No 46 - 2010

European Antibiotic Awareness Day
NDM-1 in Denmark

European Antibiotic Awareness Day

18 November 2010 will see the celebration of the third European Antibiotic Awareness Day.
The day is a joint European initiative which counts the participation of more than 27 countries. The initiative originated from the European Centre for Disease Prevention and Control (ECDC) in cooperation with the World Health Organisation (WHO).

The European Antibiotic Awareness Day is an annual event designed to increase awareness of responsible and appropriate use of antibiotics.
Internationally, there is currently a considerable overconsumption of antibiotics. One consequence of the excessive consumption is the development of antibiotic-resistant bacteria.

(A.M. Hammerum, N. Frimodt-Møller, Department for Microbiological Monitoring and Research (DBMP))

NDM-1 In Denmark

Carbapenems are frequently the only effective group of antibiotics in the treatment of infections with ESBL-producing bacteria, EPI-NEWS 15/10.

New Delhi Metallo-beta-lactamase 1 (NDM-1) is an antibiotic resistance gene which codes for carbapenem resistance.

NDM-1 was previously found in multi resistant bacteria from patients in Sweden, England and the USA. Many of these patients had been to India before NDM-1 detection.
October 2010 saw the first ever NDM-1 detection in a patient in Denmark.

Case history

The patient was admitted during vacations in Bosnia & Herzegovina due to sepsis and was subsequently transferred to Denmark. An MRI scan detected an intraspinal abscess, and culture of purulent matter yielded Staphylococcus aureus susceptible to penicillin.

After transfer to Denmark, carbapenem-resistant Pseudomonas aeruginosa were initially cultured from urine. Then, after 25 days, carbapenem-resistant Klebsiella pneumoniae were cultured from urine. The K. pneumoniae isolate was resistant to all tested antibiotics, except for colistin and intermediary resistant to tigecycline. The NDM-1 gene was detected using PCR and sequencing. The patient showed no signs of urinary tract infection and was isolated throughout the admission period in Denmark. No subsequent K. pneumoniae isolates from the hospital have tested positive for NDM-1.


The case report shows that multi-resistant gram-negative rods which occur with increasing frequency in a wide range of countries may be imported to Denmark via patients admitted abroad.
Other European countries have observed secondary spreading to other patients of imported carbapenem-resistant K. pneumoniae.

When transferring patients from hospitals abroad, tests to detect multi-resistant gram-negative rods should be performed routinely. In patients from high-risk areas, stool screening to detect such bacteria should be considered.

(A.M. Hammerum, F. Hansen, C.H. Lester, R. Skov, DBMP, B. Kristensen, K. Fuursted, DCM, Aarhus University Hospital, Skejby)


Melioidosis caused by the Burkholderia pseudomallei bacterium is rare in Denmark, but may be acquired during travels to e.g. South-East Asia and North Australia. In North Thailand melioidosis is the primary cause of sepsis. The bacterium is widespread in water and soil, and is primarily transferred via sores and inhalation of aerosoles. The illness manifests itself as formation of abscess which may either occur locally in the lungs or systemically as sepsis.

Over the past three years, a total of five cases of the illness have been detected in Denmark. The most recent and fatal case was a 33-year-old man with bilateral pulmonary abscesses, which were only discovered at the post-mortem examination.

Diagnosis and treatment

The bacterium is detected by standard microbiological culture, but may not be multiplied in standard microbiology laboratories due to its biosafety level 3 (BSL3) classification.
In case of confirmatory test or clinical suspicion of melioidosis, PCR is performed at Statens Serum Institut (SSI). Acute identification via mass spectometry can be performed at the SSI by appointment.

B. pseudomallei is widely resistant to e.g. penicillin, 2nd generation cephalosporins and aminoglycosides. Following determination of resistance, prolonged antibiotic treatment shall be administered in the form of e.g. ceftazidime or a carbapenem, and abscesses shall be drained. No vaccine is available to counter infection with the bacterium.


The rare occurrence of melioidosis in Denmark means that disease trajectories may become serious, typically including abscesses in several organ systems before the diagnosis is considered.

As travelling activity to Thailand is increasing, the diagnosis should be considered in connection with travel-associated fever. This is particularly important in patients with underlying risk factors such as massive smoking, chronic disease, immunosuppression (incl. alcoholism) or advanced age. Prolonged latent infection has been reported, but recent infection is far more frequent.

(S. Badran et. al., DBMP)


The e-BUG teaching resource was developed in the context of the European cooperation. The objective is to improve primary and lower secondary school students' knowledge of public health and prevention.

Training in microbiology and expedient use of antibiotics serve to disseminate knowledge of pathogenic micro-organisms, antibiotic consumption and their role in the development of antibiotic resistance. Hand hygiene training is instrumental in preventing the spreading of airway infections and gastrointestinal infections at schools and may build expedient hygiene habits in students from which they may benefit for the rest of their lives.

E-Bug consists of two books targeting upper primary and lower secondary pupils. The books may be ordered free of charge from the Central Infectious Hygiene Unit (CIHU) at the SSI by mail: The books may be copied without restrictions and sale is prohibited.

The books are also available for download at This website also holds further materials which may prove helpful for training purposes, e.g. Power-Point presentations, computer games and other activities.

(J. Holt, U.S. Jensen, DBMP)

Individually notifiable diseases and selected laboratory diagnosed infections (pdf)

17 November 2010