Background Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS). Objectives To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention. Methods Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February–May 2015) and after (February–May 2017) the intervention period. Results The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9–10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5–9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention. Conclusions The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.

International audienceThe ecological environment of three aquatic rodents was studied in the French Ardennes region. Two species, the coypu () and the common muskrat (), are invasive. By contrast the native European beaver () was extirpated from the region, subsequently reintroduced, and currently is protected. The aim of this study was to compare the ecological requirements of these three species and predict their future range distributions. We studied the relationship between the species and describe the characteristics of waterways and riparian vegetation in 29 sampling sites. Coypus and muskrats were observed in a variety of riparian habitats and their probability of detection appeared to be independent of waterway width, bank height or bank slope. The availability of numerous herbaceous plants, known to be consumed by these species, may facilitate their settlement. Muskrats are widespread on the French Ardennes waterways, but coypus have not yet colonised the northern part of the region. On the other hand, the beaver was observed primarily in the widest waterways with high banks, where woody plant species, such as , and , are found in abundance. Potentially favourable sites for beaver and coypu settlement were analysed to suggest appropriate management according to each species' status. However, the number of sample sites is weak, especially for sites with beaver, limiting our conclusion

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BackgroundA high prevalence of colistin resistance among E. cloacae isolates in two intensive care units (ICU) (of 16 and 6 beds) using selective digestive decontamination (SDD) since 1990 instigated a retrospective and prospective investigation to quantify the role of clonal transmission. SDD is topical application of colistin and tobramycin and systemic use of cefotaxime during the first days of ICU-admission.MethodsMulti-resistant E. cloacae (MREb) was defined as ESBL production and/or tobramycin non-susceptibility and/or colistin non-susceptibility. Incidence of acquisition and prevalence of carriage with MREb was determined from microbiological culture results.ResultsColistin-resistant E. cloacae was first detected in November 2009 and carriage was demonstrated in 141 patients until October 2014. Mean incidence of MREb acquisition was 4.61 and 1.86 per 1000 days at risk in ICUs 1 and 2, respectively, and the mean monthly prevalence of MREb in both ICUs was 7.0 and 3.1%, respectively, without a discernible trend in time. Conversion rates from carriage of colistin-susceptible to resistant E. cloacae were 0.20 and 0.13 per 1000 patient days, respectively. Whole genome sequencing of 149 isolates revealed eight clusters, with the number of SNPs of the largest two clusters ranging between 0 and 116 for cluster 1 (n = 49 isolates), and 0 and 27 for cluster 2 (n = 36 isolates), among isolates derived between 2009 and 2014.ConclusionsThis study demonstrates a stable low-level endemicity of MREb in two Dutch ICUs with prolonged use of SDD, which was characterized by the persistent presence of two clusters, suggesting incidental clonal transmission.Electronic supplementary materialThe online version of this article (10.1186/s13756-018-0356-7) contains supplementary material, which is available to authorized users.

Introduction:Acute intermittent porphyria (AIP) is a rare autosomal dominant inherited metabolic disease characterized by mutations in the porphobilinogen deaminase gene. This mutation may provoke neurotoxic levels of delta-aminolevulinic-acid and porphobilinogen, potentially resulting in an acute life-threatening clinical syndrome, characterized by psychiatric, in particular atypical psychotic, symptoms as well as severe neurological and gastrointestinal symptoms. Since the clinical presentation varies and symptoms are nonspecific, diagnosis is often made late.Objectives:Naming of alarm symptoms based on a recent case study.Methods:Description of a recent case supplemented with data from the literature.Results:The patient is a 46 year old woman who was admitted in 2007 with abdominal pain, an epileptic seizure and weakness, interpreted as a Guillain-Barre syndrome. In 2011 she was readmitted with severe abdominal pain, diarrhea, volatile psychotic symptoms and seizures, following a short period of excessive alcohol consumption. During admission she developed progressive weakness in the upper arms, shooting pains in the limbs and a feeling of tightness. Impaired abdominal breathing was suspected. Again, Guillain-Barré syndrome was considered, but additional studies did not support this diagnosis. Because of the recurrent character of symptomatology following alcohol abuse, acute (intermittent) porphyria was considered diagnostically. The dark-colored urine indeed contained significantly increased delta-aminolevulinic-acid and porphobilinogen concentrations. Additional (genetic) diagnosis follows.Conclusion:A recurrent disease course with severe gastrointestinal, neurological and psychiatric symptoms, following alcoholabuse, is suspect for AIP.