Initial Empirical Antimicrobial Therapy Research Articles

Clinical Predictors of Bacteremia Outcome After Initial Empirical Antimicrobial Therapy in Patients with Hematological Malignancies: A Retrospective Analysis

Clinical Predictors of Bacteremia Outcome After Initial Empirical Antimicrobial Therapy in Patients with Hematological Malignancies: A Retrospective Analysis

Association of Appropriate Empirical Antimicrobial Therapy With In-Hospital Mortality in Patients With Bloodstream Infections in the US

Bloodstream infections (BSIs) are a major public health problem associated with high morbidity. Little evidence exists regarding the epidemiology of BSIs and the use of appropriate empirical antimicrobial therapy. To estimate the association between receipt of appropriate initial empirical antimicrobial therapy and in-hospital mortality. This retrospective cross-sectional study used data from the Premier Healthcare database from 2016 to 2020. The analysis included 32 100 adult patients (aged ≥18 years) with BSIs from 183 US hospitals who received at least 1 new systemic antimicrobial agent within 2 days after blood samples were collected during the hospitalization. Patients with polymicrobial infections were excluded from the analysis. Appropriate empirical therapy was defined as initiation of at least 1 new empirical antimicrobial agent to which the pathogen isolated from blood culture was susceptible either on the day of or the day after the blood sample was collected. Multilevel logistic regression models were used to estimate the association between receipt of appropriate initial empirical antimicrobial therapy and in-hospital mortality for patients infected with gram-negative rods (GNRs), gram-positive cocci (GPC), and Candida species. Among 32 100 patients who had BSIs and received new empirical antimicrobial agents, the mean (SD) age was 64 (16) years; 54.8% were male, 69.9% were non-Hispanic White, and in-hospital mortality was 14.3%. The most common pathogens were Escherichia coli (58.4%) and Staphylococcus aureus (31.8%). Among patients infected with S aureus, methicillin-resistant S aureus was isolated in 43.6%. The crude proportions of appropriate empirical therapy use were 94.4% for GNR, 97.0% for GPC, and 65.1% for Candida species. The proportions of appropriate therapy use for resistant organisms were 55.3% for carbapenem-resistant Enterobacterales species and 60.4% for vancomycin-resistant Enterococcus species. Compared with inappropriate empirical therapy, receipt of appropriate empirical antimicrobial therapy was associated with lower in-hospital risk of death for 3 pathogen groups (GNR: adjusted odds ratio [aOR], 0.52 [95% CI, 0.42-0.64]; GPC: aOR, 0.60 [95% CI, 0.47-0.78]; Candida species: aOR, 0.43 [95% CI, 0.21-0.87]). In this cross-sectional study of patients hospitalized with BSIs, receipt of appropriate initial empirical antimicrobial therapy was associated with lower in-hospital mortality. It is important for clinicians to carefully choose empirical antimicrobial agents to improve outcomes in patients with BSIs.

ALCALIGENES FAECALIS, AN UNEXPECTED AGENT OF URINARY TRACT INFECTION IN A 14-YEARS-OLD BOY

Introduction: Alcaligenes faecalis is a rare cause of urinary tract infection (UTI) in humans, especially in pediatrics. It is a potentially emerging pathogen, usually opportunistic, and it is often difficult to treat due to its increased resistance to several antibiotics. Urinary tract infection due to Alcaligenes faecalis in pediatrics it is not yet describe in literature. Case report: We report the occurrence of Alcaligenes faecalis (spp faecalis) Urinary Tract Infection (UTI), presenting as acute cystitis, in a 14-years-old boy with previous history of non-obstructive bilateral renal lithiasis due to hyperuricosuria, pyelocaliceal duplicity in the right kidney and recurrent UTI. He was treated with empirical antibiotic with amoxicillin/clavulanate, with clinical improvement. A repeated urine culture was sterile after treatment. Discussion: We review literature in pediatrics, and we found out that this agent is a very uncommon organism of infection and difficult to treat due to its increased resistance to several antibiotics such as penicillin, cephalosporins, carbapenems, aminoglycosides, and quinolones. In pediatric literature, there is still few cases of infection described, due to Alcaligenes faecalis. Conclusions: Clinicians should continue to direct initial empiric antimicrobial therapy toward the more commonly encountered bacteria. If Alcaligenes faecalis is identified in culture, it can represent a true pathogen, and not merely a contaminant. Alcaligenes faecalis is an unexpected agent of UTI that clinicians should keep in mind.

