Background Escherichia coli, the most common bacterium causing urinary tract infections (UTIs), is increasingly reported as resistant to multiple antibiotics. Swedish surveillance data from hospital and primary health care (PHC) report a 17%-19% prevalence of resistance to ciprofloxacin in E. coli from urine cultures in men over 20 years of age. Surveillance data may include nosocomial infections. However, few studies have described resistance in E. coli in men with community-acquired UTI in PHC. We aimed to describe the microbiological results, including antibiotic resistance in E. coli, in men with lower UTI (LUTI) attending PHC.Methods In this retrospective study based on information from electronic medical records, we included patients from 289 PHC centres. For all men aged 18-79 years diagnosed with LUTI in PHC from January 2012 to December 2015, we extracted data on age, UTI diagnosis and results from urine cultures.Results A total of 17 987 episodes of lower UTI were identified. E. coli was detected in 62% of positive cultures and 63% of detected E. coli isolates were susceptible to all tested antimicrobials. Resistance in E. coli to the first-choice antibiotics pivmecillinam and nitrofurantoin were 2% and 1%, respectively. Resistance to ciprofloxacin was 9%, and to trimethoprim it was 17%.Conclusions Resistance levels for ciprofloxacin in E. coli among men with LUTI in PHC were lower than in surveillance data. The results of this study point to the importance of surveillance of resistance in urine samples from patients with LUTI in PHC in order to choose the right empirical antibiotic treatment.

Abstract Background Uncomplicated urinary tract infection (UTI) causes bothersome symptoms among women and is a leading cause for antibiotic prescribing in primary healthcare (PHC). Methods A prospective observational study in eight different PHC centres in Sweden including 192 women with symptoms of uncomplicated UTI. Questionnaires and symptom diaries were used to retrieve patient data. All urine samples were analysed with urine culture and susceptibility testing. The aim was to describe the clinical presentation of symptoms in uncomplicated UTI in relation to bacterial findings in urine and to describe the course and duration of symptoms in relation to anamnestic factors, bacterial findings and antibiotic treatment. Results Median symptom duration before seeking care was four days (IQR 1–7). Restrictions in daily life related to symptoms of uncomplicated UTI were reported by the majority (74%) of respondents. The median number of days concerning any symptom after consultation was 4.0 days (IQR 2.0–5.0) for patients treated with antibiotics, and 6.5 days (IQR 3.0–10.0) for patients not treated with antibiotics. There was an association between longer symptom duration after consultation and age over 50 years, relative risk (RR) 1.76 (95% CI 1.25–2.49). Antibiotic treatment RR 0.47 (95% CI 0.27–0.81) was associated with reported shorter duration of symptoms. Conclusions Women visiting primary health care with symptoms indicating uncomplicated UTI have symptoms for several days before seeking care and after consulting. A majority of patients feel restricted in their daily activities due to uncomplicated UTI. Older women and women not treated with antibiotics have the longest symptom duration after consultation.

Objective The aim of this study was to describe the change of antibiotic prescribing in pre-school children in the municipalities of the former Copenhagen County in Denmark and Skane County in Sweden after 20 years of antibiotic stewardship effort. Furthermore, the variation in the prescribing of antibiotics between the municipalities and the correlation between municipal adult educational level and antibiotic prescribing in pre-school children was assessed. Methods In this ecological study, information on antibiotic prescribing in pre-school children was obtained from a central pharmacy settlement system in each Region. The antibiotic prescribing rate was expressed in defined daily doses per 1,000 inhabitants per day (DDD/TID) and number of prescriptions/1000 inhabitants. Information on municipal adult educational levels was obtained from Statistics Denmark and Statistics Sweden. Results The antibiotic prescribing rate during 2017 was higher in the municipalities of Copenhagen County (5.6-7.9 DDD/TID) compared to the municipalities of Skane County (4.2-6.6 DDD/TID). In 1998 a higher rate was found in Skane County (9.6-17.7 DDD/TID) compared to Copenhagen County (8.0-12.9 DDD/TID). A non-significant negative correlation between adult educational levels and antibiotic prescribing was observed in the municipalities of Copenhagen County (r= -0.233, p = .352) while the correlation was positive in the municipalities of Skane County (r= +0.410, p = .018). The same correlations were observed in 1998. Conclusion We found higher antibiotic prescribing in pre-school children in the municipalities of Copenhagen County compared to Skane County in 2017, suggesting a possible overuse of antibiotics in Denmark. Further research should try to elucidate the reasons for the observed variation.

