This study aimed to determine resistance to antimicrobials of Staphylococcus aureus strains isolated from clinical specimens in Lithuanian hospitals and to identify the genes conferring resistance and virulence. The study was carried out from June 2019 to September 2021. S. aureus strains were isolated from skin, soft tissues, blood, lower respiratory tract, urine and other specimens. Antibiotic susceptibility testing was performed using the disc diffusion method according to EUCAST guidelines. All isolates were analyzed for detection of the ermA, ermC, mecA, mecC, tetK, tetM, and lukF-PV genes by multiplex real-time PCR. The 16S rRNA coding sequence was applied as an internal PCR control. Altogether, 745 S. aureus strains were analyzed. Antimicrobial susceptibility testing revealed that all isolates were susceptible to rifampin and vancomycin. Of the 745 strains, 94.8% were susceptible to tetracycline, 94.5% to clindamycin, and 88.3% to erythromycin. The lowest susceptibility rate was found for penicillin (25.8%). Six percent of the tested strains were methicillin-resistant S. aureus (MRSA). The majority of methicillin-resistant strains were isolated from skin and soft tissues (73.3%), with a smaller portion isolated from blood (17.8%) and respiratory tract (8.9%). The ermC gene was detected in 41.1% of erythromycin-resistant S. aureus strains, whereas ermA was detected in 32.2% of erythromycin-resistant S. aureus strains. 69.2% of tetracycline-resistant S. aureus strains had tetK gene, and 28.2% had tetM gene. 7.3% of S. aureus isolates harbored lukF-PV gene. The frequency of the pvl gene detection was significantly higher in MRSA isolates than in methicillin-susceptible S. aureus isolates (p < 0.0001).

Abstract Background Staphylococcus aureus is one of the most frequently identified pathogens causing nosocomial infections worldwide and, in many cases, exhibits resistance to multiple antimicrobials. However, there is a lack of data about the prevalence of S. aureus resistance to antimicrobials in major hospitals in Vilnius city, Lithuania. Therefore, the aim of this study was to determine the resistance to antimicrobials of Staphylococcus aureus strains isolated from clinical specimens in Lithuanian hospitals and to identify the genes conferring resistance and virulence. Methods This study was carried out from June 2019 to September 2021. S. aureus strains were isolated from clinical specimens. Antibiotic susceptibility testing was performed by the disc diffusion method according to EUCAST guidelines. All our collected isolates were analysed for detection of the ermA, ermC, mecA, mecC, tetK, tetM and lukF-PV genes by multiplex real-time PCR. The 16S rRNA coding sequence was applied as an internal PCR control. Results A total of 745 S. aureus strains isolated from clinical specimens were analysed. A total of 69.0% of strains were isolated from the skin and soft tissues, 14.5% from blood, 11.7% from the lower respiratory tract, 2.7% from urine and 2.1% from other specimens. Antimicrobial susceptibility testing revealed that all 745 isolates were susceptible to rifampin and vancomycin. Of the 745 strains, 94.8% were susceptible to tetracycline, 94.5% to clindamycin and 88.3% to erythromycin. The lowest susceptibility rate was found to penicillin (25.8%). Six percent of the tested strains were methicillin-resistant S. aureus (MRSA). The majority of methicillin-resistant strains were isolated from skin and soft tissues (73.3%), with a smaller portion isolated from blood (17.8%) and the respiratory tract (8.9%). The ermC gene was detected in 41.1% of erythromycin-resistant S. aureus strains, whereas ermA was detected in 32.2% of erythromycin-resistant S. aureus strains. A total of 69.2% of tetracycline-resistant S. aureus strains had the tetK gene, and 28.2% had the tetM gene. A total of 7.3% of S. aureus isolates harboured the lukF-PV gene. The frequency of pvl gene detection was significantly higher in the MRSA isolates than in the methicillin-susceptible S. aureus (MSSA) isolates (p < 0.0001). Conclusions All tested strains were susceptible to rifampicin and vancomycin. A total of 6% of the strains were MRSA. The lowest susceptibility rate was found to penicillin. The tetK gene was predominant among S. aureus strains resistant to tetracycline, and the ermC gene was predominant among erythromycin-resistant strains. Seven percent of S. aureus isolates harboured the lukF-PV gene, which was more prevalent in methicillin-resistant strains.

