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1.  Nasopharyngeal Carriage of Streptococcus pneumonia in Pneumonia-Prone Age Groups in Semarang, Java Island, Indonesia 
PLoS ONE  2014;9(1):e87431.
Streptococcus pneumoniae is a worldwide occurring pathogen Nasopharyngeal carriage of Streptococcus pneumoniae precedes pneumonia and other pneumococcal diseases in the community. Little is known about S. pneumoniae carriage in Indonesia, complicating strategies to control pneumococcal diseases. We investigated nasopharyngeal carriage of S. pneumoniae in Semarang, Indonesia.
A population-based survey was performed in Semarang, Indonesia. Nasopharyngeal swabs and questionnaires were taken from 496 healthy young (6–60 month-old) children and 45–70 year-old adults.
Forty-three percent of children aged 6–60 months and 11% of adults aged 45–75 years carried S. pneumoniae. Determinants of carriage were being a child (OR 7.7; 95% CI = 4.5–13.0), passive smoking (OR 2.1; 95% CI = 1.3–3.4), and contact with toddler(s) at home (OR 3.0; 95% CI = 1.9–4.7). The most frequent serotypes found were 6A/B and 15B/C. The current commercially available vaccines cover <50% serotypes found in children. Twenty-four percent of S. pneumoniae strains were penicillin non-susceptible, and 45% were resistant to cotrimoxazol.
The limited coverage of commercially available vaccines against the serotypes found in this population, and the high proportion of non-susceptibility to penicillin and cotrimoxazol suggest the need for region-specific information and strategies to control S. pneumoniae.
PMCID: PMC3909120  PMID: 24498104
2.  Nasopharyngeal Carriage of Klebsiella pneumoniae and Other Gram-Negative Bacilli in Pneumonia-Prone Age Groups in Semarang, Indonesia 
Journal of Clinical Microbiology  2013;51(5):1614-1616.
Gram-negative bacilli (GNB) cause many cases of pneumonia in Indonesia. We investigated nasopharyngeal carriage of GNB in Semarang, Indonesia. Klebsiella pneumoniae carriage in adults (15%) was higher than in children (7%) (P = 0.004), while that of other GNB was comparable. Poor food and water hygiene are determinants of carriage of these bacteria.
PMCID: PMC3647929  PMID: 23486716
3.  Three-Dimensional Human Skin Equivalent as a Tool To Study Acinetobacter baumannii Colonization 
Acinetobacter baumannii can colonize body surfaces of hospitalized patients. From these sites, invasion into the host and spread to other patients and the hospital environment may occur. The eradication of the organism from the patient's skin is an important infection control strategy during epidemic and endemic episodes. In this study, a three-dimensional (3D), air-exposed human epidermal skin equivalent was exploited to study Acinetobacter skin colonization. We characterized the adherence of A. baumannii ATCC 19606T and Acinetobacter junii RUH2228T to and biofilm formation on the skin equivalent and the responses to these bacteria. Furthermore, we assessed the ability of the disinfectant chlorhexidine to decolonize the skin equivalents. The results revealed that both strains replicated on the stratum corneum for up to 72 h but did not invade the epidermis. A. baumannii, in contrast to A. junii, formed large biofilms on the stratum corneum. Bacterial colonization did not affect keratinocyte activation, proliferation, or differentiation, nor did it induce a strong inflammatory response. Disinfection with chlorhexidine solution resulted in complete eradication of A. baumannii from the skin, without detrimental effects. This 3D model is a promising tool to study skin colonization and to evaluate the effects of novel disinfectant and antimicrobial strategies.
PMCID: PMC3346587  PMID: 22290957
4.  Appropriate use of indwelling urethra catheters in hospitalized patients: results of a multicentre prevalence study 
BMC Urology  2012;12:25.
Although indwelling urethra catheterization is a medical intervention with well-defined risks, studies show that approximately 14–38% of the indwelling urethra catheters (IUCs) are placed without a specific medical indication. In this paper we describe the prevalence of IUCs, including their inappropriate use in the Netherlands. We also determine factors associated with inappropriate use of IUCs in hospitalized patients.
