Empirical Therapy Research Articles

Timely empirical antibiotic therapy against sepsis in a rural Norwegian ambulance service: a prospective cohort study

BackgroundEarly diagnosis and antibiotic therapy in patients with sepsis reduce morbidity and mortality, thus pre-hospital management is likely to affect patient outcomes. Pre-hospital administration may increase the risk of unnecessary use of broad-spectrum antibiotics, but identification of an infectious focus enables more targeted antibiotic therapy. The aim of this study was to investigate how paramedics, with or without the assistance of general practitioners, can administer empiric intravenous antibiotic treatment against sepsis in a timely manner.MethodsCohort study of patients with suspected sepsis that received pre-hospital intravenous antibiotics and were transported to hospital. The setting was mainly rural with long average distance to hospital. Patients received targeted antibiotic treatment after an assessment based on clinical work-up supported by scoring systems. Patients were prospectively included from May 2018 to August 2022. Results are presented as median or absolute values, and chi-square tests were used to compare categorical data.ResultsWe included 328 patients. Median age was 76 years (IQR 64, 83) and 48.5% of patients were female. 30-days all-cause mortality was 10.4%. In cases where a suspected infectious focus was determined, the hospital discharge papers confirmed the pre-hospital diagnosis focus in 195 cases (79.3%). The presence of a general practitioner during the pre-hospital assessment increased the rate of correctly identified infectious focus from 72.6% to 86.1% (p = 0.009). Concordance between pre-hospital identification of a tentative focus and discharge diagnosis was highest for lower respiratory tract (p = 0.02) and urinary tract infections (p = 0.03). Antibiotic treatment was initiated 44 min (median) after arrival of ambulance, and median transportation time to hospital was 69 min. Antibiotic therapy was started 76 min (median) before arrival at hospital.ConclusionsPre-hospital identification of infectious focus in suspected sepsis was feasible, and collaboration with primary care physicians increased level of diagnostic accuracy. This allowed initiation of intravenous focus-directed antibiotics more than one hour before arrival in hospital in a rural setting. The effect of pre-hospital therapy on timing was much stronger than in previous studies from more urban areas.

Bacterial Co-Infections and Antibiotic Resistance in Urinary Tract Infection of Covid-19 Patients in Erbil City

The COVID-19 pandemic has raised concerns over secondary infections because it has limited treatment options and empiric antimicrobial treatment poses serious risks of aggravating antimicrobial resistance. Many studies have shown that COVID-19 patients are predisposed to developing secondary infections. The prevalence of urinary tract infections (UTI) was evaluated in 248 patients admitted to different hospitals in Erbil city, Iraq. Results showed 138 (55.65%) patients were positive for bacterial growth, of which 72 isolates of Gram-negative and 66 isolates of Gram-positive bacteria were isolated and identified from the urine of COVID-19 patients depending on the 16S rRNA gene using PCR. The predominant obtained bacteria were Staphylococci species, of which isolates belong to 6 species, and the predominant Gram-negative species was Pseudomonas spp. which belongs to 4 species. Also, their susceptibility to 15 antibiotics was tested and it was found that most of the Gram-negative isolates were highly resistant to ampicillin 66(91.66%), amoxicillin 60(83.33%), cephalexin 52(72.22%) and cefixime 50(69.44%). While the most effective antibiotic was imipenem, and with percentage of 26(36.11%), it also showed variable sensitivity to other antibiotics. For Gram-positive bacteria, the highest resistance was against cefixime 40(60.60%), ampicillin 28(42.42%), and 18(27.27%) for both amoxicillin and ciprofloxacin, while the most effective antibiotic was gentamicin, which showed effectiveness against all the Gram-positive isolates. Another part of the study concerned with detection of the existence of ESBLs genes responsible for antibiotic resistance. The results revealed that all the isolates possessed the 16S rRNA gene, whereas blaTEM and blaCTX-M were found to be the most possessed genes in all the isolates, with a percentage of (88.33%).

Laboratory-Confirmed Influenza Hospitalizations During Pregnancy or the Early Postpartum Period - Suzhou City, Jiangsu Province, China, 2018-2023.