Clostridioides difficile has become the leading nosocomial Gram-positive pathogen in the developed countries. In Lithuania, the national surveillance program for C. difficile started in 2017. Enzyme immunoassay, the real-time PCR system, and culture are used for laboratory confirmation of C. difficile infection in Lithuanian clinical laboratories. No reference laboratory for C. difficile is present in Lithuania. Fifty-eight isolates of C. difficile were collected in 2016 and 2017 in two hospitals using real-time PCR and culture methods. Agarose gel–based PCR ribotyping, multilocus variable number tandem repeats analysis (MLVA), and multilocus sequence typing (MLST) were used for the genotypic characterization of 28 isolates. PCR ribotyping and MLST showed that 78.6% of the tested toxigenic isolates belong to the ribotype RT027/ST1. Using MLVA, 95.5% of RT027 isolates were genetically related. MLVA revealed three clonal complexes in RT027. Six non-RT027 isolates showed four different electrophoretic profiles in PCR ribotyping and were assigned to the MLST sequence types ST2, ST13, ST54, and ST63. The highest discriminatory power showed the genotyping by MLVA. In total, 20 MLVA profiles were identified. This genotyping technique allowed to identify four groups of RT027/ST1 isolates that were indistinguishable by PCR ribotyping and MLST. Our study is the first genotypic characterization of C. difficile isolates in Lithuania. We observed a high prevalence of presumptive RT027 that suggests unfavorable epidemiological situation in Lithuania. Our results stress for implementation of genotyping of C. difficile isolates in Lithuanian surveillance.

Objectives: High-quality diagnosis of bloodstream infections (BSI) is important for successful patient management. As knowledge on current practices of microbiological BSI diagnostics is limited, this project aimed to assess its current state in European microbiological laboratories. Methods: We performed an online questionnaire-based cross-sectional survey comprising 34 questions on practices of microbiological BSI diagnostics. The ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis (ESGBIES) was the primary platform to engage national coordinators who recruited laboratories within their countries. Results: Responses were received from 209 laboratories in 25 European countries. Although 32.5% (68/209) of laboratories only used the classical processing of positive blood cultures (BC), two-thirds applied rapid technologies. Of laboratories that provided data, 42.2% (78/185) were able to start incubating BC in automated BC incubators around-the-clock, and only 13% (25/192) had established a 24-h service to start immediate processing of positive BC. Only 4.7% (9/190) of laboratories validated and transmitted the results of identification and antimicrobial susceptibility testing (AST) of BC pathogens to clinicians 24 h/day. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry from briefly incubated sub-cultures on solid media was the most commonly used approach to rapid pathogen identification from positive BC, and direct disc diffusion was the most common rapid AST method from positive BC. Conclusions: Laboratories have started to implement novel technologies for rapid identification and AST for positive BC. However, progress is severely compromised by limited operating hours such that current practice of BC diagnostics in Europe complies only partly with the requirements for optimal BSI management. (C) 2019 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Extended-spectrum beta-lactamases (ESBL) and AmpC producing-Escherichia coli have spread worldwide, but data about ESBL-producing-E. coli in the Northern and Eastern regions of Europe is scant. The aim of this study has been to describe the phenotypical and molecular epidemiology of different ESBL/AmpC/Carbapenemases genes in E. coli strains isolated from the Baltic States (Estonia, Latvia, and Lithuania), Norway and St. Petersburg (Russia), and to determine the predominant multilocus sequence type and single nucleotide polymorphisms diversity of E. coli isolates deduced by whole genome sequencing (WGS). A total of 10,780 clinical E. coli strains were screened for reduced sensitivity to third-generation cephalosporins. They were collected from 21 hospitals located in Estonia, Latvia, Lithuania, Norway and St. Petersburg during a 5 month period in 2012. The overall prevalence of ESBL/AmpC strains was 4.7% by phenotypical test and 3.9% by sequencing. We found more strains with the ESBL/AmpC phenotype and genotype in St. Petersburg and Latvia than other countries. Of phenotypic E. coli strains, 85% contained confirmed ESBL genes (including bla(CTX-M), bla(TEM-29), bla(TEM-71)), AmpC genes (bla(CMY-59), bla(ACT-12/-15/-20), bla(ESC-6), bla(FEC-1), bla(DHA-1)), or carbapenemase genes (bla(NDM-1)). bla(CTX-M-1), bla(CTX-M-14) and bla(CTX-M-15) were found in all countries, but bla(CTX-M-15) prevalence was higher in Latvia than in St. Petersburg (Russia), Estonia, Norway and Lithuania. The dominating AmpC genes were bla(CMY-59) in the Baltic States and Norway, and bla(DHA-1) in St. Petersburg. E. coli strains belonged to 83 different sequence types, of which the most prevalent was ST131 (40%). In conclusion, we generally found low ESBL/AmpC/Carbapenemase prevalence in E. coli strains isolated in Northern/Eastern Europe. However, several inter-country differences in distribution of particular genes and multilocus sequence types were found.