In 28 Dutch hospitals, prevalence surveys were performed biannually in 2009 and 2010 within the PREZIES-network. All patients admitted to a participating hospital and who had an IUC in place at the day of the survey were included. Pre-determined criteria were used to categorize the indication for catheterization as appropriate or inappropriate.
A total of 14,252 patients was included and 3020 (21.2%) of them had an IUC (range hospitals 13.4-27.3). Initial catheter placement was inappropriate in 5.2% of patients and 7.5% patients had an inappropriate indication at the day of the survey. In multivariate analyses inappropriate catheter use at the time of placement was associated with female sex, older age, admission on a non-intensive care ward, and not having had surgery. Inappropriate catheter use at the time of survey showed comparable associated factors.
Although lower than in many other countries, inappropriate use of IUC is present in Dutch hospitals. To reduce the inappropriate use of IUCs, recommended components of care (bundle for UTI), including daily revision and registration of the indication for catheterization, should be introduced for all patients with an IUC. Additionally, an education and awareness campaign about appropriate indications for IUC should be available.
PMCID: PMC3502298  PMID: 22954383
Catheterization; Hospitalized patients; Inappropriate use; Prevalence study; Urethra catheters.
5.  Differences in Acinetobacter baumannii Strains and Host Innate Immune Response Determine Morbidity and Mortality in Experimental Pneumonia 
PLoS ONE  2012;7(2):e30673.
Despite many reports documenting its epidemicity, little is known on the interaction of Acinetobacter baumannii with its host. To deepen our insight into this relationship, we studied persistence of and host response to different A. baumannii strains including representatives of the European (EU) clones I–III in a mouse pneumonia model. Neutropenic mice were inoculated intratracheally with five A. baumannii strains and an A. junii strain and at several days morbidity, mortality, bacterial counts, airway inflammation, and chemo- and cytokine production in lungs and blood were determined. A. baumannii RUH875 and RUH134 (EU clone I and II, respectively) and sporadic strain LUH8326 resulted in high morbidity/mortality, whereas A. baumannii LUH5875 (EU clone III, which is less widespread than clone I and II) caused less symptoms. A. baumannii type strain RUH3023T and A. junii LUH5851 did not cause disease. All strains, except A. baumannii RUH3023T and A. junii LUH5851, survived and multiplied in the lungs for several days. Morbidity and mortality were associated with the severity of lung pathology and a specific immune response characterized by low levels of anti-inflammatory (IL-10) and specific pro-inflammatory (IL-12p40 and IL-23) cytokines at the first day of infection. Altogether, a striking difference in behaviour among the A. baumannii strains was observed with the clone I and II strains being most virulent, whereas the A. baumannii type strain, which is frequently used in virulence studies appeared harmless.
PMCID: PMC3275605  PMID: 22347396
6.  Multidrug-Resistant Acinetobacter baumannii in Veterinary Clinics, Germany 
Emerging Infectious Diseases  2011;17(9):1751-1754.
An increase in prevalence of multidrug-resistant Acinetobacter spp. in hospitalized animals was observed at the Justus-Liebig-University (Germany). Genotypic analysis of 56 isolates during 2000–2008 showed 3 clusters that corresponded to European clones I–III. Results indicate spread of genotypically related strains within and among veterinary clinics in Germany.
PMCID: PMC3322069  PMID: 21888812
zoonoses; Acinetobacter baumannii; animals; veterinary clinics; antimicrobial susceptibility; antimicrobial resistance; DNA fingerprinting; amplified fragment length polymorphism; pulsed-field gel electrophoresis; PFGE; clones; Germany; dispatch
7.  An evidence-based recommendation on bed head elevation for mechanically ventilated patients 
Critical Care  2011;15(2):R111.
A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.
A systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure.
Three trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes.
Although the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.
PMCID: PMC3219392  PMID: 21481251
8.  Cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (Over The Counter) in Surabaya, Indonesia 
BMC Infectious Diseases  2010;10:203.
Antimicrobial resistance is an increasing problem in developing countries and antibiotic use is widespread. Our previous surveys in Java, Indonesia, revealed that most antibiotic use was probably unnecessary or ineffective. The aim of this study was to explore a potential connection between resistance and substandard antibiotics sold in the area.
