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  • CMLIntroduction
    R factors became dominant Already in the late 1940 ies penicillinase producing Staphylococcus aureus was described in Denmark by Eriksen 3 Lund 4 1956 and Siboni 5 1960 in their dissertations described the distribution of antibiotic resistant S aureus among patients and personnel in hospitals 4 5 that carriers were twice as prone to get staphylococcal infections and in 2 3 due to the strains carried 5 and the difficult prophylaxis due to antibiotic selection 5 then by penicillin and streptomycin They were supported from 1957 by the new phage typing laboratory part of the Department of Hospital Infections Statens Seruminstitut SSI 6 Cumulations later quoted of infections due to other species of microorganisms revived the scope of epidemiological interest exemplified by the dissertations of the Oerskovs 7 8 and by Jepsen s 9 10 dissertation 1970 on the mechanisms of infection in hospitals At the end of 1950 ies KA Jensen professor of general pathology University of Copenhagen recommended the erection of laboratories of Clinical Microbiology CM in the central county hospitals established by the SSI from 1963 and from 1986 by county or metropolitan administrations The organization of these departments and their patients responsabilities have been described by

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  • CMLMethods
    or taxa or 2 by the repeated isolation of strains unusual as regards species or sensitivity pattern other type characters 12 i e by the taxon 3 Comments on antibiotic consumption and resistance In all cases Electronic Data Processing EDP has proved useful Registration hereby was performed at Odense University Hospital since 1974 of specimens from selected wards 13 since 1986 of all specimens examined 14 with great advantages 15

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  • CMLResults,1-2
    3 per 1000 children 14 years Source Pig faeces Prevention better food hygiene less pig manure 44 2 2 By the repeated isolation of the same taxon Tables I II S aureus The dominant strains of phage group I resistant to penicillin P and streptomycin S were towards the end of the 1950 ies replaced by strains also resistant to tetracycline T phage type 83A 45 and worse 1965 69 by strains also resistant to methicillin M which c 1970 amounted to 25 46 They declined 1970 1984 to 1 47 but imported strains may spread in Danish hospitals 48 49 50 These epidemiological changes have been synthesized in dissertations by Bülow 51 and by Westh 52 from investigations started in different hospitals and rounded up in the Phage Typing Laboratory SSI since 1957 collecting all S aureus isolates 53 Insuffucient diagnostics and or technique led to arthritis or bursitis in nine patients 54 Recent developments are the increasing frequency of resistance to erythromycin E 52 and of vertebral osteomyelitis 55 The higher infection rate in carriers 5 also proved to be true with haemo and peritoneal dialysis patients 16 9 versus 6 1 in non carriers 56 see also table I 46 47 48 49 50 54 Coagulase negative staphylococci CoNS there of 80 Staphylococcus epidermidis Colonization with methicillin R strains of patients after open heart surgery was reduced from 80 to 40 after their isolation in cubicles in the ICU with perioperative methicillin for three days instead of seven 57 58 se also table I 57 Multiresistant strains with frequencies of 28 6 44 4 and 92 3 correlated to antibiotic consumptions of 3 755 5 302 and 16 136 DDD per year 59 so the frequency of antibiotic resistance revealed the need to alterations in antibiotic regimen 60 see also table I 61 62 Streptococcus pyogenes group A T type 1 gave 1987 89 148 community acquired bacteraemias and 94 nosocomial 63 and type 28 and type T3 13 B3264 gave outbreaks of puerperal feber 64 65 Also a surgical team has been the source of postoperative infection 66 In institutions for the mentally retarded 90 persons had infections due to M type 18 Six patients died 67 Tetracycline resistant strains of group G table I 68 Group B Streptococcus agalactiae Four of eight new born with meningitis died 1965 76 After the changing of treatment 1977 to benzylpenicillin 120 mg kg day for 21 days and streptomycin 30 mg kg day eight of eight infants survived 1977 80 69 Other surveys 70 71 72 where the three of four meningitis infants treated with ampicillin and aminoglycoside survived 70 Streptococcus pneumoniae table I 73 Neisseria meningitidis table I 74 Acinetobacter calcoaceticus see table I 75 Legionella pneumophila type 5 infected four kidney transplanted patients two died 76 Precautions reduced Legionella in tap water and in ice machines There are still sporadic cases in Danish hospitals 77 and since 2000 only sterile water has been used in the