Objective To compare the proportion of therapy failure, recurrence and complications within 30 days after consultation between men diagnosed with lower urinary tract infection (UTI) treated with narrow-spectrum antibiotics (nitrofurantoin or pivmecillinam) and broad-spectrum antibiotics (fluoroquinolones or trimethoprim or trimethoprim/sulfamethoxazole). Design A retrospective cohort study based on data derived from electronic medical records between January 2012 and December 2015. Setting Primary health care and hospital care in five different counties in Sweden. Patients: A total of 16,555 men aged between 18 and 79 years diagnosed with lower UTI. Main outcome measures Treatment with narrow-spectrum antibiotics was compared with broad-spectrum antibiotics regarding therapy failure, recurrence and complications within 30 days. Results The median age of included men was 65 IQR (51–72) years. Narrow-spectrum antibiotics were prescribed in 8457 (40%) and broad-spectrum antibiotics in 12,667 (60%) cases, respectively. Therapy failure was registered in 192 (0.9%), recurrence in 1277 (6%) and complications in 121 (0.6%) cases. Therapy failure and recurrence were more common in patients treated with narrow-spectrum antibiotics and trimethoprim (p < 0.001), but no such difference could be detected regarding complications. Conclusion There was no difference in incidence of complications within 30 days between men treated with narrow- or broad-spectrum antibiotics. Patients prescribed broad-spectrum antibiotics had lower odds of reconsultation because of therapy failure and recurrence. From current data, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men with lower UTI.KEY POINTS Complications such as pyelonephritis and sepsis are uncommon in men diagnosed with lower urinary tract infection treated with antibiotics. There was no difference in incidence of complications among men diagnosed with lower urinary tract infection treated with narrow- or broad-spectrum antibiotics. In spite of higher incidence of therapy failure and recurrence, treatment with narrow-spectrum antibiotics seems to be an optimal choice regarding preventing complications when treating men diagnosed with lower UTI.

Objective: The objective of this study was to compare antibiotic-prescribing rates in 2016 and antibiotic-resistance rates in 2017 among citizens aged >= 85 years between the Capital Region in Denmark and the Skane Region in Sweden, with regards to overall antibiotic use and antibiotics of choice for urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs). Methods: Inhabitants >= 85 year old on the date of prescription during 2016 and residing in the Capital Region or the Skane Region were included for antibiotic-prescription analyses. Samples from 2017 from residents of the same regions who were >= 85 years old were included for antibiotic-resistance analyses. Antimicrobial use was determined according to the drugs of choice for UTIs and SSTIs in Denmark and Sweden. Students t-tests were used to compare antibiotic prescribing while a Chi-Squared test was performed to compare antibiotic resistance. Results: There was a significantly higher overall prescription rate among citizens >= 85 years in the Capital Region than in the Skane Region. The same pattern was evident for the antibiotics of choice for UTIs and SSTIs except for clindamycin. Antibiotic resistance against all antibiotics included was more prominent in the Capital Region than in the Skane Region. Conclusion: Considerable variation in antibiotic prescribing and resistance exists among elderly citizens between these two adjacent Nordic regions. Information and reflection on current practices and resistance patterns may direct attention towards antimicrobial stewardship as a higher priority and may help inform and motivate prescribing behaviours.

