGNB) by the enteral administration of oral nonabsorbable antimicrobial agents, i.e., colistin and tobramycin. We retrospectively investigated the impact of SDD, applied for 5 years as part of an infection control program for the control of an outbreak with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in an intensive care unit (ICU), on resistance among AGNB. Colistin MICs were determined on stored ESBL-producing K. pneumoniae isolates using the Etest. The occurrence of both tobramycin resistance among pathogens intrinsically resistant to colistin (CIR) and bacteremia caused by ESBL-producing K. pneumoniae and CIR were investigated. Of the 134 retested ESBL-producing K. pneumoniae isolates, 28 were isolated before SDD was started, and all had MICs of K. pneumoniae before SDD and 9 patients thereafter. No bacteremia caused by CIR was found before SDD, but its occurrence increased to 26 after the introduction of SDD. In conclusion, colistin resistance among ESBL-producing K. pneumoniae isolates emerged rapidly after SDD. In addition, both the occurrence and the proportion of tobramycin resistance among CIR increased under the use of SDD. SDD should not be applied in outbreak settings when resistant bacteria are prevalent.

In 271 Enterobacter blood culture isolates from 12 hospitals, extended-spectrum beta-lactamase (ESBL) prevalence varied between 0% and 30% per hospital. High prevalence was associated with dissemination, indicating the potential relevance of infection control measures. Screening with cefepime or Vitek 2, followed by a cefepime/cefepime-clavulanate Etest, was an accurate strategy for ESBL detection in Enterobacter isolates (positive predictive value, 100%; negative predictive value, 99%).

Tigecycline is often one of the few therapeutic options for infections by multidrug-resistant Gram-negative bacteria. Therefore, accurate MIC testing is critical. Since in many laboratories tigecycline is not included in the routine panel of antibiotics for susceptibility testing, tigecycline MICs are frequently determined by Etest. However, previous studies have shown that tigecycline MICs determined by Etest may be influenced by the brand of Mueller-Hinton (MH) agar, hypothetically due to variations in the concentration of manganese (2). Furthermore, for Acinetobacter species with MICs ≥ 2 mg/liter by Etest, the MIC was at least 2 doubling dilutions lower by broth microdilution (BMD) (1). The aim of this study was to evaluate the Etest as a method to determine tigecycline MICs for Enterobacter species. Tigecycline MICs were determined by BMD and Etest for 271 Enterobacter blood culture isolates (84% Enterobacter cloacae isolates and 16% Enterobacter aerogenes isolates) obtained in 2006 and 2007 from 12 laboratories in the Netherlands. BMD was performed using Becton Dickinson (BD) MH II medium for BMD (Merlin, Germany), according to International Organization for Standardization (ISO) guideline 20776-1 (3) (the reference method of the Clinical and Laboratory Standards Institute [CLSI]) and the European Committee on Antimicrobial Susceptibility Testing [EUCAST]). Etests (bioMerieux, France) were performed on agar with the same MH medium used in the BMD method and on Iso-Sensitest agar (Oxoid, United Kingdom). In each experiment, Escherichia coli ATCC 25922 was used as a control strain. FDA and EUCAST breakpoints were used (susceptible ≤ 2 mg/liter and ≤ 1 mg/liter, respectively). The manganese concentrations of the MH broth and both agars were determined using induction-coupled plasma atomic emission spectrometry (ICP-AES) after the medium was dissolved with 65% nitric acid. Compared to BMD, MICs determined by Etest were significantly higher using either MH agar or Iso-Sensitest agar (Fig. ​(Fig.11 and Table ​Table1).1). The correlation between the results of the BMD and Etest on MH agar was high (Spearman's nonparametric correlation coefficient, 0.9; P < 0.001), and the geometric mean difference ± standard deviation (SD) was 2.4 ± 0.4 doubling dilutions, pointing toward a systematic difference between the methods. In 84% of the isolates, tigecycline MICs were 2 or more doubling dilutions higher by Etest on MH agar compared to the values found by BMD. The MICs determined by Etest on MH agar were also significantly higher than by Etest on Iso-Sensitest agar. No correlation between the manganese concentration in the test medium and the tigecycline MIC was observed (Table ​(Table11). FIG. 1. Distribution of MICs of 271 Enterobacter isolates by BMD, Etest on BD Mueller-Hinton agar (MHA), and Etest on Iso-Sensitest agar. TABLE 1. Susceptibility results for 271 Enterobacter isolates using BMD, Etest on MHA (BD), and Etest on Iso-Sensitest agar The susceptibility rates were significantly higher by the BMD method than by Etest (Table ​(Table1).1). When FDA breakpoints were used, false nonsusceptibility was observed in 18% of the isolates when performing Etest on MH agar. When EUCAST breakpoints were used, 97% of isolates were susceptible by the BMD method, whereas only 30% were susceptible by Etest on MH agar, corresponding to false nonsusceptibility in 67% of the isolates. No false-susceptible Etest results were observed using either MH agar or Iso-Sensitest agar. The MICs of the E. coli control strain were within the specified range (0.03 mg/liter to 0.25 mg/liter) for the three methods, although the MICs were 0.0325 mg/liter using BMD and 0.25 mg/liter using Etest on MH agar. In conclusion, this study shows that tigecycline MICs for Enterobacter species determined by Etest are significantly higher than MICs determined by BMD. Differences in the manganese concentration of the test media could not explain the observed differences, and further research is required to resolve this issue. We conclude that nonsusceptible tigecycline Etest results should be confirmed using a BMD method. The misclassification of isolates as tigecycline nonsusceptible may deny patients an important antibiotic option.