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  • 3
    a urological department halved the amount used of antibiotics and the corresponding resistance traits 109 see also 2 2 9 5 89 In Odense University Hospital the amount used 1965 was 301 DDD 1000 beddays 46 quantitatively unchanged 1990 110 293 but with tetracycline and chloramphenicol reduced from 17 5 to 2 8 and from 14 6 to 0 4 respectively and with erythromycin increased from 0 91 to 17 2 The amount used increased 1997 to 416 DDD 1000 beddays 111 The use in Hvidovre University Hospital was 1987 350 and 1996 397 DDD 1000 beddays 112 and 1991 in another metropolitan hospital 247 113 Under these conditions the frequencies 1997 at the two university hospitals of S aureus resistant to methicillin were 0 1 and 0 7 resp of S pneumoniae resistant to penicillin MIC 0 1 mg l 2 1 and 0 9 of H influenzae resistant to ampicillin 6 6 and 19 6 and of E coli resistant to ampicillin 41 and 32 112 The correlation between antimicrobial use and microbial resistance has been analysed extensively in the dissertations of Søgaard 114 and of Møller 16 and not least the phenomenon of co selection It should

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  • Discussion
    consisting of species or at least a biochemically characterized group and resistance type plus other type characters This is true with most of the cumulations included in table I and 25 35 37 41 65 73 102 111 112 117 With rare patterns observed once a months out of at least a few hundreds of rare patterns the isolation of two such strains within a month constitutes an epidemic e g 101 because the probability to isolate one more by chance will be 0 01 This is true with the cumulations listed in table II and it is true also with Streptococcus pyogenes in a maternity or surgical ward 63 64 65 The question in tracing of the source is Which procedure or misuse of the manual has left these clues or traces The problem is the same as described for archaeology or criminology by Ginzburg 116 This tracing and unveiling after recognition of the cumulation may take some time in table I months or weeks in table II often weeks or a few days perhaps due to the increasing experience of the clinical microbiologist The success of the unveiling is made probable by the finding of a possible source