Background: Antibiotic resistance, either intrinsic or acquired, is a major obstacle for treating bacterial infections. Aim: Our objective was to compare the country-specific species distribution of the four Gram-negative species Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter species and the proportions of selected acquired resistance traits within these species. Method: We used data reported for 2016 to the European Antimicrobial Resistance Surveillance Network (EARS-Net) by 30 countries in the European Union and European Economic Area. Results: The country-specific species distribution varied considerably. While E. coli accounted for 31.9% to 81.0% (median: 69.0%) of all reported isolates, the two most common intrinsically resistant species P. aeruginosa and Acinetobacterspp. combined (PSEACI) accounted for 5.5% to 39.2% of isolates (median: 10.1%). Similarly, large national differences were noted for the percentages of acquired non-susceptibility to third-generation cephalosporins, carbapenems and fluoroquinolones. There was a strong positive rank correlation between the country-specific percentages of PSEACI and the percentages of non-susceptibility to the above antibiotics in all four species (rho > 0.75 for 10 of the 11 pairs of variables tested). Conclusion: Countries with the highest proportion of P. aeruginosa and Acinetobacter spp. were also those where the rates of acquired non-susceptibility in all four studied species were highest. The differences are probably related to national differences in antibiotic consumption and infection prevention and control routines.

This study has evaluated the correlation between different carbapenemases detection methods on carbapenem non-susceptible Klebsiella pneumoniae strains from Northern and Eastern Europe; 31 institutions in 9 countries participated in the research project, namely Finland, Estonia, Latvia, Lithuania, Russia, St. Petersburg, Poland, Belarus, Ukraine, and Georgia. During the research program, a total of 5,001 clinical K. pneumoniae isolates were screened for any carbapenem non-susceptibility by the disk diffusion method, Vitek 2 or Phoenix system following the EUCAST guideline on detection of resistance mechanisms, version 1.0. Strains isolated from outpatients and hospitalized patients from April 2015 to June 2015 were included. All types of samples (blood, pus, urine, etc.) excluding fecal screening or fecal colonization samples have been represented. In total, 171 carbapenemase screening-positive K. pneumoniae isolates (3.42%) were found and characterized. Several methods were used for detection of carbapenemases production, including Luminex assay (PCR and hybridization), whole genome sequencing, MALDI-TOF based Imipenem degradation assay, and immunochromatography testing. Minimal inhibitory concentration determination for Meropenem by agar-based gradient method was also used. Finally, 83 K. pneumoniae strains were carbapenemase negative by all confirmation methods (49.4% of all screening-positive ones), 74-positive by three methods (44.0%), 8-positive by two methods (4.8%) and 3-positive by only one method (1.8%). The sensitivity of the tests was 96.3% for Whole genome sequencing and MALDI-TOF assay (both three undetected cases), and 95.1% for Luminex-Carba (4 undetected cases). The most commonly detected carbapenemases were NDM (n = 54) and OXA-48 (n = 26), followed by KPC-2, VIM-5, and OXA-72 (one case of each). Our results showed that different types of carbapenemases can be detected in the countries involved in the project. The sensitivity of our methods for carbapenemase detection ( including screening as a first step and further confirmation tests) was >95%, but we would recommend using different methods to increase the sensitivity of detection and make it more precise.