A cross-sectional field study using the simulated client method was conducted in Surabaya. Five first-line antibiotics were requested with or without prescription (OTC). A certified laboratory analysed the drug content using validated methods. Possible determinants of substandard quality were explored.
In total, 104 samples from 75 pharmacies, ten drug stores and 39 roadside stalls (kiosks) were obtained. Pharmacy employees filled all OTC requests. Three quarters of kiosks sold antibiotics. Antibiotics were dispensed as single blister strips or repackaged (16%) without label. Ninety five percent of samples carried the label of 14 Indonesian manufacturers. The pharmaceutical quality did not meet BP standards for 18% of samples. Deviations (less active ingredient) were small. There was no association between low content and type of outlet, sold with or without prescription, registration type, price or packaging. Median retail prices of products carrying the same label varied up to 20 fold.
Antibiotics were available OTC in all visited pharmacies and sold in the streets of an Indonesian city. Most samples contained an active ingredient. We urge to increase enforcement of existing regulations, including legislation that categorizes antibiotics as prescription-only drugs for all types of medicine outlets, to limit further selection of antimicrobial resistance.
PMCID: PMC2914770  PMID: 20618975
9.  Do Biofilm Formation and Interactions with Human Cells Explain the Clinical Success of Acinetobacter baumannii? 
PLoS ONE  2010;5(5):e10732.
The dramatic increase in antibiotic resistance and the recent manifestation in war trauma patients underscore the threat of Acinetobacter baumannii as a nosocomial pathogen. Despite numerous reports documenting its epidemicity, little is known about the pathogenicity of A. baumannii. The aim of this study was to obtain insight into the factors that might explain the clinical success of A. baumannii.
Methodology/Principal Findings
We compared biofilm formation, adherence to and inflammatory cytokine induction by human cells for a large panel of well-described strains of A. baumannii and compared these features to that of other, clinically less relevant Acinetobacter species. Results revealed that biofilm formation and adherence to airway epithelial cells varied widely within the various species, but did not differ among the species. However, airway epithelial cells and cultured human macrophages produced significantly less inflammatory cytokines upon exposure to A. baumannii strains than to strains of A. junii, a species infrequently causing infection.
The induction of a weak inflammatory response may provide a clue to the persistence of A. baumannii in patients.
PMCID: PMC2874002  PMID: 20505779
10.  Limited value of chest radiography in predicting aetiology of lower respiratory tract infection in general practice 
In patients with lower respiratory tract infection (LRTI), changes on chest radiography are rare but poorly characterised, especially in general practice.
To describe the range of findings on chest radiographs and the associations between these findings and the aetiology of LRTI.
Design of study
A prospective observational study.
General practices in the Leiden region, The Netherlands.
Adult patients with a defined LRTI were included. Standard medical history and physical examination were performed. Sputum, blood, and throat swabs were collected for diagnostic tests. Chest X-ray findings were assessed in relation to the aetiology.
An abnormality on the chest X-ray was observed in 72 (55%) patients. Forty-five patients (35%) had changes due to infection, and 26 (20%) due to pneumonia. Pathogens were detected in 84 patients (33 single bacterial, 43 single viral, and 8 dual). Twelve (29%) patients with a bacterial infection (including dual infections) compared to four (9%) patients with viral infection had pneumonia on the chest X-ray (odds ratio [OR] = 4.0; 95% confidence interval [CI] = 1.2 to 13.8). Using the presence of pneumonia on chest X-ray as a test to predict a bacterial infection, the positive predictive value and the negative predictive value were 75% (CI = 48 to 93%) and 57% (CI = 45 to 69%), respectively.
Pneumonia on the chest X-ray was found more frequently in patients with a bacterial infection than in patients with a viral infection. However, the sensitivity and the specificity are such that pneumonia on the chest X-ray is not a reliable test to discriminate between bacterial and non-bacterial LRTI in the general practice setting.
PMCID: PMC2233958  PMID: 18307852
adult; etiology; primary health care; radiography, thoracic; respiratory tract infections
11.  Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study 
BMJ : British Medical Journal  2006;332(7554):1355.
Objective To compare the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.
Design Randomised, double blind, placebo controlled non-inferiority trial.
Setting Nine secondary and tertiary care hospitals in the Netherlands.
Participants Adults with mild to moderate-severe community acquired pneumonia (pneumonia severity index score ≤ 110).