Background Urinary tract infection (UTI) is common in primary care and leads to a high number of antibiotic prescriptions. Antimicrobial resistance is a global health problem; better antimicrobial prescribing is one way to limit antimicrobial resistance. We aimed to describe the number of consultations for patients diagnosed with lower urinary tract infection (LUTI) and pyelonephritis and changes in prescribing of antibiotics to men and women with LUTI and pyelonephritis in Swedish PHC between the years 2008 and 2013. Methods We performed a descriptive study of changes in UTI diagnosis and antibiotic prescribing in UTI for the years 2008, 2010 and 2013. The Primary Care Record of Infections in Sweden, a database regarding diagnosis linked antibiotic prescribing in primary care, was analyzed concerning data for men and women of all ages regarding UTI visits and antibiotic prescribing. The results were analyzed in relation to current national guidelines. Results There was a variability in consultation incidence for LUTI with an increase between 2008 and 2010 and a decrease between 2010 and 2013, resulting in a slight rise in consultation incidence between 2008 and 2013. The use of recommended nitrofurantoin or pivmecillinam in LUTI in women increased from 54% in 2008 to 69% in 2013. Fluoroquinolones or trimethoprim were prescribed in 24% of LUTI cases in women in 2008 and in 7% of cases in 2013. Prescriptions of pivmecillinam or nitrofurantoin in male LUTI cases increased from 13% in 2008 to 31% in 2013. Fluoroquinolones or trimethoprim were prescribed in 54% of male LUTI cases in 2008 and 32% in 2013. Conclusions Swedish GPs seem to follow national guidelines in the treatment of LUTI in women. In male LUTI cases, the prescriptions of fluoroquinolones remain high and further research is needed to follow prescription patterns and enhance more prudent prescribing to this group of patients.

Uncomplicated urinary tract infection (uUTI) is common and a majority of patients are prescribed antibiotics. There is little knowledge about antibiotic resistance in urine samples from patients with uUTI in primary health care (PHC).

Objectives:To describe and compare the prescribing of antibiotics used for urinary tract infections and its correlation with resistance in Escherichia coli in urinary samples across two adjacent regions-the Capital Region and the Skaane Region-and their municipalities in Denmark and Sweden.Methods:The Capital Region consists of 29 municipalities and 725 960 female inhabitants aged ≥18 years and the Skaane Region consists of 33 municipalities and 515 668 female inhabitants aged ≥18 years. Aggregated data from outpatient care on the prescribing of pivmecillinam, trimethoprim and nitrofurantoin from both regions were analysed. The Department of Clinical Microbiology in both regions provided data on E. coli resistance in urinary samples from women aged ≥18 years. Data were measured as the number of prescriptions/1000 women/year, number of DDDs/1000 women/year and DDDs/prescription. Correlation analyses between antibiotic prescribing and antibiotic resistance rates were performed.Results:Antibiotic prescribing and resistance rates were significantly higher in the Capital Region compared with the Skaane Region. Large variations in prescription and resistance rates were found at the municipal level, but there were no correlations between the antibiotic prescription and resistance rates when each region was analysed separately.Conclusions:Although closely related, there are large differences in antibiotic prescribing and antibiotic resistance. It is suggested that the regional guidelines are an important driver and explanatory factor for the variations; however, further research is needed in this new field and factors such as the influence of cultural aspects should be the target of further research.

The majority of antibiotics consumed in developed countries are prescribed in primary care. However, little is known about resistance levels in the primary care population.

Eradication of methicillin-resistant Staphylococcus aureus (MRSA) colonisation may prevent transmission of strains between patients and reduces the risk of clinical infection. Colonisation of the throat is associated with prolonged carriage and is more difficult to eradicate. An open randomised study was conducted to evaluate two eradication protocols. Patients with pharyngeal carriage of MRSA were enrolled at six Swedish centres during 4 years. One treatment group received oral rifampicin and either clindamycin or trimethoprim/sulfamethoxazole (SXT) for 7 days in combination with nasal mupirocin. Patients in the other group were treated with nasal mupirocin only. Patients in the same household were randomised together. Both groups followed a hygiene protocol including chlorhexidine washing. Cultures from the nares, perineum and throat were taken at baseline and then at 2 weeks, 2 months and 6 months after the end of treatment. A total of 28 patients received rifampicin-based systemic antibiotics and 24 subjects received mupirocin only. At follow-up 6 months after the end of treatment, 61% of patients and 50% of households in the systemic antibiotics group had culture results negative for MRSA. Significantly less patients (12%) and households (10%) became decolonised in the group receiving topical treatment only. A combination of rifampicin and either clindamycin or SXT was more effective in eliminating pharyngeal MRSA carriage compared with topical treatment with mupirocin only.

Swedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines.

Background: Pseudomonas aeruginosa may colonize water systems via biofilm formation. In hospital environments, contaminated sinks have been associated with nosocomial transmission. Here we describe a prolonged outbreak of a metallo-beta-lactamase-producing P. aeruginosa (Pae-MBL) associated with sink drains, and propose a previously unreported decontamination method with acetic acid.Aim: To describe a nosocomial outbreak of Pae-MBL associated with hospital sink drains and to evaluate acetic acid as a decontamination method.Methods: The outbreak was investigated by searching the microbiology database, microbiological sampling and strain typing. Antibacterial and antibiofilm properties of acetic acid were evaluated in vitro. Pae-MBL-positive sinks were treated with 24% acetic acid once weekly and monitored with repeated cultures.Findings: Fourteen patients with positive cultures for Pae-MBL were identified from 2008 to 2014. The patients had been admitted to three wards, where screening discovered Pae-MBL in 12 sink drains located in the patient bathrooms. Typing of clinical and sink drain isolates revealed identical or closely related strains. Pae-MBL biofilm was highly sensitive to acetic acid with a minimum biofilm eradication concentration of 0.75% ( range: 0.19 -1.5). Weekly treatment of colonized sink drains with acetic acid resulted in negative cultures and terminated transmission.Conclusion: Acetic acid is highly effective against Pae-MBL biofilms, and may be used as a simple method to decontaminate sink drains and to prevent nosocomial transmission. (C) 2016 The Authors. Published by Elsevier Ltd

Background. Antimicrobial stewardship programs are increasingly implemented in hospital care. They aim to simultaneously optimize outcomes for individual patients with infections and reduce financial and health-associated costs of overuse of antibiotics. Few studies have examined the effects of antimicrobial stewardship programs in settings with low proportions of antimicrobial resistance, such as in Sweden.Methods. An antimicrobial stewardship program was introduced during 5 months of 2013 in a department of internal medicine in southern Sweden. The intervention consisted of audits twice weekly on all patients given antibiotic treatment. The intervention period was compared with a historical control consisting of patients treated with antibiotics in the same wards in 2012. Studied outcome variables included 28-day mortality and readmission, length of hospital stay, and use of antibiotics.Results. A reduction of 27% in total antibiotic use (2387 days of any antibiotic) was observed in the intervention period compared with the control period. The reduction was due to fewer patients started on antibiotics as well as to significantly shorter durations of antibiotic courses (P < .001). An earlier switch to oral therapy and a specific reduction in use of third-generation cephalosporins and fluoroquinolones was also evident. Mortality, total readmissions, and lengths of stay in hospital were unchanged compared with the control period, whereas readmissions due to a nonresolved infection were fewer during the intervention of 2013.Conclusions. This study demonstrates that an infectious disease specialist-guided antimicrobial stewardship program can profoundly reduce antibiotic use in a low-resistance setting with no negative effect on patient outcome.