Effectiveness of antimicrobial therapy for community-acquired pneumonia in real clinical practice

Background. Community-acquired pneumonia (CAP) remains one of the most common infectious diseases, occupying an important place in the structure of mortality worldwide.Aim. To evaluate the effectiveness of antimicrobial therapy for community-acquired pneumonia in hospitalized patients in real clinical practice.Materials and methods. A retrospective, observational study was conducted, which included 236 patients hospitalized for community-acquired pneumonia at the Regional Clinical Hospital in Ryazan in 2019. Based on these case histories, an analysis of the effectiveness of the initial empiric antimicrobial therapy was performed.Results. The initial empiric antimicrobial therapy in 73% of cases included administration of ceftriaxone, in 45% of cases – levofloxacin, in 14% of cases – azithromycin. It was found that initial antimicrobial therapy was effective in 58% of patients who did not require replacement for the antibiotic. A need for a change in the treatment regimen was significantly associated with an increase in the length of hospitalization (p < 0.001), heart rate upon admission (p = 0.032), myelocyte count in the complete blood count (p < 0.001), and urea and blood creatinine levels (p = 0.004 and p = 0.044, respectively). The selected antimicrobial therapy regimen was significantly associated with the expected treatment effectiveness (p = 0.039). The choice of levofloxacin in monotherapy or in combination with ceftriaxone was accompanied by a decrease in the relative risk of replacing the antimicrobial, compared with other treatment regimens (odds ratio (OR) = 0.86 (95% confidence interval (CI): 0.55–1.34) and OR = 0.57 (95% CI: 0.37–0.87), respectively).Conclusion. Empiric antimicrobial therapy for community-acquired pneumonia in real clinical practice complies with current recommendations, however, at the same time, its ineffectiveness persists. Respiratory fluoroquinolones are most effective in treating pneumonia in hospitalized patients.

Outcome of Bacterial Sepsis in Neonate with Determination of Pathogens and Their Antimicrobial Susceptibility

Background: Sepsis in neonate remains a significant cause of mortality and morbidity in developing countries. Neonatal sepsis requires accurate and timely clinical and laboratory diagnosis and proper management for better outcome. In this study an attempt has been made to know the positivity rate of neonatal sepsis, identify the bacterial isolates responsible for EOS and LOS and determine their sensitivity pattern to various antimicrobial agents, and outcome of neonatal sepsis. Methods: A cross sectional descriptive single-centre study was conducted on neonates , over a period of 12 months. Essential investigations were sent by collecting samples under aseptic precautions. Empirical antimicrobial therapy was started according to antimicrobial guidelines in this NICU. Results: Out of 1423 screened blood cultures 13.49% reported as positive and EOS and LOS accounted for 33.85% and 66.15% of cases respectively. Over half (52.60%) of neonates had sepsis with gram negative bacteria and 47.40% with gram positive bacteria and ratio was 1.1:1. Common organisms were Coagulase-Negative Staphylococci-CONS (42.19%), Acinetobacter (22.40%),Enterobacter (18.75%).Total mortality rate was 6.96% & death rate was 23.96% in culture proven sepsis & 04.31% in culture negative isolates (p-value: <0.00001). In culture-proven sepsis the mortality rate 30.71% & 10.77% (P-value: 0.00219) in LOS & EOS; and 30.69% &16.48% (p-value: 0.02126) in gram positive & gram negative sepsis respectively. Acinetobacter (44.19%) showed higher death rate followed by MRSA (33.33%), E.Coli (33.33%). In EOS, gram positive & gram negative bacteria accounted for 55.38% & 44.62%; and in LOS, 43.31% & 56.69% respectively. CONS (50.77%), the commonest followed by Acinetobacter (18.46%) and Enterobacter (13.85%) in EOS. In LOS, CONS (37.80%) was the most isolated prevalent organism followed by Acinetobacter (24.41%) and Enterobacter (21.26%). Gram positive organisms showed higher level of sensitivity to Vancomycin (91%), Linezolid (90%), Netilmicin (65%). Among the Staphylococci (Coagulase negative & positive), around 86% were resistant to Cloxacillin/Methicillin. Gram negative bacteria had best susceptibilities to Colistin (74%) & Polymyxin-B (70%) than Cotrimoxazole (51%), Netilmicin (32%), Ciprofloxacin (32%), Piperacillin+ Tazobactem (27%), and Levofloxacin (24%). Among the commonly used antibiotics, the susceptibilities were remarkably low to Ampicillin (5.73%), Gentamicin (26.04%), Amikacin (11.46%), Ceftazidime (4.69%), Cefepime (2.08%) in comparison to Ciprofloxacin (31.25%), Imipenem/Meropenem (35.42%) & Netilmicin (47.92%) for both gram positive & negative isolates. Conclusion: Present study indicated that more mortality observed in culture-proven sepsis especially in gram negative sepsis. CONS continue to be the predominant causative organism in both EOS and LOS followed by Acinetobacter, Enterobacter. The antibiotic susceptibility profile suggested that for a given cohort empiric Netilmicin- Imipenem / Vacomycin or Netilmicin- Ciprofloxacin / Vancomycin initial choice where patient can not improve with initial empiric antimicrobial therapy (Ampicillin and Gentamicin) in EOS before blood culture reports are available or can considered be for initial empiric therapy in LOS. Early intervention with evidence based unit specific empiric chemotherapy before availability of culture reports that will improve outcome of neonate with sepsis and can reduce the morbidity and mortality as well. Bangladesh Crit Care J September 2021; 9 (2): 79-86