A carbapenem-resistant Pseudomonas stutzeri strain isolated from a Dutch patient was analyzed in detail. This isolate produced a metallo-β-lactamase (MBL) whose gene, with 43.5% GC content, was cloned and expressed in Escherichia coli. β-Lactamase DIM-1 (for D utch im ipenemase) was weakly related to other Ambler class B β-lactamases, sharing

Sir, We thank Abecasis and colleagues for their comments on our paper on the detection of extended-spectrum b-lactamase (ESBL)-producing positive aerobic Gram-negative bacilli (ESBL-GNB) in patients on the intensive care unit (ICU) of our hospital, where selective decontamination of the digestive tract (SDD) is routinely used in mechanically ventilated patients. Their main comment is that the link that we suggest between SDD use and the detection of these strains is only circumstantial; they also argue that the occurrences of such isolates is related to their resistance to tobramycin, an antibiotic in the SDD regimen which could be replaced by neomycin or paromomycin. We agree that during treatment with SDD, ESBL-GNB isolates will only reach detectable numbers in cultures from patients if they have decreased susceptibility to tobramycin. We isolated four genetically different strains that carried identical plasmids, had identical resistance patterns, and carried identical ESBL genes. As we noted in our paper, the emergence of the four strains could be due to: (i) an increase in these strains from below to above detection level; (ii) acquisition of the strains carrying the resistance plasmid; or (iii) acquisition of the resistance plasmid by strains that belong to the normal flora of the patients. We do not state that the emergence of these strains would not have occurred if these patients had not received SDD; we only want to show that SDD does not prevent the emergence of such strains and possibly, like any other antimicrobial treatment including cephalosporins, even promotes their emergence. Possibility (i) is unlikely, as it implies that isolates with decreased cefotaxime and tobramycin susceptibility are frequently missed during screening in an SDD setting. Acquisition of strains with identical plasmids seems improbable because this presumes a widespread presence of plasmids with identical RFLP patterns in different isolates. RFLP analyses of plasmids isolated from two ESBL-positive and one ESBL-negative bacterial strains isolated during the same period in our ICU, showed different patterns. Since four independent events of acquisition of different strains with similar plasmids is unlikely, acquisition of the resistance plasmid by different strains seems the most likely explanation for our observation. The multidrug-resistant (MDR) strains described in our study were intermediately susceptible to polymyxin E. Of note, in our hospital, outside the ICU, polymyxin E is not usually used to treat infections caused by Escherichia coli or Klebsiella pneumoniae. Cefotaxime, the most common systemic antibiotic used in SDD regimens has been reported to be associated with the emergence of ESBL-producing strains and with an increase in ESBL prevalence. In our view, an important part of the problem is the colonization with strains carrying MDR plasmids, as every colonized patient forms a potential source which may facilitate further dissemination of ESBL genes. Although adjustment of the SDD regimen or isolation measures can eventually contain outbreaks, detection of ESBL plasmid-mediated outbreaks is more complex than that of clonal outbreaks. In all studies that evaluated emergence of resistance with SDD wherein cefotaxime is used, there was no optimal screening for ESBLs. Therefore, we suggest that for optimal evaluation of SDD regimens with respect to ESBL-producing strains and emergence of resistance, optimal screening techniques for detection of ESBLs is warranted. Obviously, optimal screening for ESBL production is also needed in ICUs where SDD is not used.

