Significant increase in the prevalence of erythromycin-resistant,clindamycin- and miocamycin-susceptible (M phenotype) Streptococcus pyogenes in Spain

In 1998 we conducted a multicentre study in Spain on the susceptibility of Streptococcus pyogenes isolates to different 14-, 15- and 16-membered macrolides and clindamycin, in which the number of strains examined was proportional to the number of inhabitants in each geographical area. The aim of the present work was to re-examine the antimicrobial susceptibility of S. pyogenes in 2001, using the same methodology and centres as in 1998, to determine the different susceptibility phenotypes to macrolides-lincosamides, and to compare the results from the 2 years by statistical tests. A total of 529 unique isolates of S. pyogenes, collected in 21 laboratories, were studied. Throat swabs provided 417 isolates (78.8%), and the remaining 112 were from other sources. Four hundred and thirty-five (82.2%) were isolated from children and 94 (17.8%) from adults. One hundred and fifty-seven (29.7%) of the isolates were resistant to erythromycin and azithromycin, whereas resistance to miocamycin, a 16-membered macrolide, was 1.5%. The prevalence of resistance to clindamycin was 1.3%. The majority (98.7%) of the 157 erythromycin-resistant strains presented the M phenotype. When we compared the results obtained in 1998 and 2001, we observed a statistically significant increase in resistance to erythromycin and azithromycin (P = 0.02, chi(2) test), but not to clindamycin or miocamycin (P = 0.47, chi(2) test with Yates' correction). The significant increase in the prevalence of resistance to some macrolides of S. pyogenes in Spain underscores the need for continuous surveillance of antimicrobial resistance in this species.     

Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study

ObjectiveThe objective of this investigation was to compare the value of primary spine care (PSC) with usual care for management of patients with spine-related disorders (SRDs) within a primary care setting.MethodsWe retrospectively examined existing patient encounter data at 3 primary care sites within a multi-clinic health system. Designated clinicians serve in the role as PSC as the initial point of contact for spine patients, coordinate, and follow up for the duration of the episode of care. A PSC may be a chiropractor, physical therapist, or medical or osteopathic physician who has been trained to provide primary care for patients with SRDs. The PSC model of care had been introduced at site I (Lebanon, New Hampshire); sites II (Bedford, New Hampshire) and III (Nashua, New Hampshire) served as control sites where patients received usual care. To evaluate cost outcomes, we employed a controlled quasi-experimental design for analysis of health claims data. For analysis of clinical outcomes, we compared clinical records for PSC at site I and usual care at sites II and III, all with reference to usual care at site I.We examined clinical encounters occurring over a 24-month period, from February 1, 2016 through January 31, 2018.ResultsPrimary spine care was associated with reduced total expenditures compared with usual care for SRDs. At site I, average per-patient expenditure was $162 in year 1 and $186 in year 2, compared with site II ($332 in year 1; $306 in year 2) and site III ($467 in year 1; $323 in year 2).ConclusionAmong patients with SRDs included in this study, implementation of the PSC model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.     

Multicenter Study on Spreading of the tet(M) Gene in Tetracycline-Resistant Streptococcus Group G and C Isolates in Argentina

A prospective multicenter study on invasive infections caused by beta-hemolytic streptococci was performed over 6 months and involved 42 centers from 16 cities in Argentina. Among 33 isolates recovered, 9 group G Streptococcus isolates (39.1%) and 2 group C Streptococcus isolates (20%) exhibited resistance to tetracycline and harbored the tet(M) gene. Genealogical analysis revealed that tetracycline resistance has a polyclonal origin in Argentina.     

Antimicrobial Susceptibilities of 1,684 Streptococcus pneumoniae and 2,039 Streptococcus pyogenes Isolates and Their Ecological Relationships: Results of a 1-Year (1998–1999) Multicenter Surveillance Study in Spain

A nationwide multicenter susceptibility surveillance study which included 1,684 Streptococcus pneumoniae and 2,039 S. pyogenes isolates was carried out over 1 year in order to assess the current resistance patterns for the two most important gram-positive microorganisms responsible for community-acquired infections in Spain. Susceptibility testing was done by a broth microdilution method according to National Committee for Clinical Laboratory Standards M100-S10 interpretative criteria. For S. pneumoniae, the prevalences of highly resistant strains were 5% for amoxicillin and amoxicillin-clavulanic acid; 7% for cefotaxime; 22% for penicillin; 31% for cefuroxime; 35% for erythromycin, clarithromycin, and azithromycin; and 42% for cefaclor. For S. pyogenes, the prevalence of erythromycin resistance was 20%. Efflux was encountered in 90% of S. pyogenes and 5% of S. pneumoniae isolates that exhibited erythromycin resistance. Erythromycin resistance was associated with clarithromycin and azithromycin in both species, regardless of phenotype. Despite the different nature of the mechanisms of resistance, a positive correlation (r = 0.612) between the two species in the prevalence of erythromycin resistance was found in site-by-site comparisons, suggesting some kind of link with antibiotic consumption. Regarding ciprofloxacin, the MIC was >or=4 microg/ml for 7% of S. pneumoniae and 3.5% of S. pyogenes isolates. Ciprofloxacin resistance (MIC, >or=4 microg/ml) was significantly (P < 0.05) associated with macrolide resistance in both S. pyogenes and S. pneumoniae and with penicillin nonsusceptibility in S. pneumoniae.     