Challenges in the Management of Gram-Negative Bacterial Infections in Patients With Ventriculoperitoneal Shunt.

Gram-negative bacterial infections of the central nervous system (CNS) have worse clinical outcomes. The most common bacteria include Escherichia Coli, Citrobacter species, Enterobacter species, Serratia species, and Pseudomonas aeruginosa. There are multiple risk factors for CNS infection after shunt insertion, including younger age, obstructive hydrocephalus, shunt revision surgery, and trauma. The clinical presentation of a ventriculoperitoneal (VP) shunt infection includes the signs and symptoms of meningitis to fever with abdominal pain and peritonitis. Apart from cerebrospinal fluid (CSF) analysis, microbiological cultures and radiological studies are key diagnostic tools. Initial empirical intravenous antimicrobial therapy is preferably broad spectrum with appropriate coverage for resistant Gram-negative pathogens and the duration of treatment depends upon pathogenesis, host factors, and clinical response to the therapy.Considering the importance of this disease and associated clinical outcomes, in this review article, we have summarized the epidemiology, clinical features, management, and prevention of Gram-negative VP shunt infections in adults.

Guiding Antimicrobial Therapy using Gram Stain in Patients with Ventilator Associated Pneumonia- An Effective Preliminary Diagnostic Tool

Introduction: Empirical antimicrobial therapy is the mainstay of antimicrobial stewardship. The gram stain can be used to guide initial empiric antimicrobial therapy in cases where culture report is not available. This rapid test can therefore be helpful in preventing the initiation of inappropriate therapy and its adverse outcomes. Aim: To determine the effectiveness of gram stain of tracheal aspirate samples in order to predict the causative microorganism and starting appropriate initial antimicrobial therapy. Materials and Methods: This cross-sectional study was done for 208 tracheal aspirate samples that were sent to Department of Microbiology, Lady Hardinge Medical College, New Delhi, India, with a request for bacterial culture and Antibiotic Susceptibility Testing (AST) from January 2019 to June 2019. Each sample was inoculated on 5% Sheep blood agar, Chocolate agar and MacConkey agar followed by gram stain preparation and smears. The culture plates were checked after 24 hours for any bacterial growth and further identification was done by gram stain, motility and biochemical tests. The AST was performed as per Clinical and Laboratory Standards Institute (CLSI) 2019 guidelines. All data entry was done on MS excel software and appropriate statistical tests were applied. Results: Out of total 208 samples significant gram stain findings were seen in 90 cases (43.2%). Out of 208 samples 132 (63.5%) cases grew significant pathogens on culture. Out of these 90 cases, 68 (75.5%) of gram stain finding matched with culture results. The correlation between gram stain and culture was found to be 75.5%. Conclusion: Gram stain is not only a quick and cost-effective method but also easily available in most laboratories and is highly reproducible. Gram stain, a rapid diagnostic tool, can thus be very useful in antimicrobial stewardship especially for the critically ill patients.