Pregnancy is associated with increased risk for severe illness and complications associated with influenza infection. Insufficient knowledge about the risk for influenza among pregnant women and their health care providers in China is an important barrier to increasing influenza vaccination coverage and treating influenza and its complications among pregnant women. Improved influenza incidence estimates might promote wider vaccine acceptance and higher vaccination coverage. In Suzhou, active population-based surveillance during October 2018-September 2023 estimated that the annual rate of hospitalization for acute respiratory or febrile illness (ARFI) among women who were pregnant or <2 weeks postpartum was 11.1 per 1,000 live births; the annual rate of laboratory-confirmed influenza-associated ARFI (influenza ARFI) hospitalization in this group was 2.1 per 1,000 live births. A majority of hospitalized pregnant or early postpartum patients with ARFI (82.6%; 2,588 of 3,133) or influenza ARFI (85.5%; 423 of 495) were admitted to obstetrics wards rather than respiratory medicine wards. Only one (0.03%) pregnant or postpartum ARFI patient had received influenza vaccination, and 31.3% of pregnant or postpartum women hospitalized for influenza ARFI received antiviral treatment; the lowest percentage of hospitalized women with influenza ARFI who received antiviral treatment was among women admitted to obstetrics and gynecology wards (29.6% and 23.1%, respectively), compared with 54.1% of those admitted to a respiratory medicine ward. These findings highlight the risk for influenza and its associated complications among pregnant and postpartum women, the low rates of influenza vaccination among pregnant women, and of antiviral treatment of women with ARFI admitted to obstetrics and gynecology wards. Increasing awareness of the prevalence of influenza ARFI among pregnant women, the use of empiric antiviral treatment for ARFI, and the infection control in obstetrics wards during influenza seasons might help reduce influenza-associated morbidity among pregnant and postpartum women.

Trends in Urinary Tract Infection Management in Women.

Urinary tract infections (UTIs) are a common cause of health care utilization in the United States. The coronavirus disease 2019 (COVID-19) pandemic accelerated virtual care for UTIs. This retrospective cohort study analyzes more than 1.2 million encounters for UTI based on diagnosis codes, examining temporal trends focusing on virtual compared with in-person encounters, antibiotic dispensation rates, and culture-confirmed UTIs. From 2015 to 2022, UTI encounters increased by 325.9%, with a majority occurring at virtual visits. The rate of UTI encounters per 1,000 adult female patients increased by 241.6%. Antibiotic dispensation rates increased, surpassing the rise in rate of positive urine cultures, suggesting increasing use of empiric antibiotics. Our findings underscore the importance of balancing telemedicine's accessibility with maintaining antibiotic stewardship and highlight the need for updated guidelines.

A Comparison of Different Strategies for Optimizing the Selection of Empiric Antibiotic Therapy for Pneumonia Caused by Gram-Negative Bacteria in Intensive Care Units (ICUs): Unit-Specific Combination Antibiograms Versus Patient-Specific Risk Factors

Abstract Background Guidelines suggest dual anti-pseudomonal therapy for empiric treatment of pneumonia caused by Gram-negative bacteria in ICU patients. Additionally, consideration of local susceptibility data and patient-specific risk factors for resistance is recommended for selecting optimal empiric regimens. However, data assessing how to best do this are lacking, and it is unclear whether a local susceptibility data-based or a patient specific risk factor-based approach will better drive appropriate empiric treatment. This study aims to compare these two strategies. Methods This retrospective study was divided into two periods. In period I, Gram-negative respiratory cultures from ICU patients were used to develop unit-specific combination antibiograms, and individual patient charts were reviewed to assess the impact of risk factors on antimicrobial susceptibility to develop a risk-factor based treatment algorithm. Optimal empiric regimens based on these two strategies were then defined. In period II, these regimens were hypothetically applied to patients to compare rates of appropriate empiric therapy and overuse by the two methods. Results Risk factor-based regimens had a higher appropriateness rate compared to regimens derived from antibiograms (89.9% vs 83.7%). Additionally, applying antibiogram based regimens resulted in a higher prevalence of antibiotic overuse than a patient-specific risk factor based approach (69.8% vs. 40.3%), with excess overuse driven by a higher frequency of unnecessary use of combination therapy. Conclusion Both strategies provided high rates of appropriateness in empiric antibiotic selection. However, the patient-specific risk factor-based approach demonstrated a higher rate of appropriate therapy and offered advantages in reducing rates of unnecessary combination therapy.