Interventions Patients who had substantially improved after three days' treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (n = 63) or placebo (n = 56) three times daily for five days.
Main outcome measures The primary outcome measure was the clinical success rate at day 10. Secondary outcome measures were the clinical success rate at day 28, symptom resolution, radiological success rates at days 10 and 28, and adverse events.
Results Baseline characteristics were comparable, with the exception of symptom severity, which was worse in the three day treatment group. In the three day and eight day treatment groups the clinical success rate at day 10 was 93% for both (difference 0.1%, 95% confidence interval - 9% to 10%) and at day 28 was 90% compared with 88% (difference 2.0%, - 9% to 15%). Both groups had similar resolution of symptoms. Radiological success rates were 86% compared with 83% at day 10 (difference 3%, - 10% to 16%) and 86% compared with 79% at day 28 (difference 6%, - 7% to 20%). Six patients (11%) in the placebo group and 13 patients (21%) in the active treatment group reported adverse events (P = 0.1).
Conclusions Discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.
PMCID: PMC1479094  PMID: 16763247
12.  Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review 
BMJ : British Medical Journal  2005;331(7507):26.
Objectives To evaluate the diagnostic accuracy of C reactive protein in detecting radiologically proved pneumonia and to evaluate how well it can discriminate between bacterial and viral infections of the lower respiratory tract.
Data sources Medline and Embase (January 1966 to April 2004), with reference checking.
Study selection We included articles comparing C reactive protein with a chest radiograph or with microbiological work-up as a reference test. Two authors independently assessed methodological items.
Results None of the studies met all validity criteria. Six studies used an infiltrate on chest radiograph as reference test. Sensitivities ranged from 10% to 98%, specificities from 44% to 99%. For adults, the relation of C reactive protein with an infiltrate (in a subgroup analysis of five studies) showed an area under the curve of 0.80 (95% confidence interval 0.75 to 0.85). In 12 studies, the relation of C reactive protein with a bacterial aetiology of infection of the lower respiratory tract was studied. Sensitivities ranged from 8% to 99%, specificities from 27% to 95%. These data were epidemiologically and statistically heterogeneous, so overall outcomes could not be calculated.
Conclusion Testing for C reactive protein is neither sufficiently sensitive to rule out nor sufficiently specific to rule in an infiltrate on chest radiograph and bacterial aetiology of lower respiratory tract infection. The methodological quality of the diagnostic studies is generally poor. The evidence not consistently and sufficiently supports a wide introduction of C reactive protein as a rapid test to guide antibiotics prescription.
PMCID: PMC558535  PMID: 15979984
13.  Pathogens involved in lower respiratory tract infections in general practice. 
BACKGROUND: There are few investigations into the aetiology of lower respiratory tract infections (LRTIs) in general practice. AIM: To describe the aetiology of LRTI among adult patients in general practice in The Netherlands. DESIGN OF STUDY: Prospective observational study. SETTING: General practices in the Leiden region, The Netherlands. METHOD: Adult patients with a defined LRTI were included. Standard medical history and physical examination were performed. Sputum, blood and throat swabs were collected for diagnostic tests. Aetiological diagnosis, categorised as definite or possible, was based on the results of bacterial and viral cultures, serological techniques, and on polymerase chain reaction. Proportions of pathogens causing LRTI were assessed in relation to chest X-ray findings. RESULTS: A bacterial cause was established in 43 (30%), and a viral cause in 57 (39%) of the 145 patients with a LRTI. Influenza virus A was the most frequently diagnosed microorganism, followed by Haemophilus influenzae, and Mycoplasma pneumoniae. Streptococcus pneumoniae was found in 6% of the patients. CONCLUSIONS: Pathogens were found in two-thirds of the patients. In half of these patients there was a viral cause. Influenza virus A was the most frequently found pathogen. The treatment with antibiotics of at least one-third of the patients with LRTI was superfluous. This observation should result in changes in the prescription of antibiotics in LRTI.