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  • References
    staff of the County hospitals in Funen Ugeskr Læger 1979 141 2525 2527 Jensen ET Christensen M Meyer M Et tiltagende problem på sygehusene Sygeplejersken 1999 1 48 52 65 Astrup I Prag J Ascariasis i Danmark Zoonoser Maanedsskr Prakt Lægegern 2002 80 1741 1747 Rosendal K Jessen O Epidemic spread of S aureus phage type 83A Acta path microbiol scand 1964 60 571 576 Siboni K Poulsen ED The dominance of methicillin resistant staphylococci in a county hospital Dan Med Bull 1968 15 161 165 Ipsen T Gahrn Hansen B Occurrence of methicillin resistant S aureus in a department of orthopedic surgery Eur J Clin Microbiol Inf Dis 1988 7 400 403 Espersen F Nielsen PB Lund K Sylvest B Jensen K Hospital acquired infections in a burns unit caused by an imported strain of Staphylococcus aureus with unusual multiresistence J Hyg Camb 1982 88 535 541 Schlünzen L Lund B Schouenborg P Skov RL Outbreak of methicillin resistant Staphylococcus aureus Ugeskr Læger 1997 159 431 435 Haahr V Pedersen K Møller JK Spread of imported methicillin resistant Staphylococcus aureus strain within a Danish surgical ward Ugeskr Læger 1996 158 3471 3472 Bülow P Staphylococci in Danish hospitals during the last decade Ann NY Acad Sci 1971 182 21 39 Westh H Erythromycin resistant S aureus in Denmark APMIS 1996 104 suppl 57 1 37 Schønheyder H Jensen KT Pers C Korsager B Rosdahl VT Spread of Staphylococcus aureus strains of phage type 95 in Denmark 1968 1989 J Hosp Inf 1992 20 25 34 Bak K Haugegaard M Heltberg O Purulent arthritis after injection of depot steroids Ugeskr Læger 1993 155 1047 49 Jensen AG Espersen F Skinhøj P Rosdahl VT Frimodt Møller N Increasing frequency of vertebral osteomyelitis following S aureus bacteraemia in Denmark 1980 90 J Inf 1997 34 113 118 Zimakoff J Pedersen FB Bergen L Baagø Nielsen J Daldorph B Espersen F Gahrn Hansen B Høiby N Jepsen OB Joffe P Kolmos HJ Klausen M Kristoffersen K Ladefoged J Olesen Larsen S Rosdahl VT Scheibel J Storm B Tofte Jensen P and additional members of The Danish Study Group of Peritonitis in Dialysis DASPID Staphylococcus aureus carriage and infections among patients in four haemo and peritoneal dialysis centres in Denmark J Hosp Inf 1996 33 289 300 Gahrn Hansen B The occurrence of Staphylococcus epidermidis in a department of thoracic and cardiovascular surgery Scand J Thor Cardiovasc Surg 1982 16 269 274 Gahrn Hansen B Coagulase negative staphylococci and micrococci in clinical microbiology diss Dan Med Bull 1987 34 96 115 Gahrn Hansen B Consumption of antibiotics in three clinical departments and antimicrobial susceptibility of clinically significant isolates of coagulase negative Micrococcaceae Acta path microbiol immunol scand 1985 B 93 341 346 Jarløv JO Phenotypic characteristics of coagulase negative staphylococci typing and antibiotic susceptibility APMIS 1999 107 suppl 91 1 42 Bülow P Sørensen I opportunistic bacteria and their susceotibility against antibiotics In Nordbring F Bergan T Boréus LO Holm SE eds ASTRA symposium om parenteral intensivterapi med antibiotika p 215 226 ASTRA Läkemedel AB Stockholm 1976 Møller JK Observations on multiple drug resistance in coagulase negative staphylococci isolated in hospitals from 1975 to 1985 J Hosp Inf 1988 11 26 35 Strøbæk S Jepsen OB Zimakoff J Rønne T Increased number of nosocomial group A streptococcal bacteraemias during a community epidemic J Hosp Inf 1991 19 129 136 Strøbæk S Zimakoff J Kristensen KF Borgen H Sørensen L Puerperal fever The elucidation of a group A streptococcal epidemic using case control analysis Ugeskr Læger 1997 159 4117 4122 Ejlertsen T Prag J Pettersson E Holmskov A A 7 months outbreak of relapsing postpartum group A streptococcal infections linked to a nurse with atopic dermatitis Scand J Infect Dis 2001 33 734 737 Kolmos HJ Svendsen RN Nielsen SV The surgical team as a source of postoperative wound infections caused by Streptococcus pyogenes J Hosp Inf 1997 35 207 214 Kristensen B Egelund B Meyer M Henrichsen J Jepsen OB Sievers CJ Lundstedt C Outbreak of group A streptococcal infections in institutions for the mentally retarded in Greater Copenhagen 1995 Ugeskr Læger 1996 158 1679 1682 From E Heydenreich G Siboni K Tetracycline resistant haemolytic streptococci in patients with leg ulcers Acta dermatoven 1972 52 67 70 Christensen HO Kamper J Olsen H Siboni K Treatment of meningitis in infants caused by group B streptococci using benzylpenicillin and streptomycin Dan Med Bull 1983 30 416 418 Friis Møller A Busk HE Korner B al Infections and colonizations with hemolytic streptococci group B in a Danish neonatal intensive care unit Dan Med Bull 1984 31 494 499 Carstensen H Henrichsen J Jepsen OB A national survey of severe group B streptococcal infections in neonates and young infants in Denmark 1978 83 Acta paediat scand 1985 74 934 941 Kristensen B Schønheyder HC A 13 year survey of bacteraemia due to ß haemolytic streptococci in a Danish county Med Microbiol 1995 43 63 67 Folkersen BH Højbjerg T Urth TR Schønheyder HC Nosocomial infections with penicillin resistant Streptococcus pneumoniae Four Danish clusters with serotype 9V Ugeskr Læger 2001 163 2362 2365 Eriksen NHR Espersen F Laursen L Skinhøj P Høiby N Lind I Nosocomial outbreak of group C meningococcal disease BMJ 1989 298 568 569 Gerner Smidt P Hansen L Knudsen A Siboni K Søgaard I Epidemic spread of Acinetobacter calcoaceticus in a neurosurgical department analyzed by electronic data processing Gahrn Hansen B Uldum SA Schmict J Nielsen B Birkeland SA Jørgensen KA Nosocomial infection with Legionella pneumophila in a department of nephrology Ugeskr Læger 1995 157 590 594 Asbjørn J Andersen H K Legionella pneumophila i det varme brugsvand på danske sygehuse og institutioner Ugeskr Læger 1995 157 586 590 Kolmos HJ Nielsen B Gahrn Hansen B Legionella in Odense University Hospital What happened Ugeskr Læger 2001 163 5384 5385 Jepsen OB Uldum SA Samuelsson S Surveillance and prevention of nosocomial Legionella pneumonia Ugeskr Læger 2002 165 21 26 Søgaard P Laboratorieinfektioner memento Nyt om