Investments to reduce the spread of antimicrobial resistance (AMR) in the European Union have been made, including efforts to strengthen prudent antimicrobial use. Using segmented regression, we report decreasing and stabilising trends in data reported to the European Surveillance of Antimicrobial Consumption Network and stabilising trends in data reported to the European Antimicrobial Resistance Surveillance Network. Our results could be an early indication of the effect of prioritising AMR on the public health agenda.

The aim of this study was to compare the prevalence of different virulence factor (VF) genes in extended-spectrum beta-lactamase (ESBL) producing Escherichia coli strains isolated from the Baltic Sea region. A total of 432 strains of phenotypically ESBL positive E. coli were collected from 20 institutions located in Estonia, Latvia, Lithuania, and the region of St. Petersburg in Russia from January to May 2012 and analyzed for phylogenetic group and prevalence of 23 VF genes. The strains were collected from clinical material (urine, blood, wound, and respiratory tract). Bacterial isolates were compared according to phylogenetic group, clinical material, and geographical origin. Most of the VF genes were concentrated within phylogenetic group B2 and/or D. When comparing strains isolated from different countries, it was found that strains originating from Estonia and Latvia belonged mainly to group B2 and strains from Lithuania and Russia mainly to groups B2 and D. The P-fimbrial adhesin gene papEF was more prevalent in Russian strains, colicin gene cvaC in Lithuanian strains, and capsular gene kpsMTII in Latvian strains; serum resistant gene traT was less prevalent in Estonian strains. The regional differences of VF genes remained statistically significant after taking into account the phylogenetic distribution in the countries.

The spread of carbapenemase-producing Enterobacteriaceae is a global problem; however, no exact data on the epidemiology of carbapenemase in the Baltic countries and St. Petersburg area is available. We aimed to evaluate the epidemiology of carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in the Baltic States and St. Petersburg, Russia, and to compare the different methods for carbapenemase detection. From January to May 2012, all K. pneumoniae (n = 1983) and E. coli (n = 7774) clinical isolates from 20 institutions in Estonia, Latvia, Lithuania, and St. Petersburg, Russia were screened for carbapenem susceptibility. The IMP, VIM, GIM, NDM, KPC, and OXA-48 genes were detected using real-time PCR and the ability to hydrolyze ertapenem was determined using MALDI-TOF MS. Seventy-seven strains were found to be carbapenem nonsusceptible. From these, 15 K. pneumoniae strains hydrolyzed ertapenem and carried the bla(NDM) gene. All of these strains carried integron 1 and most carried integron 3 as well as genes of the CTX-M-1 group. No carbapenemase-producing E. coli or K. pneumoniae strains were found in Estonia, Latvia, or Lithuania; however, NDM-positive K. pneumoniae was present in the hospital in St. Petersburg, Russia. A MALDI-TOF MS-based assay is a suitable and cost-effective method for the initial confirmation of carbapenemase production.