Background: The aim of this study was to evaluate the day-care interventions implemented in southern Sweden to restrict the dispersion of penicillin-non-susceptible pneumococci with a minimum inhibitory concentration of penicillin G of at least 0.5 mg/l (PNSP0.5). Methods: A retrospective epidemiological study was performed and data from 109 day-care centre interventions from 2000 to 2010 were analysed, including screening results from 7157 individuals. Results: It was found that 42% of the children were carriers of pneumococci and 5% of the screened children were PNSP0.5 carriers. Very few personnel were PNSP0.5 carriers and they were carriers for only a short time. Significantly more contact cases with the same serogroup as the index case were found in the first screening and in the same department as the index case, but a substantial number of contact cases were found in adjacent departments. Conclusions: Screening of personnel is not worth the effort. Based on our results, procedures to restrict dispersion of PNSP0.5 in day-care centres could be improved. To find the majority of contact cases with PNSP0.5 an early screening including adjacent departments seems to be the best approach.

In this retrospective epidemiologic study, we present pneumococcal carriage data from 109 Swedish day care centers over a period of 10 years. Aspects of season, age, personnel and group size were studied. We found a significant seasonal variation in pneumococcal carriage. Group size was a significant risk factor for pneumococcal carriage. Pneumococcal carriage was 4.5 % in personnel.

BACKGROUND:Extended-spectrum beta-lactamase (ESBL)-producing bacteria are an escalating problem threatening health. Devastating consequences can result in neonatal intensive care units (NICU) due to these bacteria. The aim of this study was to investigate the efficacy of once-a-week screening (July 2010 to September 2012) versus screening on demand (April 2008 to June 2010).MATERIALS AND METHODS:The investigation was an open retrospective descriptive study comparing 2 unpaired groups, the first exposed to screening on demand and the second to screening once a week. All other infection control measures were unchanged. Both groups were cared for in the NICU of Skåne University Hospital. Parameters compared were the proportion of cultured neonates, prevalence, time before detection, number of secondary cases, and clinical infections due to ESBL-producing bacteria.RESULTS:The proportion of cultured neonates increased from 28% to 49% (p < 0.05) in period 2. The time from admission to detection was 8 days shorter in period 2 (p < 0.05). Secondary cases decreased from 44% to 9% (p < 0.05), and clinical infections from 4 to 0 cases (p < 0.05). During period 2, the prevalence of colonization was 1.77%.CONCLUSIONS:Once-a-week screening is a strategy to control the epidemiology of unwanted pathogens among newborn infants. It provides the opportunity for early intervention, thereby avoiding secondary cases and infections. Premature neonates in particular benefit from this approach. The prevalence of ESBL of 1.77% is low from an international perspective. ESBL appear to be introduced onto the ward by mothers colonized with ESBL.

In this retrospective epidemiologic study, we present pneumococcal carriage data from 109 Swedish day care centers over a period of 10 years. Aspects of season, age, personnel and group size were studied. We found a significant seasonal variation in pneumococcal carriage. Group size was a significant risk factor for pneumococcal carriage. Pneumococcal carriage was 4.5 % in personnel.

BACKGROUND Upper respiratory tract infections (URTIs) are the most common reason for consulting a GP and for receiving an antibiotic prescription, although evidence shows poor benefit but rather increasing antibiotic resistance. Interventions addressing physicians have to take into consideration the complexity of prescribing behaviour. OBJECTIVE To study whether interventions based on behavioural theories can reduce the prescribing of antibiotics against URTIs in primary care. Setting and subjects. GPs at 19 public primary health care centres in southern Sweden. METHODS We performed a randomized controlled study using two behavioural theory-based interventions, the persuasive communication intervention (PCI) and the graded task intervention (GTI), which emerged from social cognitive theory and operant learning theory. GPs were randomized to a control group or one of two intervention groups (PCI and GTI). MAIN OUTCOME MEASURES Changes in the rate of prescription of antibiotics against URTIs in primary care patients of all ages and in patients aged 0-6 years. RESULTS No significant differences were seen in the prescription rates before and after the interventions when patients of all ages were analysed together. However, for patients aged 0-6 years, there was a significant lower prescription rate in the PCI group (P = 0.037), but not the GTI group, after intervention. CONCLUSION Theory-based interventions have limited impact on reducing the prescription of antibiotics against URTIs in primary care. Future studies are needed to draw firm conclusions about their effects.