OBJECTIVES: During treatment with selective decontamination of the digestive tract (SDD), four multidrug-resistant (MDR) strains, three different Escherichia coli and one Klebsiella pneumoniae, were isolated from four patients not known as carriers of such MDR strains before their admission to the intensive care unit (ICU) in the Academic Medical Center (AMC) in Amsterdam. These isolates were extended-spectrum beta-lactamase (ESBL)-positive. We investigated whether this was due to interspecies transfer of resistance genes. METHODS: The MDR strains were typed by amplified fragment length polymorphism (AFLP) analysis. The plasmids from these strains were characterized by restriction fragment length polymorphism and the resistance genes were characterized by PCR and sequence analysis. RESULTS: The strains were genetically unrelated and contained identical plasmids with ESBL genes. CONCLUSIONS: We identified an outbreak of plasmid-mediated ESBL genes during SDD treatment in the ICU. The use of third-generation cephalosporins in SDD is associated with the emergence of ESBLs. We conclude that identification of emerging MDR Gram-negative bacteria and recognition of resistance plasmid transfer during SDD treatment are crucial for optimal application of this regimen in ICUs

SHV β-lactamases, encoded by blaSHV genes, confer resistance to a broad spectrum of β-lactam antimicrobial agents and are of significant therapeutic concern for infections caused by many species of gram-negative bacteria (4, 9, 11). At present, there are more than 50 varieties of SHV β-lactamases (7), the majority of which confer the extended-spectrum β-lactamase (ESBL) phenotype (10, 13, 14). Several molecular methods for the detection and differentiation of different SHV β-lactamases have been proposed, but nucleotide sequencing remains the standard for determination of the β-lactamase gene present in a strain (4). Although automated thermal cycling has improved sequence analysis of blaSHV genes (3), the quality of nucleotide sequencing data may vary, e.g., due to template quality. Usually, overall low-quality sequence data are easily identified and not used for further analysis, as are the low-quality starts and ends of sequence reads. However, quality values (e.g., Phred values [5]) are also assigned for individual positions by most sequence analysis software, but these are seldom reported. Minimal standards corresponding to a Phred value of 40 have been proposed for (human) whole-genome sequencing and for human clinical samples, but they are not uniformly applied to sequencing of bacterial targets. In this report we describe how careful interpretation and assessment of quality values prevented the misidentification of two different blaSHV alleles in single bacterial isolates. During a study on ESBL epidemiology (1), PCR products for β-lactamase genes of three ESBL-positive clinical strains of three different species, Escherichia coli, Pseudomonas aeruginosa, and Enterobacter cloacae, were amplified and sequenced with the Big Dye sequencing kit 1.1 (Applied Biosystems, Foster City, Calif.) as described previously (1). The sequence assembly of the individual sequence traces for each sample, generated with Codoncode Aligner 1.3.4 (CodonCode Corporation, Dedham, MA) using default parameters, yielded an SHV-2 gene for the E. coli and E. cloacae isolates and an SHV-5 gene for the P. aeruginosa isolate. Sequence assemblies of sequence traces of PCR products often show low-quality positions near the ends of the assembly. This was also the case in the present analyses. However, the present assemblies contained three additional low-quality positions (Fig. ​(Fig.1).1). Visual inspection of the individual trace files showed two overlapping signals at these three positions: A or T at position 92, A or G at position 402, and A or G at position 703 (Fig. ​(Fig.2A).2A). The polymorphisms at positions 92 and 703 lead to amino acid polymorphisms at positions 35 and 240 in the numbering scheme of Ambler and colleagues (2). The four possible different combinations correspond to SHV types SHV-2 (L35, E240), SHV-2a (Q35, E240), SHV-5 (L35, K240), and SHV-12 (Q35, K240) (http://www.lahey.org/Studies/), which differ in spectrum and activity. A possible explanation for the double signals could be that two or more blaSHV alleles were amplified from each isolate, resulting in a mixture of templates in the sequence reaction mixture. FIG. 1. Graphic representation of Phred quality values for the contig assembled from four separate trace files for one of the blaSHV PCR products. The quality value scale is logarithmic: a Phred value of 20 means a 1/100 likelihood of error, a Phred value of ... FIG. 2. Low-quality positions in sequence traces of a blaSHV PCR product. (A to C) Electropherograms of the regions containing nucleotide positions 92, 402, and 703. (A) Double signals in the PCR amplicon. (B) Signals in one class of clones, T92A402G703, corresponding ... To assess the number and type of blaSHV alleles in the PCR amplicons, the alleles were ligated into cloning vector pCR 2.1 (Invitrogen, Breda, The Netherlands). Ligation products were transformed to E. coli DH5α. Insert size was confirmed by colony PCR with the vector primers M13F (5′ GTA AAA CGA CGG CCA G 3′) and M13R (5′ CAG GAA ACA GCT ATG AC 3′). Each clone is the result of one individual DNA molecule from the population of blaSHV alleles in the PCR amplicon. Eight different clones for each of the PCR amplicons of the three different isolates were sequenced, and the signals at nucleotide positions 92, 402, and 703 were compared. Only two combinations of the three polymorphisms were detected in the 24 sequenced clones (Fig. 2B and C). A92G402A703, corresponding to SHV-2, was detected in four clones derived from the P. aeruginosa amplicon, five clones derived from the E. coli amplicon, and four clones from the E. cloacae amplicon. The remaining clones all contained the combination T92A402G703, corresponding to SHV-12. The distribution among the clones suggests that these two SHV genes were present in approximately identical copy numbers in each of the three isolates. The initial analysis of the sequence traces, based on the sequence assembly using default parameters, identified an SHV-2 gene in the E. coli and E. cloacae strains and an SHV-5 gene in the P. aeruginosa strain. This indicates that the use of default sequence assembly parameters without careful inspection of individual low-quality positions may lead to misidentification of the number and type of SHV genes carried by a single bacterial isolate. To our knowledge, this is the first report of two blaSHV genes in a single P. aeruginosa isolate. Only recently, the presence in a single E. cloacae isolate of two different blaSHV genes that differ by a single nucleotide, SHV-7 and SHV-30, was reported (12). Szabo and colleagues developed a method to detect this single-nucleotide polymorphism by fluorescence resonance energy transfer real-time PCR. Unfortunately, adapting this method to detect the SHV-2 and SHV-12 combination in the present isolates will be impossible, as these alleles contain three nucleotide polymorphisms, which theoretically give rise to four different combinations. The presence of the two β-lactamases in one strain has implications for its phenotype. The lysine residue at position 240 in SHV-12 is critical for the efficient hydrolysis of cefotaxime (6). In addition, the hydrolysis rate of aztreonam by SHV-12 is superior to that of SHV-2 (8). Therefore, proper identification of the SHV ESBL genes is important for optimal assessment of the cephalosporin sensitivity of a given strain. In addition, full understanding of the epidemiology of extended-spectrum β-lactamases requires accurate data on the presence of the different types of these enzymes in various species. Hence, careful evaluation of low-quality values (Fig. ​(Fig.11 and ​and2)2) in individual sequence traces is warranted. This is particularly relevant for positions where polymorphisms are known to cause changes in the spectrum of SHV β-lactamases, i.e., the positions corresponding to amino acid positions 35, 238, and 240 (4). Identification of multiple alleles can be crucial to identify outbreaks of resistance plasmids that carry ESBL genes and is essential to understand the dynamics and the evolution of these genes.