Prognosis and effectiveness of antibacterial treatment of endometritis after cesarian section with isolating drug-resistent ESKAPE pathohens

Purpose. The purpose of this study was to determine the frequency of isolation of drug-resistant ESKAPE pathogens isolation in endometritis after cesarean section; to assess the prognosis of the disease and the effectiveness of initial empirical antimicrobial therapy for isolating multiresistant pathogens.
 Methods. A retrospective analysis of all the cases of endometritis after cesarean section in St. Petersburg was performed. The study period: September 2008 September 2019.
 Results. 68 (26.7%) out of 255 cases of endometritis after cesarean section were caused by pathogens of the rESKAPE group. In puerperas with endometritis caused by rESKAPE pathogens, the following are more often observed: clinical failures in prescribing initial empirical antimicrobial therapy compared with endometritis of another etiology (p = 0.0012); severe course of infectious process with the risk of its generalization and hysterectomy (p 0.05).
 Conclusions. Endometritis after abdominal delivery caused by rESKAPE pathogens is associated with an unfavorable prognosis of the disease and a high risk of ineffective antimicrobial therapy.

Bacterial infections in cirrhosis: a narrative review and key points for clinical practice

Bacterial infections are frequent complications of liver cirrhosis, accounting for severe clinical courses, and increased mortality. The reduction of the negative clinical impact of infections may be achieved by a combination of prophylactic measures to reduce the occurrence, early identification, and management. Spontaneous bacterial peritonitis (SBP), urinary tract infections, pneumonia, cellulitis, and spontaneous bacteremia are frequent in cirrhosis. The choice of initial empirical antimicrobial therapy should be based on both site, severity, and origin of infection (community-acquired, nosocomial, or healthcare-associated) and on antibiotic resistance patterns. 3rd generation cephalosporins are generally indicated as empirical therapy in most community-acquired cases. However, for nosocomial and healthcare-associated infections, due to a high rate of multidrug-resistant (MDR) pathogens, a broader spectrum treatment is appropriate. In order to prevent antibiotic resistance emergence, microbiological cultures should be collected, and a de-escalation applied when antimicrobial susceptibility tests are available. Standard measures to prevent infections and the identification of carriers of MDR bacteria are essential strategies to prevent infections in cirrhosis. Antibiotic prophylaxis should be applied only to gastrointestinal bleeding, SBP recurrence prevention, and cirrhotics at high risk of a first episode of SBP.

2002. Evaluation of the BioFire® Pneumonia Panel in ICU Patients With Suspected Ventilator-Associated Pneumonia

BackgroundVentilator-associated pneumonia (VAP) is one of the most commonly encountered hospital-acquired infections worldwide, and one of the major contributors to an over mortality in critically ill patients. Initial empirical antimicrobial therapy is often broad-spectrum. Fast identification and quantification of microorganisms is of great importance to enable early effective targeted antimicrobial treatment. This trial compares the performance of the new BioFire® Pneumonia Panel (BPP) with quantitative conventional culture (CC) and an independent real-time quantitative molecular-based method (MM), in Intensive Care Unit (ICU) patients with VAP suspicion.MethodsBronchoalveolar lavage (BAL) specimens from 120 patients with suspected VAP, enrolled at four different French ICUs, during January to November 2013, were analysed by CC, following microbiological standard procedures, by BPP and MM. A total of 15 bacterial targets, commonly detected by the three methods, were analysed for concordance above an agreed threshold for positivity. While every step is fully integrated, from specimen-to-results (BPP), bacterial DNA was extracted from each sample on the NucliSENS easyMAG® Platform, and real-time polymerase chain reactions were run in an ABI 7500 Dx thermocycler (MM).ResultsA total of 117 different BAL specimens were processed. Positive culture was obtained for 65.8% of BAL, while positive detections were observed in 79.4% with BPP and 75.4% with independent MM. Fourteen different species were detected by the three methods, with majority of the bacteria being S. aureus, P. aeruginosa, and H. influenzae. Overall concordance performance between BPP and CC was 89.0% (83.1%–94.9%) positive percentage agreement (PPA) and 95.9% (95.0%–96.9%) negative percentage agreement (NPA). Overall concordance between BPP and MM was 97.1% (93.8%–100.3%) PPA and 96.6% (95.6%–97.6%) NPA. Following discrepancy analyses overall performance increased to 95.3% (91.2–99.3%) PPA when comparing BPP to CC.ConclusionThe new BioFire® Pneumonia Panel provides reliable quantitative microbiological data in BAL specimens, in only 65 minutes, which can lead to more appropriate management of VAP suspected patients in the ICU.RUO products used in this study have not been evaluated by the FDA or other regulatory agencies for In Vitro Diagnostic use.Disclosures A. Iannello, bioMérieux: Employee, Salary. C. Dubost, bioMérieux: Employee, Salary. C. Weber, bioMérieux: Employee, Salary. C. Alberti-Segui, bioMérieux: Employee, Salary. C. Mousset, bioMérieux: Employee, Salary. C. Ginocchio, bioMérieux: Employee, Salary. M. Rogatcheva, BioFire: Employee, Salary. V. Moucadel, bioMérieux: Employee, Salary. J. Yugueros-Marcos, bioMérieux: Employee, Salary.