We studied the prevalence of K. pneumoniae and E. coli resistance to extended spectrum cephalosporins and carbapenems, isolated from patients of eight hospitals in St-Petersburg from January to May, 2012. Prevalence of cephalosporin resistant isolates varied in different hospitals: E. coli - from 7,8 to 50%, K. pneumoniae -from 25,4 to 88,4%. Isolates produced extended spectrum beta-lactamases CTX-M, mainly CTX-M-1, also CTX-M-2 and CTX-M-9. Twenty two carbapenem-resistant K. pneumoniae strains (also resistant to other antimicrobials) were isolated in three hospitals. MALDI-TOF MS showed that carbapenem resistance was caused by carbapenemase. Carbapenemases of all isolates belonged to metallo-beta-lactamases according to results of the ROSCO Diagnostica tests. The gene coding production of New Delhi metallo-beta-lactamase (blaNDM-1) were detected in all strains. Our data confirmed that the main cephalosporin resistance mechanism of E. coli. K. pneumoniae in Baltic region (including Russia, St-Petersburg) is CTX-M-1 production. For the first time in Russia K. pneumoniae strains producing metallo-beta-lactamases NDM-1 were isolated in several hospitals of St-Petersburg.

The study evaluated the changes in the prevalence of Helicobacter pylori strains with primary resistance to antibiotics during the last 10 years in Lithuania. H. pylori susceptibilities to antibiotics were tested in 89 patients in 1998, in 81 patients in 2001 and in 90 patients in 2007/2008. Susceptibility to metronidazole, clarithromycin, amoxicillin and tetracycline was tested using E-test or agar dilution method. Susceptibility to ciprofloxacin was only tested in 2007/2008. Data about utilization of all authorized and available on market macrolides and clindamycin in Lithuania during 2003–2007 were evaluated using WHO ATC/DDD methodology. A total of 260 H. pylori strains cultured from untreated adult patients were investigated. Primary resistance rates (1998, 2001 and 2007/2008) for metronidazole were 24.7%, 33.3%, and 35.6%, for clarithromycin 1.1%, 3.7%, and 3.3% and for tetracycline 0%, 2.5% and 0% respectively. No cases of amoxicillin resistance have been detected. The resistance rate for ciprofloxacin was 5.6% in 2007/2008. Data of total macrolides and clarithromycin utilization in Lithuania revealed that despite an increase of consumption of these drugs in Lithuania during 2003–2007 in 1.5 times, the total macrolide consumption remains one of the lowest in Europe. We have not observed any significant changes in the susceptibility of H. pylori to the most widely used antibiotics during the recent 10-year period. The low resistance rate to clarithromycin might be related to the policy to avoid use of macrolides as first-line treatment for pulmonary and other infections.

The study evaluated the changes in the prevalence of Helicobacter pylori strains with primary resistance to antibiotics during the last 10 years in Lithuania. H. pylori susceptibilities to antibiotics were tested in 89 patients in 1998, in 81 patients in 2001 and in 90 patients in 2007/2008. Susceptibility to metronidazole, clarithromycin, amoxicillin and tetracycline was tested using E‐test or agar dilution method. Susceptibility to ciprofloxacin was only tested in 2007/2008. Data about utilization of all authorized and available on market macrolides and clindamycin in Lithuania during 2003–2007 were evaluated using WHO ATC/DDD methodology. A total of 260 H. pylori strains cultured from untreated adult patients were investigated. Primary resistance rates (1998, 2001 and 2007/2008) for metronidazole were 24.7%, 33.3%, and 35.6%, for clarithromycin 1.1%, 3.7%, and 3.3% and for tetracycline 0%, 2.5% and 0% respectively. No cases of amoxicillin resistance have been detected. The resistance rate for ciprofloxacin was 5.6% in 2007/2008. Data of total macrolides and clarithromycin utilization in Lithuania revealed that despite an increase of consumption of these drugs in Lithuania during 2003–2007 in 1.5 times, the total macrolide consumption remains one of the lowest in Europe. We have not observed any significant changes in the susceptibility of H. pylori to the most widely used antibiotics during the recent 10‐year period. The low resistance rate to clarithromycin might be related to the policy to avoid use of macrolides as first‐line treatment for pulmonary and other infections.