Baseline Characteristics May Help Indicate the Best Choice of Health Care Provider for Back Pain Patients in Primary Care: Results From a Prospective Cohort Study

ObjectiveBaseline characteristics of patients low back pain differ substantially between care settings, but it is largely unknown whether predictors are of equal importance across settings. The aim of this study was to investigate whether 8 known predictors relate differently to outcomes in chiropractic practice and in general practice and to which degree these factors may be helpful in selecting patients benefiting more from one setting or the other.MethodsPatient characteristics were collected at baseline, and outcomes of pain intensity (numeric rating scale 0-10) and activity limitation (Roland-Morris Disability Questionnaire 0-100) after 2, 12, and 52 weeks. Differences in the prognostic strength between settings were investigated for each prognostic factor separately by estimating the interaction between setting and the prognostic factor using regression models. Between-setting differences in outcome in high-risk and low-risk subgroups, formed by single prognostic factors, were assessed in similar models adjusted for a propensity score to take baseline differences between settings into account.ResultsPrognostic factors were generally associated more strongly with outcomes in general practice compared with chiropractic practice. The difference was statistically significant for general health, duration of pain, and musculoskeletal comorbidity. After propensity score adjustment, differences in outcomes between settings were insignificant, but negative prognostic factors tended to be less influential in chiropractic practice except for leg pain and depression, which tended to have less negative impact in general practice.ConclusionKnown prognostic factors related differently to outcomes in the 2 settings, suggesting that some subgroups of patients might benefit more from one setting than the other.     

深圳地区儿童A群致病性链球菌感染流行现状及M蛋白基因分型分析

目的 了解深圳地区儿童A群致病性链球菌(group A streptococcus,GAS)感染流行现状及其M蛋白基因(emm)分布状况,为该区GAS疫苗的研制提供科学依据。方法 收集2014年3月～2015年12月来医院门诊和住院部就诊的急性咽炎、急性化脓性扁桃体炎、风湿热及猩红热患儿的咽拭子及皮肤化脓性感染伤口分泌物共1 634例,分别对标本进行细胞培养与鉴定,分析不同年龄儿童GAS感染流行情况,并对GAS的M蛋白N末端进行PCR扩增测序,分析GAS的emm基因分型及其在疾病中的分布情况。结果 1 634例标本中共分离鉴定出61株GAS,检出率为3.73%(61/1 634),其中学龄前和学龄儿童分别检测出14株和47株,检出率分别为22.95%(14/61)和77.05%(47/61),学龄儿童GAS感染率明显高于学龄前儿童,两者结果之间差异有统计学意义(χ2=32.035,P<0.01),但学龄儿童不同年龄段GAS感染率之间比较差异无统计学意义(χ2=1.572,P>0.05); GAS在急性咽炎和化脓性扁桃体炎的患儿中检出率最高,分别为34.43%(21/61)和27.87%(17/61); 61株GAS的emm基因型以emml和emm12最为多见,分别占40.98%(25/61)和29.51%(18/61)。结论 深圳地区学龄儿童GAS感染率明显高于学龄前儿童,且以急性咽炎和急性化脓性扁桃体炎患儿检出率最高。61株GAS感染的emm基因以emm1和emm12为主,因此,各地加强GAS的emm基因分型研究,可为该区GAS疫苗的研制提供重要的分子流行病学依据。     

Prospective study of high-sensitivity C-reactive protein as a determinant of mortality: results from the MONICA/KORA Augsburg Cohort Study, 1984-1998

BACKGROUND: C-reactive protein (CRP), an exquisitely sensitive systemic marker of inflammation, has emerged as an independent predictor of cardiovascular diseases (CVD). Because other chronic diseases are also associated with an inflammatory response, we sought to assess the association of high-sensitivity CRP (hsCRP) with total and cause-specific mortality in a large cohort of middle-aged men. METHODS: We measured hsCRP at baseline in 3620 middle-aged men, randomly drawn from 3 samples of the general population in the Augsburg area (Southern 0Germany) in 1984-85, 1989-90, and 1994-95. Outcome was defined as all deaths, fatal CVD, fatal coronary heart disease (CHD) including sudden cardiac deaths, and cancer deaths. RESULTS: During an average follow-up of 7.1 years, 408 deaths occurred (CVD 196, CHD 129, cancer 127). In multivariable Cox regression analysis, subjects with hsCRP >3 mg/L at baseline showed an almost 2-fold increased risk to die vs those with hsCRP <1 mg/L [hazard ratio (HR) 1.88, 95% CI 1.41-2.52]. HRs were 2.15 (95% CI 1.39-3.34) for fatal CVD, 1.74 (1.04-2.92) for fatal CHD, and 1.65 (1.01-2.68) for cancer mortality. In contrast, neither total nor HDL cholesterol significantly predicted all-cause or cancer mortality, and cholesterol had only modest effects on CVD mortality. CONCLUSIONS: Our results suggest that increased circulating hsCRP concentrations are associated with an increased risk of death from several widespread chronic diseases. Persistently increased hsCRP is a sensitive and valuable nonspecific indicator of an ongoing disease process that deserves serious and careful medical attention.     