Myringotomy as a Diagnostic and Therapeutic Tool in a Case of Otitis Media in a Guinea Pig (Cavia porcellus)

A 1.5 year old male adult guinea pig (Cavia porcellus) presented with acute vestibular disease, consisting of a right head tilt, circling, and ataxia. The head tilt was non-responsive to initial empirical antimicrobial therapy for presumptive otitis media. Video otoscopy and a myringotomy were performed under general anesthesia. A large amount of purulent debris was flushed from the middle ear and submitted for culture. Treatment with appropriate systemic and topical antibiotics was pursued for 4 weeks. Near complete resolution of clinical signs was achieved by the end of treatment with only a minor residual head tilt. This is the first described use of a diagnostic and therapeutic myringotomy for the treatment and resolution of otitis media in a guinea pig. Based on the clinical success seen in this case and the relative ease of the procedure, myringotomies should be considered for diagnosis and treatment of otitis media in guinea pigs.

Resistance profiles and risk factors of resistant microorganisms in bacteraemia of abdominal origin

Abstract Objective The presence of resistant microorganisms is a major cause of failure in initial empirical antimicrobial therapy. The objectives of this study are to determine the resistance profile of microorganisms that cause bacteraemia of abdominal origin and to identify whether the previous use of antibiotics and the place of acquisition of bacteraemia are risk factors associated with the presence of resistant organisms. Material and methods A clinical, observational, epidemiological, retrospective cohort study was conducted with all the adult patients admitted to a university hospital from 2011 to 2013. Antimicrobial resistance profiles were described and a 95% confidence interval chi-square test was used to determine whether the variables studied were risk factors in the isolation of resistant microorganisms. Results Of the 1245 patients with bacteraemia, 212 (17%) presented bacteraemia of abdominal origin. The resistance profile highlights the incidence of methicillin resistant Staphylococcus aureus (50%), coagulase-negative staphylococci resistant to linezolid (20.58%), enterococci resistant to vancomycin (3.12%), Escherichia coli resistant to third-generation cephalosporins (9.9%) and fluoroquinolones (35.64%), Klebsiella pneumoniae resistant to third-generation cephalosporins (8.33%), Pseudomonas aeruginosa resistant to fluoroquinolones and carbapenem (25% and 25% respectively) and Acinetobacter baumanii resistant to fluoroquinolones and carbapenem (100% and 100% respectively), Candida albicans resistant to fluconazole (11.11%), single Candida krusei isolate resistant to fluconazole and Candida parapsilosis resistant to echinocandins (12.5%). In our study, previous use of antibiotics had a statistically significant association with the isolation of resistant microorganisms (p = 0.013) but not the place of acquisition of bacteraemia (p = 0.239). Conclusion Establishing the incidence of resistant organisms can improve empirical antimicrobial therapy in patients with bacteraemia of abdominal origin. Previous use of antibiotics was statistically significantly related to the isolation of resistant microorganisms.

Perfiles de resistencia y factores de riesgo de microorganismos resistentes en bacteriemia de origen abdominal