Tyrimo tikslas. Įvertinti trijų Lietuvos vaikų intensyviosios terapijos skyrių tiesiogines išlaidas, susijusias su hospitalinių infekcijų atvejais bei apžvelgti hospitalinių infekcijų prevencijos programos (intervencijos) ekonominį efektyvumą. Metodika. Perspektyvusis stebėsenos tyrimas atliktas trijuose Lietuvos vaikų intensyviosios terapijos skyriuose 2005 m. sausio – 2007 m. gruodžio mėn. Tikslinės atrankos būdu į tyrimą įtraukti visi 1 mėn. – 18 metų vaikai, kurie gydyti vaikų intensyviosios terapijos skyriuose ilgiau nei 48 val. Tiesioginės vaikų intensyviosios terapijos skyrių hospitalinių infekcijų sąlygotos išlaidos apskaičiuotos vienam hospitaline infekcija susirgusiam ligoniui ir vienam hospitalinės infekcijos atvejui. Vidutiniam vieno lovadienio įkainiui apskaičiuoti panaudoti hospitalinių infekcijų registro duomenys, taip pat remtasi ligoninių gaunamų lėšų už suteiktas vaikų reanimacijos paslaugas analize pagal 2005 m. spalio 27 d. Lietuvos Respublikos sveikatos apsaugos ministro įsakymu Nr. V-802 patvirtintus stacionarinių sveikatos priežiūros paslaugų įkainius. Pagal gydymo trukmę reanimacijos paslaugų įkainius ir hospitalinių infekcijų sąlygotas išlaidas visi ligoniai suskirstyti į dvi grupes – įgiję ir neįgiję hospitalinių infekcijų. Vertinant intervencijos ekonominį efektyvumą, ligoniai suskirstyti į kitas dvi grupes – prieš ir po intervencijos. Ekonominis įvertinimas apskaičiuotas nacionaline šalies valiuta – litais. Rezultatai. Tyrime dalyvavo 755 pacientai. Pagal daugialypės tiesinės regresijos modelį (r2=0,47), vienam ligoniui įgijus hospitalinę(-es) infekciją(-as), vaikų intensyviosios terapijos skyriaus gydymo trukmės pailgėjimas sudarė vidutiniškai 6,32 (95 proc. PI: 4,32–8,33; p=0,003) lovadienio. Vieno ligonio įgytos(-ų) hospitalinės(-ių) infekcijos(ų) sąlygotos vidutinės išlaidos sudarė 5215,47 litų (95 proc. PI: 3565,00–6874,19). Vieno hospitalinės infekcijos atvejo sąlygotos vidutinės išlaidos sudarė 4070,61 litų (95 proc. PI: 2782,44–5365,22). Hospitalinių infekcijų profilaktikos programos (intervencijos) bendrasis ekonominis efektas buvo 20046,14 litų. Apsaugojus vieną ligonį nuo hospitalinės(-ių) infekcijos(-ų), išlaidų sumažėjimas sudarė 1336,41 litų, pavykus išvengti vieno hospitalinės infekcijos atvejo, išlaidų sumažėjimas sudarė 1113,67 litų, o sąnaudų ir naudos santykis – 1:4. Išvados. Vaikų intensyviosios terapijos skyrių hospitalinių infekcijų sąlygotos išlaidos buvo pakankamai didelės. Įdiegus hospitalinių infekcijų profilaktikos programoje numatytas priemones, užfiksuotas teigiamas ekonominis efektyvumas – hospitalinių infekcijų profilaktikai panaudojus 1 litą, sutaupyti 4 litai lėšų.