Suspected nocardiosis in an immunosuppressed patient: a case report highlighting diagnostic challenges and management strategies

Nocardiosis is a rare but potentially fatal opportunistic infection caused by Nocardia species, predominantly affecting immunocompromised individuals. This case report details the clinical course, diagnostic workup, and management of a 63-year-old female with a history of renal transplantation. Initial investigations, including imaging studies, revealed multiple cavitary pulmonary nodules and a solitary brain lesion, raising concerns for disseminated infection. The diagnostic challenge was compounded by the broad differential diagnosis in this patient population, including fungal, mycobacterial, and other opportunistic infections. Empirical antimicrobial therapy was initiated, and subsequent microbiological confirmation of Nocardia asteroides from bronchoalveolar lavage specimens established the diagnosis. Despite initial therapeutic response, the patient developed worsening neurological symptoms indicative of CNS involvement, necessitating prolonged treatment with a combination of trimethoprim-sulfamethoxazole and imipenem. This report underscores the importance of early recognition, comprehensive diagnostic evaluation, and individualized therapeutic approaches in managing suspected nocardiosis in immunocompromised patients. Furthermore, it discusses the diagnostic pitfalls, highlights the need for a high index of suspicion, and reviews current therapeutic recommendations for both pulmonary and disseminated nocardiosis, providing a valuable reference for clinicians managing similar cases.

Spectrum and Antifungal Drug Resistance among Fungal Pathogens Isolated from Prison Inmates in Nairobi, Kenya

Background The emergence of antifungal resistance in fungal pathogens highlights the need for local epidemiological data to guide empirical therapy in clinical settings. Fungal research and anti-fungal drug resistance studies are limited in developing countries; hence, there is a need for burden estimation in low- and middle-income countries. This study aimed to determine the spectrum of fungal pathogens and the anti-fungal resistance profile of fungal pathogens isolated from the respiratory and urinary tracts of prison inmates in Nairobi, Kenya. Methods A cross-sectional study was conducted in which sputum and urine samples were obtained from inmates presenting with symptoms of respiratory and urogenital infections at a prison outpatient clinic. One hundred and sixty-two samples were collected and subjected to fungal investigation using standard protocols. Susceptibility to fluconazole, itraconazole, and voriconazole was assessed using standard broth microdilution. Clinical and sociodemographic data were obtained using a structured questionnaire. Results From the 162, 94 samples were positive for fungal pathogens, with an overall prevalence of 58%. Seventeen (18%) of the isolated fungi were Aspergillus fumigatus, Aspergillus flavus and Histoplasma. There was a statistically significant difference between fungal pathogens isolated from the respiratory and urogenital tracts in both sexes (p&lt;0.05). Antifungal susceptibility testing against itraconazole showed 2 of Aspergillus flavus and Aspergillus fumigatus were resistant. Conclusion Mycological agents are significant causes of respiratory and UTI infections among prison inmates, which could be attributed to prison conditions and misdiagnosis as bacterial infections. This highlights the need for specific control measures to reduce exposure to fungal infections in prisons and in the general population.

Neuroschistosomiasis in Young Filipino Patient Presenting with Seizure.

Diagnostic challenge and insightThis case highlights the importance of considering a broad differential diagnosis in patients with atypical neurological presentations, particularly in those from regions where parasitic infections are endemic. The internist plays a crucial role in integrating clinical, serological, and imaging data to arrive at a correct diagnosis, in this case, neuroschistosomiasis.Tailored treatment strategyThe case illustrates the value of personalized patient care. Initiating empirical treatment based on a combination of clinical suspicion, high-risk patient demographics, and imaging findings, without invasive procedures, demonstrates the internist's role in managing complex cases where patient preferences must be balanced with medical necessity.