ObjectiveThe presence of resistant microorganisms is a major cause of failure in initial empirical antimicrobial therapy. The objectives of this study are to determine the resistance profile of microorganisms that cause bacteraemia of abdominal origin and to identify whether the previous use of antibiotics and the place of acquisition of bacteraemia are risk factors associated with the presence of resistant organisms. Material and methodsA clinical, observational, epidemiological, retrospective cohort study was conducted with all the adult patients admitted to a university hospital from 2011-2013. Antimicrobial resistance profiles were described and a 95% confidence interval chi-square test was used to determine whether the variables studied were risk factors in the isolation of resistant microorganisms. ResultsOf the 1245 patients with bacteraemia, 212 (17%) presented bacteraemia of abdominal origin. The resistance profile highlights the incidence of methicillin resistant Staphylococcus aureus (50%), coagulase-negative staphylococci resistant to linezolid (20.58%), enterococci resistant to vancomycin (3.12%), Escherichia coli resistant to third-generation cephalosporins (9.9%) and fluoroquinolones (35.64%), Klebsiella pneumoniae resistant to third-generation cephalosporins (8.33%), Pseudomonas aeruginosa resistant to fluoroquinolones and carbapenem (25% and 25% respectively) and Acinetobacter baumanii resistant to fluoroquinolones and carbapenem (100% and 100% respectively), Candida albicans resistant to fluconazole (11.11%), single Candida krusei isolate resistant to fluconazole and Candida parapsilosis resistant to echinocandins (12.5%). In our study, previous use of antibiotics had a statistically significant association with the isolation of resistant microorganisms (P=.013) but not the place of acquisition of bacteraemia (P=.239). ConclusionEstablishing the incidence of resistant organisms can improve empirical antimicrobial therapy in patients with bacteraemia of abdominal origin. Previous use of antibiotics was statistically significantly related to the isolation of resistant microorganisms.

Clinical Impact of Expedited Pathogen Identification and Susceptibility Testing for Gram-negative Bacteremia and Candidemia Using the Accelerate Pheno™ System

BackgroundInappropriate initial antibiotic therapy (IIAT) for sepsis increases mortality. Fast diagnostic tests providing earlier identification (ID) of pathogens and antimicrobial susceptibility testing (AST) have the potential to improve mortality and antimicrobial stewardship. The Accelerate Pheno™ system (AXDX) is a newly FDA cleared fast diagnostic testing system that provides ID and AST for Gram-positive and Gram-negative bacteria (GNB) and ID for Candida bloodstream isolates.MethodsFrom April 14, 2016 to March 13, 2017, blood cultures from unique patients in the emergency department or medical intensive care units at Barnes-Jewish Hospital signaling positive and Gram-stain positive for GNB or yeast were eligible for inclusion. Standard-of-care (SOC) diagnostics were conducted in parallel with AXDX, though AXDX could be delayed up to 8 hours depending on research technician availability. Differences in time to ID and AST between SOC and AXDX were determined. Clinical outcomes included appropriateness of initial empiric antimicrobial therapy, potential for early antimicrobial de-escalation with AXDX, and mortality.ResultsOf 341 screened blood cultures, 123 met inclusion criteria; 101 had organisms that were on-panel for AXDX, 88 GNB and 13 C. glabrata or C. albicans. For GNB, mean time from blood culture positivity to ID and AST using SOC was 19.8 and 53.5 hours, respectively, and 1.4 and 6.7 hours using AXDX (from time AXDX started). For Candida spp., mean time to ID was 33.1 hours for SOC, 1.4 hours for AXDX. Antimicrobial de-escalation was possible based on AXDX testing in 52.9% of patients with GNB infections. A total of 27 (27.3%) patients received IIAT. In-hospital mortality was higher (48.1%) in the IIAT group than in those receiving appropriate initial antibiotics (12.5%), P < 0.001. AXDX could have improved antimicrobial therapy in 89.8% of GNB and 92.3% of Candida spp. cases.ConclusionThe Accelerate Pheno™ system is a novel fast diagnostic that significantly reduces the time to ID and AST for GNB and ID of Candida spp. bloodstream infections, with the potential to impact clinical outcomes. Prospective clinical trials are needed to evaluate the impact of this new system on clinical outcomes and antimicrobial stewardship.Disclosures C. A. D. Burnham, Accelerate Diagnostics: Investigator, Research support; M. Kollef, Accelerate Diagnostics: Consultant, Research support

Escherichia coli Resistance to Ciprofloxacin in Acute Uncomplicated Pyelonephritis