To the Editor: Atypical disease presentations and the high prevalence of asymptomatic bacteriuria make diagnosing urinary tract infection (UTI) in older adults difficult.1,2 Misdiagnosis rates of hospitalized elderly patients may be as high as 40%.3 No reliable diagnostic test exists. Criteria based on collection of clinical features have been developed, although these are primarily designed to guide antibiotic treatment in nursing home settings.4–6 The need to reduce unnecessary antibiotic use has led to the suggestion that such criteria may aid diagnosis in acute hospital settings. A sample of patients with bacteremia caused by a known uropathogen with concomitant isolation of the same organism from the urinary tract without a more likely alternative source was identified. Bacteremic UTI (bUTI) has a worse prognosis than non-bacteremic UTI in hospitalized older adults (mortality 15–33% vs 6%).3,7,8 Any useful diagnostic criteria would need to be sensitive enough to detect such cases most of the time. Patients were identified with concurrent positive blood and urine cultures for the same organism from the pathology laboratory computer system. Patients' records were then retrospectively obtained to extract relevant clinical information. Patients with a likely alternative source of the bacteremia with secondary urinary tract seeding were excluded. Patients were divided into two groups—aged 18 to 74 and 75 and older. Three sets of proposed diagnostic criteria were applied retrospectively for the older patients to try to evaluate their sensitivity to detect significant (bacteremic) UTI in hospitalized patients.4–6 Data were available for 61 patients (mean age 76.7; 55.7% male). Thirty-seven were age 75 and older (mean age 84.7, 56.8% male, 21.6% residing in a care home), and 24 were aged 18 to 74 (mean age 66.5, 58.3% male, none residing in a care home). Symptoms and clinical signs are summarized in Table 1. There was a low rate of reported urinary tract–specific symptoms in both age groups, particularly for dysuria in older patients, which was recorded in just one of the 37 cases. Of the patients aged 75 and older, 18 (48.6%) did not report any urinary tract symptoms. The most frequently detected clinical sign was the presence of at least mild pyrexia (>37.0°C), present in all of the younger group and 91.9% of the older group. Just 73.0% of the older group met the stricter criteria of temperature greater than 37.9°C. Based on the assumption that some older, frailer adults may start at a lower baseline temperature or be incapable of mounting an optimal febrile response to infection, some authors have suggested a rise of 1.5°C or more above baseline on two or more occasions could represent significant infection. Baseline temperatures were estimated from an average of three convalescent values. The use of this criterion as an alternative to temperature greater than 37.9°C led to just two more cases out of 37 being identified. Baseline temperatures averaged 36.3°C in the older group (range 35.1–36.8°C) and in the younger group (range 35.5–36.7°C). The overall mortality rate for patients with bUTI was 18.0%. The rate was higher in the older group (27.0%) than the younger (4.1%). The diagnostic criteria of McGeer4 would have detected 16 of the 37 cases of bacteremia in patients aged 75 and older (a false negative rate of 56.8%). The criteria of Loeb5,6 had a false negative rate of 43.2% (21 of 37 cases correctly identified). The finding that only approximately half of elderly patients with UTI have any urinary tract symptoms is consistent with previous studies.3,9 Nonspecific declines in function or symptoms suggesting a respiratory origin have previously been associated with bUTI in older adults.9 Despite proven bacteremia, 8.1% of patients aged 75 and older did not have even mild pyrexia (>37.0°C) at any stage of their illness. Twenty-seven percent of patients aged 75 and older did not reach the more stringent criteria of a temperature greater than 37.9°C. Previous studies of bUTI have also found that 37% to 49% of older patients do not have significant pyrexia at the time of presentation.7,9 The observed mortality rate of 27% in the group aged 75 and older is similar to that reported in other studies (15–33%).3,7,8 None of the schemes evaluated against the data in this series showed reliable sensitivity to detect bUTI in a hospitalized patient group. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: HJW designed the study, reviewed the patients' records to extract data, and wrote the article. CG, MM, and JM obtained bacteriological data. Sponsor's Role: NA.