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  • Table I
    meningosepticum Other carriers 14 days 2 days Enforced asepsis 1989 104 Infectious diseases 18 HIVpos 4 died gastro enteritis Cryptosporidium parvum Inc patient via ice machine 2 weeks 10 weeks Access to ice machine restricted 1991 64 Maternity 7 puerperal fever wound infection Streptococcus pyogenes type 28 Personnel family 14 days 5 weeks Enforced prevention of indirect contact 1990 91 66 Orthopedic surgery 3 wound infection septicaemia Streptococcus pyogenes type 28 Surgeon throat carrier 3½ months 2 days Carriers treated with penicillin vancomycin 1991 99 ICU Burns unit 5 septicaemia 4 carriers Pseudomonas aeruginosa Tap water for irrigation 3 days 2 weeks Heat disinfection of shower heads 1991 92 80 81 Clinical microb Lab 3 brucellosis Brucella melitensis Patients specimens 3 weeks Class II bench for blood cultures 1993 76 Nephrology 4 2 died peumonia Legionella pneumophila Tap water Sterile water for the immunosuppressed 1990 93 54 General practice 9 arthritis or bursitis Staphylococcus aureus Injection of steroid 2 years 1 month Improved diagnostics asepsis 1994 49 Surgery ICU 1 wound 1 UTI 5 RespTI 1wound S aureus MR A S aureus MR B S aureus MR C Transferred From abroad Not traced 1day 6 weeks 3days 6 weeks 3 days 6 weeks Isolation Information Chlorhexidine Mupirocin 350 not colonized 1996 50 Surgery 1 bacteraemia 1 carrier S aureus MR Patient from abroad 2 days 2 weeks Isolation Information from referring hospital 1996 99 73 4 wards of Intern Med 11 pneumonia septicaemia S pneumoniae penicillin R 4 patients Isolation 1998 65 Maternity 16 puerperal fever wound infection S pyogenes type T3 13 B3264 Nurse with atopic dermat 4½ months 2 months Carriers treated aseptic procedures stressed 2000 105 Int medicine 13 scabies S scabiei Index patient 14 days 8 months Permethrin ivermectin 2000 106 Dermatology geriatrics 77 scabies S

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