Community-Associated MRSA—Not So Innocent Sibling per Se: A Case Report

Background: Methicillin-resistant S. aureus (MRSA) is a major healthcare burden and is classified as healthcare-associated (HA-MRSA) and community-associated (CA-MRSA). While HA-MRSA is clinically feared, CA-MRSA is often considered less pathogenic. This case report highlights the serious course of illness due to CA-MRSA infection and provides a treatment strategy for the management of such cases. Case description: A 41-year-old male presented with fever and breathlessness for five days. Upon admission, he was provided empirical treatment for atypical infections and vasopressor support for hypotension. His condition deteriorated, necessitating ventilator support. Although the initial tracheal Bio Fire test indicated MRSA, his clinical manifestations did not match MRSA pneumonia symptoms; however, CA-MRSA was confirmed within 12 h. Skin legions developed within 16 h and progressed gradually from ecchymosis, petechial, and palpable purpura to bullous lesions over 72 h. The antibiotic regimen was modified and optimized with the addition of Clindamycin, Vancomycin, and Meropenem–Colistin. Owing to high IL-6 levels, dual vasopressor support, and acute kidney failure, he was started on early (within 12 h) continuous renal replacement therapy (CRRT) with CytoSorb filter (for 3 days) for cytokine removal. IL-6 levels decreased after two days of CytoSorb use. Subsequently, the patient stabilized with reduced dependence on vasopressor and ventilator assistance. Discussion: Early diagnosis of CA-MRSA and management with CRRT using CytoSorb may help improve patient outcomes. To our knowledge, this is the first report of clinical management of CA-MRSA with CytoSorb therapy in India that resulted in positive outcomes.

Benefits and Safety of Empiric Antibiotic Treatment Active Against KPC-Producing Klebsiella pneumoniae for Febrile Neutropenic Episodes in Colonized Children with Acute Leukemia—An 8-Year Retrospective Observational Study

In children with acute leukemia (AL), the mortality rate from Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae bloodstream infection (KPC-KpBSI) exceeds 50%, highest when active treatment is delayed. Neutropenic KPC-K. pneumoniae carriers are at high risk of KPC-KpBSI, and preemptive empiric antibiotic treatment (EAT) of febrile neutropenic episodes (FNEs) active against KPC-K. pneumoniae may reduce this mortality. We conducted an 8-year (2014–2021) retrospective observational study of 112 febrile neutropenic episodes (FNEs) in 32 children with AL who were KPC-K. pneumoniae carriers: standard EAT for 39 FNEs and active EAT for 73 FNEs (52 ceftazidime/avibactam (CAZAVI)-based and 21 colistin-based combinations, and 5 CAZAVI monotherapy). Successful outcomes (survival from FNE) were observed in 94%; seven were fatal, with four due to infectious causes. KPC-KpBSIs caused 10/112 FNEs, 10/20 g-negative BSIs, and 3 deaths. The mortality rate of KPC-KpBSI was 30%. Active EAT was successful in 97% of the FNEs, compared to 87% with standard EAT. All deaths from KPC-KpBSI occurred in patients who received standard EAT, while none occurred with active EAT. KPC-KpBSI mortality rate with initial inactive treatment was 60%. CAZAVI-based EAT was successful in all FNEs, with a higher success rate without any modification compared to colistin-based EAT, where nephrotoxicity occurred in 14%. Therefore, active EAT, mainly a CAZAVI-based combination, was effective, safe, and associated with low overall and KPC-KpBSI-related mortality.

A Case Report on Multi Drug Resistance in Community Acquired Pneumonia Due to Escherichia coli with Cholangiocarcinoma

Escherichia coli is an important cause of severe community acquired pneumonia with mortality higher than pneumococcal pneumonia but like other gram-negative pneumonia. Antibiotics are the treatment of choice in treating pneumonia. When it comes to bacterial community-acquired pneumonia, multidrug resistant Escherichia coli (MDR E. Coli) is a less common cause than Staphylococcus aureus and Streptococcus pneumoniae. The majority of patients with community-acquired pneumonia (CAP) respond well to typical antibiotic regimens consisting of either a fluoroquinolone or a macrolide plus cephalosporin. We present a case where patient diagnosed with E. coli causing pneumonia showed MDR to various empirical antibiotics and managed with culture sensitive antibiotics. Antibiotic resistance has become a major issue for healthcare providers, where the effective management of patients will be more challenging which necessitates the need for optimising the use of antibiotics. Keywords: Multi Drug Resistance, Community Acquired Pneumonia, Escherichia Coli, Cholangiocarcinoma.