Mental Health Nurses Supporting the Routine Assessment of Anxiety of Older People in Primary Care Settings: Insights from an Australian Study

Anxiety in older age is a worldwide problem and co-associated with other mental health problems, physical health conditions, disability, reduced quality of life and increased healthcare utilisation. Yet the symptoms of anxiety are often unrecognised in older people, challenging early diagnosis and increasing the risk of older people developing more chronic and disabling illness. This article reports on research led by mental health nurses and a primary care nurse that supported primary care practitioners to undertake a routine assessment of anxiety in older people in Australia. The Geriatric Anxiety Inventory-Short Form was incorporated into the annual, in-depth 75?years and older, health assessment that is undertaken in primary care settings and funded by Australia’s Medicare. An initial feasibility study demonstrated good acceptance levels of the routine assessment by the primary care practitioners. These findings suggest fertile ground for the everyday use of the routine assessment in primary care settings in Australia, with transferability internationally in low-, middle- and high-income global communities. Mental health nurses can play a key role in supporting primary care nurses to recognise and respond to anxiety in older people. Illness prevention and health promotion activities are low cost and have the potential to make a difference worldwide to the health of people across the lifespan.     

Differences in the DNA sequences in the upstream attenuator region of erm(A) in clinical isolates of Streptococcus pyogenes and their correlation with macrolide/lincosamide resistance

The regulatory regions of 52 erm(A) [formerly erm(TR)] clinical Streptococcus pyogenes isolates were studied. Differences in the upstream regulatory region of erm(A) correlated with macrolide/lincosamide resistance patterns. Nine macrolide/lincosamide/streptogramin B-resistant isolates had changes in the leader sequence of erm(A) including base changes, insertions, or deletions. Isolates were also emm typed.     

A Cross-Sectional Study to Investigate the Effects of Perceived Discrimination in the Health Care Setting on Pain and Depressive Symptoms in Wheelchair Users With Spinal Cord Injury

ObjectivesIn a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which participant characteristics are associated with greater perceived discrimination in the health care setting, and how such discrimination relates to health outcomes of pain and depressive symptoms.DesignSurvey, cross-sectional.SettingSpinal Cord Injury Model Systems (SCIMS) Center.ParticipantsFull-time wheelchair users with SCI from 9 SCIMS centers (N=410), with data collected between 2011 and 2016.InterventionsN/A.Main OutcomesA 7-item questionnaire inquiring about perceived discrimination by hospital staff, self-reported pain severity over the past month using a 0-10 Numeric Rating Scale, and depressive symptoms using the 2-question Patient Health Questionnaire screener.ResultsParticipants who were black or from the lowest income group were more likely to report experiencing more discrimination than those who were white or from the highest income group, respectively (incidence rate ratio=2.2-2.6, P<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (relative risk [RR]=1.11; 95% confidence interval [95% CI], 1.01-1.23; P<.05), mild depressive symptoms (RR=1.09; 95% CI, 1.02-1.17; P<.05), and severe depressive symptoms (RR=1.12; 95% CI, 1.04-1.21; P<.05) compared to no symptoms.ConclusionsWheelchair users with SCI who were from more disadvantaged groups (black, lower income levels) reported experiencing more discrimination in their health care setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in health care settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the effect of discrimination on the many facets of living with an SCI.     

High prevalence of antibiotic resistance of common pathogenic bacteria in Taiwan. The Antibiotic Resistance Study Group of the Infectious Disease Society of the Republic of China

We analyzed the antimicrobial susceptibilities of all clinical isolates of 14 common pathogenic bacteria recovered from patients in eight medical centers in Taiwan during 1995 and 1996. Susceptibility to commonly used antimicrobial agents was tested by the disk diffusion method as recommended by the National Committee for Clinical Laboratory Standards. Of the Staphylococcus aureus isolates, 59.3% and 62% were oxacillin-resistant in 1995 and 1996, respectively, whereas 63.2% of the coagulase-negative staphylococci isolates during the study period were oxacillin-resistant. The rate of penicillin-resistance among Streptococcus pneumoniae isolates was 39.7% in 1995 and 53.7% in 1996. Macrolide-resistance was found in 71.4%, 42.1%, and 46.7% of S. pneumoniae, beta-hemolytic streptococci, and viridans streptococci, respectively, in 1996. Less than 2% of the enterococcal isolates were vancomycin resistant, but 77% of them were gentamicin resistant. Resistance to gentamicin was also common in Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Various degrees of resistance to ampicillin, piperacillin, cephalosporins, aztreonam, and ciprofloxacin were detected in Enterobacteriaceae, P. aeruginosa, and A. baumannii. More than 55% of Haemophilus influenzae isolates were ampicillin resistant. In summary, resistance to many antimicrobial agents in various common pathogenic bacteria is very common in Taiwan. Our results implicate that antibiotic resistance in the developing countries need to be monitored closely.