A transferable plasmid encoding SHV-12 extended-spectrum β-lactamase, TEM-116, and aminoglycoside resistance was responsible for two sequential clonal outbreaks of Enterobacter cloacae and Acinetobacter baumannii bacteria. A similar plasmid was present among isolates of four different bacterial species. Recognition of plasmid transfer is crucial for control of outbreaks of multidrug-resistant nosocomial pathogens.

New Delhi metallo-beta-lactamase 1 (NDM-1) was first identified in 2008 in a Klebsiella pneumoniae strain from a Swedish patient of Indian origin with a history of medical treatment in a New Delhi hospital for a urinary tract infection ([12][1]). Since then, more such cases in different parts of the

Traditionally, bacteria in The Netherlands have low levels of resistance to antibiotics. This report describes what is believed to be the first carbapenem-resistant Klebsiella pneumoniae producing an OXA-48 type β-lactamase in The Netherlands. The isolate co-produced a CTX-M-15 type β-lactamase and was recovered from a patient who was transferred from a hospital in India to an intensive care unit in The Netherlands. His recovery in The Netherlands was complicated by pneumonia due to the carbapenem-resistant K. pneumoniae to which he eventually succumbed. Pre-emptive screening for carbapenem-resistant Enterobacteriaceae in selected patients could be imperative to maintain the low prevalence of these highly resistant bacteria in Dutch hospitals.

common mechanisms of fluoroquinolone resistance in Gramnegative organisms, whole-cell DNA of isolate 13 was extracted and used as a template for PCR amplification using primers able to amplify the corresponding quinolone resistance determining regions (‘QRDRs’) of the gyrA and parC genes of P. stutzeri ATCC 17588 (as control) and of P. stutzeri 13, and subsequently sequenced. The primers used were: GyrA-PstF (5 0 -CAT GGG CGA ACT GGC CAA AG-3 0 ) and GyrA-PstR (5 0 -CTG CCG GAA TCT GCT CGG TG-3 0 ) for gyrA (expected amplicon of 473 bp); and ParC-PstF (5 0 -ATG AGC GAA TCC CTC GAC CTG-3 0 ) and ParC-PstR (5 0 -GGT TCG TCC AGG GTG CCG TCG A-3 0 ) for parC (expected amplicon of

A Salmonella enterica serotype Typhi strain was cultured from blood and fecal samples from a 54-year-old man with fever and diarrhea. He had returned from travel to the Philippines a few days earlier. Phenotypic and genotypic analysis confirmed the production of the SHV-12 extended-spectrum beta-lactamase.