Frequency and Clinical Outcomes of Respiratory Infections in Children with Cancer Presenting with Febrile Illness

Objectives Fever is a known complication in pediatric cancer patients when on chemotherapy for which prompt initiation of empiric antibiotics is the single most important life-saving intervention. Nearly two-thirds of all children are treated without identifying the source of fever. Molecular diagnostics can improve management of febrile episodes and reduce unnecessary antibiotic use. The purpose of our study was to evaluate the pathogenic etiology of febrile episodes and analyze their clinical characteristics. Materials and Methods We conducted a prospective observational study at our tertiary care institution from January 2019 to March 2020, to identify the etiology of febrile episodes with or without neutropenia in pediatric cancer patients and to study their clinical outcomes. Results Forty febrile episodes were observed among 27 patients over a period of 15 months. The mean age group was 5 years. In 28 febrile episodes without a focus (70%), a respiratory organism (virus, bacteria, or coinfection) was detected. Rhinovirus was the most common single respiratory isolate (47.36%), followed by Streptococcus pneumoniae (21.05%) and six episodes had multiple viral isolates (21.42%). There was no prolonged hospitalization, need for intensive care unit or oxygen requirement, or mortality. The most common antibiotic used in empiric management was piperacillin–tazobactam. Aminoglycosides were added when there was a clinical suspicion of resistant organism. Conclusion Around 70% of febrile episodes without a focus or documented infection in cancer children had a respiratory pathogen identified in nasopharyngeal swab. Molecular diagnostics greatly enhances diagnostic sensitivity and thereby individualizes the management of febrile illness in these children.

Integrating genomic and molecular data to predict antimicrobial minimum inhibitory concentration in Klebsiella pneumoniae

Minimum inhibitory concentration (MIC) denotes the in vitro benchmark indicating the quantity of antibiotic required to inhibit proliferation of specific bacterial strains. Determining MIC values corresponding to the infecting bacterial strain is paramount for tailoring appropriate antibiotic therapy. In the interim between specimen collection and laboratory-derived MIC outcomes, clinicians frequently resort to empirical therapy informed by retrospective analyses. Here introduces two deep learning approaches, a Convolutional Neural Network (CNN)-based model and an Enformer-based model, integrating genomic data of Klebsiella Pneumoniae and molecular structural data of 20 antibiotics to anticipate the MIC value of the bacterium for each antibiotic under consideration. These models demonstrate enhanced raw accuracy over the existing state-of-the-art model, which rely exclusively on genomic data. The CNN-based model achieves a notable 20% increase in raw accuracy while further mirroring the 1-tier accuracy of the state-of-the-art model. Although the Enformer-based model does not quite reach the performance levels of the CNN-based model, it offers an advantage by eliminating the need for arbitrary data processing steps. This streamlining of the data processing pipeline facilitates fast updates and improves the model interpretability. It is expected that these deep learning paradigms can significantly inform and bolster clinician decision-making during the empirical treatment phase.

Empiric embolization by vasospasm therapy for acute lower gastrointestinal bleeding: a preliminary report

To report the preliminary result of empiric embolization for angiographycally-negative lower gastrointestinal bleeding (LGIB) by using the pharmaco-induced vasospasm technique with or without the adjunctive use of intra-arterial multi-detector computed tomography (MDCT). 23 LGIB patients with positive MDCT findings but negative angiographic results underwent empiric pharmaco-induced vasospasm therapy. The presumed bleeding artery was semi-selectively catheterized, and a segment of bowel was temporarily spasmed with bolus injection of epinephrine and immediately followed by 4-h’ vasopressin infusion. The rebleeding, primary and overall clinical success rates were reported. MDCT showed 19 bleeders in the SMA territory and 4 bleeders in the IMA territory. Early rebleeding was found in 6 patients (26.1%): 2 local rebleeding, 3 from new-foci bleeding and 1 uncertain. Of the 10 small bowel bleeding patients, only 1 out of the 7 who underwent intra-arterial MDCT showed rebleeding, whereas 2 out of the 3 without intra-arterial MDCT rebled. No patients exhibited procedure-related major complications, including bowel ischemia and cardiopulmonary distress. The overall clinical success rate was 91.3% (21/23) with a 30-day mortality rate of 26.1% (2 of the 6 patients had early rebleeding). Empiric pharmaco-induced vasospasm therapy, when localized with/without adjunctive intra-arterial MDCT, seems to be a safe and effective method to treat angiographically-negative LGIB patients.