PMCID: PMC1314772  PMID: 14965401
14.  A diagnostic rule for the aetiology of lower respiratory tract infections as guidance for antimicrobial treatment. 
BACKGROUND: The majority of patients with lower respiratory tract infections (LRTIs) are treated with antibiotics; some of them are unnecessary because of a viral cause. Information on prediction of the aetiology, especially in a general practice setting, is missing. AIM: To differentiate between viral and bacterial LRTI on simple clinical criteria, easily obtained at the bedside. DESIGN OF STUDY: Prospective observational study. SETTING: General practices in the Leiden region of The Netherlands. METHOD: Adult patients with LRTI were included. Standard medical history and physical examination were performed. Sputum, blood and throat swabs were collected for diagnostic tests. According to microbiological findings, patients were classified as bacterial, viral, dual infection and unknown cause. In a logistic regression model independent predictors were determined. Scoring systems were developed. The accuracies of the diagnostic rules were tested by using receiver operating characteristic (ROC) curves. RESULTS: One-hundred and forty-five patients were classified as having bacterial (n = 35), viral (n = 49), or dual infection (n = 8), or infection of unknown cause (n = 53), respectively. Independent predictors for bacterial infection were fever (odds ratio [OR] = 8.0; 95% confidence interval [CI] = 0.9 to 71.0), headache (OR = 4.3; 95% CI = 1.0 to 19.1) cervical painful lymph nodes (OR = 8.7; 95% CI = 1.1 to 68.0), diarrhoea (OR = 0.3; 95% CI = 0.1 to 1.0) and rhinitis (OR = 0.3; 95% CI = 0.1 to 0.9). As an additional independent predictor, an infiltrate on chest X-ray (OR = 5.0; 95% CI = 1.2 to 20.5) was found. The diagnostic rules developed from these variables classified the aetiology of LRTI with a ROC curve area of 0.79 (clinical score), 0.77 (simplified score) and 0.83 (extended score). CONCLUSIONS: A diagnostic rule was developed, based on information that is easy to obtain at the bedside, to predict a bacterial infection. This diagnostic rule may be a tool for general practitioners in their management of patients with LRTI.
PMCID: PMC1314773  PMID: 14965402
15.  The Synthetic N-Terminal Peptide of Human Lactoferrin, hLF(1-11), Is Highly Effective against Experimental Infection Caused by Multidrug-Resistant Acinetobacter baumannii 
Antimicrobial Agents and Chemotherapy  2004;48(12):4919-4921.
The lactoferrin-derived peptide hLF(1-11), but not its control peptide, was highly effective against five multidrug-resistant Acinetobacter baumannii strains in vitro (3 to 4 log reduction) and against four of these strains in an experimental infection in mice (2 to 3 log reduction). Therefore, this peptide is a promising candidate as a novel agent against infections with multidrug-resistant A. baumannii.
PMCID: PMC529198  PMID: 15561882
16.  Comparison and Evaluation of Real-Time PCR, Real-Time Nucleic Acid Sequence-Based Amplification, Conventional PCR, and Serology for Diagnosis of Mycoplasma pneumoniae 
Journal of Clinical Microbiology  2003;41(9):4366-4371.
Mycoplasma pneumoniae is a common cause of community-acquired pneumonia and lower-respiratory-tract infections. Diagnosis has traditionally been obtained by serological diagnosis, but increasingly, molecular techniques have been applied. However, the number of studies actually comparing these assays is limited. The development of a novel duplex real-time PCR assay for detection of M. pneumoniae in the presence of an internal control real-time PCR is described. In addition, real-time nucleic acid sequence-based amplification (NASBA) on an iCycler apparatus is evaluated. These assays were compared to serology and a conventional PCR assay for 106 clinical samples from patients with lower-respiratory-tract infection. Of the 106 samples, 12 (11.3%) were positive by all the molecular methods whereas serology with acute sample and convalescent samples detected 6 (5.6%) and 9 (8.5%), respectively. Clinical symptoms of the patients with Mycoplasma-positive results were compared to those of the other patients with lower-respiratory-tract infections, and it was found that the results for mean lower age numbers as well as the presence of chills, increased erythrocyte sedimentation rate, and raised C-reactive protein levels showed significant differences. Molecular methods are superior for diagnosis of M. pneumoniae, providing more timely diagnosis. In addition, using real-time methods involves less hands-on time and affords the ability to monitor the reaction in the same tube.
PMCID: PMC193789  PMID: 12958270

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