UNLABELLED:The aim of this study was to estimate direct costs related to nosocomial infection in three pediatric intensive care units in Lithuania and to overview the effectiveness of preventive programs of nosocomial infections.MATERIAL AND METHODS:A prospective empirical surveillance study was launched in 3 Lithuanian pediatric intensive care units during the period of January 2005 to December 2007. Using the method of targeted selection, all children aged from 1 month and 18 years, treated in pediatric intensive care units for more than 48 hours, were enrolled into the study. Direct costs of nosocomial infections in pediatric intensive care units were calculated for each patient and each case of nosocomial infection. For calculation of average expenditures per patient-day, data from nosocomial infection registry and from analysis of hospital income for services provided at pediatric intensive care units according to price-list of health care price approved by the order of the Minister of Health of the Republic of Lithuanian (No. V-802, October 27, 2005) were used. According to length of stay, costs of intensive care services, and costs caused by nosocomial infections, all the patients were divided into two groups: those who did and did not acquire an infection. For the evaluation of economic efficiency, the patients were divided into other two groups: pre- and postintervention groups. All economic evaluation was made in national currency (litas).RESULTS:The data of 755 patients were used. Multiple linear regression analysis (R(2)=0.47) revealed a 6.32-day increase (95% CI, 4.32-8.33; P=0.003) in hospital stay in a pediatric intensive care unit if a patient acquired nosocomial infection. Costs related to nosocomial infections for one patient made up 5215.47 litas (95% CI, 3565.00-6874.19). Average costs caused by one nosocomial infection case were 4070.61 litas (95% CI, 2782.44-5365.22). Nosocomial infection prevention programs (interventions) gave a total economical effect of 20046.14 litas. Prevention of one patient from nosocomial infection caused a reduction of 1336.41 litas, and one avoided nosocomial infection case resulted in a 1113.67-litas reduction; cost-to-effect ratio was 1:4.CONCLUSIONS:Total costs related to nosocomial infections in pediatric intensive care units were high. The implementation of nosocomial infection prevention program resulted in a positive economic effect - 1 litas spent for the prevention of nosocomial infections saved 4 litas.

OBJECTIVE:The aim of the study was to identify the most important risk factors for nosocomial infections, evaluate the incidence rates and risk changes after the multimodal intervention, and to assess mortality attributable to nosocomial infections.MATERIAL AND METHODS:This was a prospective surveillance study. Data were collected from January 2005 until December 2007 in three pediatric intensive care units. All patients aged between 1 month and 18 years hospitalized in units for more than 48 hours were included in the study. The patients were divided into preintervention (2006) and postintervention (2007) groups. The multimodal intervention included education of the staff and implementation of evidence-based infection control measures.RESULTS:A total of 755 children were included in the study. Major risk factors for nosocomial infections were identified: mechanical ventilation, central line, intracranial pressure device, and tracheostomy. Overall, the incidence rate (15.6 vs. 7.5 cases per 100 patients, P=0.002), incidence density (19.1 vs. 10.4 cases per 1000 patient-days, P=0.015), and the incidence of pneumonia (5.6 vs. 1.9 per 100 patients, P=0.016) have decreased in the postintervention as compared with the preintervention group. The relative risk reduction, absolute risk reduction, and number needed to treat were statistically significant for ventilator-associated pneumonia (66.5%, 3.7%, 27, respectively; P=0.016). There was no significant difference in survival time by the presence of nosocomial infection (83.67 patient-days without vs. 74.33 patient-days with infection, P>0.05)CONCLUSIONS:The most important risk factors for nosocomial infections were mechanical ventilation, central line, intracranial pressure device, and tracheostomy. After the multimodal intervention, there was a statistically significant decrease in the incidence rates of nosocomial infections and the risk reduction for ventilator-associated pneumonia. No significant impact of nosocomial infections on mortality was determined.