Impact of EUCAST Rapid Antimicrobial Susceptibility Testing (RAST) on optimal antimicrobial therapy in gram-negative bloodstream infections

ObjectivesTo evaluate the possible impact of RAST on optimal antimicrobial therapy via de-escalation or escalation, and to determine the reduction in antibiotic susceptibility reporting time with RAST. MethodsIn this single-center, prospective descriptive study, RAST was performed on clinical blood cultures containing E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii isolates. Very major error, major error, and categorical agreements with VITEK 2 were analyzed. ResultsOne hundred and three isolates were included in the study, out of which 29.1 % were carbapenem-resistant and 36.9 % were multidrug-resistant according to VITEK 2. Categorical agreement of the RAST method with standard antimicrobial susceptibility test (AST) was > 90 % at 6 h, except for piperacillin/tazobactam. Antibiotic revision could be carried out in 79.6 % of the patients either by de-escalation (61.2 %) or escalation (18.4 %) for optimal therapy based on the RAST 6 h result. RAST could provide carbapenem-sparing therapy in 24 % of patients. Reduction in antibiotic susceptibility reporting time was 41.5 h (38.8 to 63.2, median (IQR)). ConclusionsRAST can provide early antibiotic revision in a majority of patients with significantly reduced antibiotic susceptibility reporting time. Six hours is the shortest optimal time for antibiotic revision with RAST. In countries where empirical broad-spectrum antibiotics are prevalent due to high antibiotic resistance pressure, RAST should be proposed primarily in de-escalation and carbapenem-sparing strategies.

Extended Spectrum β-Lactamase: Tackling Antibiotic Resistance and Overcoming Treatment Challenges

Antibiotics, also known as antibacterials, kill or inhibit bacterial growth but are ineffective against viruses, fungi, or parasites, often leading to misuse. They are categorized by molecular structure, mode of action, and spectrum of activity. Antimicrobial Resistance (AMR) occurs when pathogens no longer respond to antimicrobial drugs, arising naturally or through acquisition. Resistance mechanisms include enzymatic (most common), genetic and physical. Bacteria produce various β-lactamases, such as Extended Spectrum β-lactamases (ESBLs), AmpC enzymes, and carbapenemase to exert resistance to Beta-Lactam (βL) class of antibiotics. ESBL families include TEM, SHV, and CTX-M, with E. coli being the most prevalent host. Any Gram-Negative Bacteria (GNB) can be an ESBL producer, but most common ones are the Enterobacteriaceae including Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca and Proteus mirabilis. ESBL-producing Enterobacteriaceae (ESBL-E) resist penicillin, aztreonam, and cephalosporins except cephamycins and carbapenems, posing a significant public health risk. Genetic resistance mechanisms involve random mutations and horizontal gene transfer through either of the following processes namely conjugation, transformation, transduction. Physical mechanisms include efflux pump production and decreased porin channels. In some microbiological laboratories, ESBL production are often not determined, rather resistance based on MIC values to third generation Cephalosporins are considered as resistance due to ESBL production. Antibiotic use in agriculture and medicine has increased Multi-drug resistant (MDR) ESBL-producing E. coli and evidenced in retail meat and among meat shop employees. Community-acquired ESBL-E infections are a growing concern, with hospital transmission primarily occurring among patients sharing rooms with ESBL carriers. Empirical and definitive therapies for ESBL-E infections must be adjusted based on Antibiotic Susceptibility Testing (AST). The MERINO trial identified urinary tract infections as the most common source of ESBL-E bacteremia, with E. coli being predominant. For critically ill patients with non-urinary tract infections, Meropenem or Imipenem-cilastatin are recommended. For uncomplicated UTIs, Nitrofurantoin, Cotrimoxazole, and Piperacillin-Tazobactam (Pip-Taz) are effective, while Cotrimoxazole, Fluoroquinolones, and Ceftolozane-tazobactam are suitable for complicated UTIs. New β-lactamase inhibitors like avibactam, vaborbactam, and relebactam are promising for treatment. Misuse of antibiotics, such as inappropriate dosing and duration, contributes to AMR, a growing global challenge. Deaths from AMR, estimated at 1.27 million in 2019, could reach 10 million by 2050. ESBLs drive the use of broad-spectrum antibiotics, accelerating resistance development. Inadequate therapy exacerbates infections, leading to prolonged hospital stays, complications, and increased mortality. Balancing new drug development with resistance emergence is crucial to combat AMR.

Using anginal symptoms to predict underlying etiology in patients with angina and no obstructive coronary disease (ANOCA)

Abstract Background Patients with angina with no obstructive coronary disease (ANOCA) can present with exertional anginal symptoms or angina at rest. Invasive coronary functional angiography (CFA) is used to diagnose endothelial-dependent and independent coronary microvascular dysfunction (CMD), microvascular spasm, and epicardial spasm. Historically, the type of anginal symptoms has been thought to be suboptimal in predicting the etiology of ANOCA. However, the sensitivity, specificity, predictive value, and correlation of angina type related to CFA abnormalities are unknown. We hypothesize that patients with predominantly exertional angina are more likely to have endothelial-independent and dependent CMD, and patients with angina at rest are more likely to have microvascular or epicardial spasm. Objective To explore sensitivity, specificity, predictive value, and correlation of angina type with underlying etiology of ANOCA as diagnosed by CFA. Methods A prospective registry-based cohort study of consecutive CFA performed in 197 ANOCA patients between 2020 and 2023 using the Doppler-tipped guidewire method. ANOCA was defined as &amp;lt;50% stenosis in any major epicardial artery at time of CFA. Patients were classified based on CFA diagnosis: (1) endothelial-independent CMD (coronary flow reserve [CFR] &amp;lt; 2.5 in response to adenosine), (2) endothelial-dependent CMD (coronary blood flow [CBF] &amp;lt; 50% or no change in vessel diameter in response to 54mcg intracoronary acetylcholine), (3) microvascular (&amp;lt;90% constriction) and epicardial spasm (&amp;gt;90% constriction) to 108 mcg intracoronary acetylcholine. Patients were categorized based on anginal symptoms (exertional angina or at rest angina) documented at cardiologist visit prior to CFA. McNemar’s test and Spearman correlations were performed for both types of angina and the 3 ANOCA underlying diagnoses. Results Among 197 ANOCA patients, the average age was 56.5 ± 11.9 years and 91% were female. Angina at rest had a high specificity (91.3%) but a low sensitivity (25.2%) for the diagnosis of spasm with a PPV of 90.5 (Table 1). There was a significant correlation between angina at rest and spasm (p=0.012). Angina at rest had a similarly intermediate sensitivity and specificity for endothelial independent and dependent CMD. Exertional angina had similar sensitivity, specificity, and a high PPV for endothelial independent and dependent CMD. There was a significant correlation between exertional angina and endothelial dependent CMD (p=0.025). McNemar’s test was statistically significant (p&amp;lt;0.001) for all analyses. Conclusion ANOCA patients with symptoms of angina at rest had a significant correlation with coronary spasms and exertional angina correlates with endothelial-dependent CMD. We demonstrate that angina at rest can be 90% specific for the diagnosis of spasm. Our findings warrant further investigation but suggest that empiric therapy based on angina type is a reasonable first step before invasive testing.

Detection of Chlamydia trachomatis and Neisseria gonorrhoeae (and Its Resistance to Ciprofloxacin): Validation of a Molecular Biology Tool for Rapid Diagnosis and Treatment

Background and Objectives: Neisseria gonorrhoeae and Chlamydia trachomatis can cause similar clinical syndromes and may coexist in infections. In emergency medicine, empirical treatment targeting both pathogens is often employed, potentially contributing to antibiotic resistance. Gonococcal resistance has emerged against first-line antimicrobials, necessitating prior testing for fluoroquinolone susceptibility. Certest Biotec developed two molecular diagnostic products for simultaneous detection: VIASURE C. trachomatis &amp; N. gonorrhoeae Real-Time PCR Detection Kit and VIASURE Neisseria gonorrhoeae Ciprofloxacin-Resistant Real-Time PCR Detection Kit. To evaluate these products, clinical performance assessments were conducted at the Clinical Microbiology Laboratory of Miguel Servet University Hospital in Zaragoza, Spain. Results and Conclusions: Both VIASURE assays under study demonstrated high clinical sensitivity and specificity compared to reference molecular assays and Sanger sequencing. These kits offer an accurate diagnosis, facilitating appropriate treatment choices while addressing concerns about emerging antibiotic resistance. Methods: A total of 540 clinical samples from 540 patients already characterized as positive or negative for CT and NG by a molecular assay and by antibiotic susceptibility testing for ciprofloxacin using a concentration gradient diffusion method were used for the clinical evaluation. In cases where sensitivity results were unavailable, conventional PCR and Sanger sequencing were employed.

Antimicrobial resistance in Enterobacterales, Acinetobacter spp. and Pseudomonas aeruginosa isolates from bloodstream infections in Australian children, 2013-2021.

Gram-negative bloodstream infections are associated with significant morbidity and mortality in children. Increasing antimicrobial resistance (AMR) is reported globally, yet efforts to track pediatric AMR at a national level over time are lacking. The Australian Group on Antimicrobial Resistance (AGAR) surveillance program captures clinical and microbiological data of isolates detected in blood cultures across Australia. EUCAST 2022 was used for MIC interpretation and the AMR package in R for data analysis. Over a nine-year period, there were 3,145 bloodstream infections with 3,266 gram-negative isolates reported in hospitalized children aged <18 years; 21.0% were from neonates. The median length of stay was 9 days, and 30-day all-cause mortality was 5.2%. A greater odds of death was observed in those with a multi-drug resistant organism (aOR: 2.1, 95%CI: 1.3, 3.3, p: 0.001). Escherichia coli (44.5%) and Klebsiella pneumoniae complex (12.6%) were the two most frequently reported organisms. Overall resistance in Enterobacterales to gentamicin/tobramycin was 11.6%, to ceftazidime/ceftriaxone was 12.9%, and 13.2% to ciprofloxacin. Resistance increased over time.Of 201 Pseudomonas aeruginosa isolates reported, 19.7% were resistant to piperacillin-tazobactam, 13.1% resistant to cefepime/ceftazidime and 9.8% to ciprofloxacin. Of 108 Acinetobacter spp. isolates, one was resistant to meropenem, and two were resistant to ciprofloxacin. Resistance did not increase over time. AMR in gram-negative organisms causing bloodstream infections in Australian children is increasing which should be considered when updating guidelines and empiric treatment regimens. Ongoing pediatric-specific national surveillance with pediatric reporting must remain a priority to strengthen antimicrobial stewardship and infection control programs.

Isolation and Pattern of Antimicrobial Susceptibility Testing of Acinetobacter baumannii Clinical Isolates at Taksin Hospital: A Retrospective Study from 2019 to 2021

Objective: To determine the number of isolates and drug susceptibility testing of Acinetobacter baumannii at Taksin Hospital. Materials and Methods: A 3-year retrospective descriptive study was conducted between January 2019 and December 2021. Drug susceptibility testing of isolates to 13 drugs, which included amikacin, gentamycin, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, three carbapenem drugs that were imipenem, meropenem, and doripenem, ciprofloxacin, trimethoprim-sulfamethoxazole, colistin, and tigecycline, were evaluated by standard disk diffusion method and automated microdilution method. Results: One thousand six hundred sixty-five non-duplicate A. baumannii isolates from different patients were detected and included 535 in 2019, 500 in 2020, and 630 in 2021. The patients’ ages ranged from three days to 100 years. The median age of patients was 70 years with an interquartile range of 56 to 80 years. A. baumannii was mostly found in patients aged older than 50 years old at 83.6%. They were isolated from sputum in 72.3%, urine in 9%, pus in 6.3%, tissue in 6.3%, and blood in 5.2%. Overall, A. baumannii demonstrated 91.5% and 79.8% susceptibility to colistin and tigecycline, respectively, but less susceptible to other drugs tested, with a range of 0.4% to 32.6%. Drug susceptibility to carbapenem such as imipenem, meropenem, and doripenem were 19.5%, 20%, and 20.9%, respectively. The carbapenem-resistant A. baumannii (CRAB) was found at 77.6%, 80%, and 79.1% in 2019, 2020, and 2021, respectively. For total isolates tested, the mean of CRAB was 78.9±1.2%. Conclusion: The present study results suggested the importance of monitoring A. baumannii at a hospital in Bangkok. Colistin and tigecycline had the high percentages of drug susceptibility rates in vitro. The antibiogram of susceptibility helps provide guidelines for clinician to consider empirical treatment.