Background: Severe acute uncomplicated pyelonephritis is an infection of the kidneys that usually have an ascending route and occur in presumably healthy urinary tract. The most common pathogen involved is E. coli. The Infectious Diseases Society of America (IDSA) has issued an updated guideline in 2010 suggesting IV quinolones to be considered in the initial empiric antimicrobial therapy giving known resistance of less than 10%. However, E. coli resistance to quinolones has been increasing, the recent data of E. coli, causing pyelonephritis, resistance is not known in the Midwest. Local hospital antibiogram for two years showed up to 22% resistance to ciprofloxacin among E. coli isolates. Methods: We conduct a retrospective non-concurrent cohort study in one teaching hospital in the Midwest, females who were admitted with severe acute uncomplicated pyelonephritis in a three years period were included. Patients with urinary tract obstruction, pregnancy, immuno-suppression, males, and indwelling Foley’s catheters were excluded. Data collected include causative pathogens and resistance to antibiotics were collected. Percentages, frequencies, and measures of central tendency and dispersion were calculated to describe the study sample Results: 73 patients were included in the final analysis. E. coli was the most common isolated pathogen (81%), followed by other enteric gram negative. E. coli resistance to ciprofloxacin was 13.5%, 37% to trimethoprim-sulfamethoxazole, and 5% to ceftriaxone. Conclusion: Ciprofloxacin should be avoided initially in treating severe acute uncomplicated pyelonephritis until culture results and sensitivity is available.

Estimating the likelihood of success with the initial empiric antimicrobial therapy in patients with nosocomial infections

In order to estimate the likelihood of success (SL) with the initial empiric antimicrobial therapy, the following formula was constructed with data subjected to prior clinical validation in real time: SL (%) = (Nº isolates susceptible to IEAT/Nº patients with MDI) × 100. Where the numerator of the formula represents the total number of isolates recovered from the assessed type of infection, that was susceptible to any component of empiric antimicrobial therapy (IEAT) used, and the denominator represents the total number of patients with the same assessed, but microbiologically documented infection (MDI). For male hospital-acquired urinary tract infection, only imipenem reached a suitable SL value (i.e. ≥80%). In patients with hospital-acquired peritonitis, imipenem and tigecycline–ceftazidime showed the highest coverage rates. For ventilator-associated pneumonia only imipenem yielded acceptable coverage as a single drug. Implementing the present formula instead of the regular global antibiograms used to guide the selection of the initial treatment may benefit the patient outcome and improve antimicrobial usage.

Vpliv vrste povzročitelja na porast koncentracije prokalcitonina pri bolnikih s sepso

AbstractTheoretical background: Procalcitonin (PCT) is diagnostic and prognostic biomarker of sepsis. The objective of this study was to evaluate the correlation between sepsis causative agent and serum PCT concentration, since it would influence the initial empirical antimicrobial therapy selection.Methods: This retrospective study included 96 patients with sepsis who were admitted to Intensive Care Unit of Department of Infectious Diseases and Febrile Illnesses of University Clinical Center Ljubljana from September of 2011 through March of 2013. Sepsis was established clinically and defined aetiologically by haemoculture growth. Statistical evaluation was conducted in 76 patients who had not received proper antimicrobial therapy prior to blood collection. ForPCT determination imunoluminometric method was used and concentrations above 5 mg/L were considered elevated. Results: Serum PCT concentration was significantly higher in Gram-negative sepsis (PCT median was 26,3 μg/L) compared to Gram-positive sepsis (PCT median was 11,2 μg/L) (p = 0,016). Differences in PCT concentrations between Gram-positive pathogens were not statistically significant (p = 0,09), however, S. aureus sepsis is linked to higher serum PCT concentration (median PCT 12,8 μg/L) than all other Gram-positive agents put together (median PCT of 5,9 μg/L) (p = 0,016). Difference in PCT concentration in E. coli sepsis (median PCT of 38,2 μg/L) compared to other enterobacteria (median PCT of 26,3 μg/L) is not statistically significant (p = 0,902). Conclusions: Causative agent has a significant effect on serum PCT concentration in patients with sepsis. Higher values were present in Gram-negative than in Gram-positive sepsis. Amongst Gram-positive pathogens, S. aureus caused greater rise in PCT than other Gram-positive bacteria put together.

Sepsis in standard care: patients' characteristics, effectiveness of antimicrobial therapy and patient outcome--a cohort study.

Fast diagnosis and initiation of appropriate antibiotic therapy is pivotal for the survival of sepsis patients. However, most studies on suspected sepsis patients are conducted in the intensive care unit or in the emergency room setting, neglecting the standard care setting. This study evaluated sepsis risk factors, microbiological accurateness of the initial empiric antimicrobial therapy and its effect on hospital mortality in standard care patients. In this prospective observational cohort study, patients with clinically suspected sepsis meeting two or more SIRS criteria were screened on standard care wards. After hospital discharge, occurrence of an infection was assessed according to standardized criteria, and empirical antibiotic therapy was evaluated using antibiograms of recognized pathogens by expert review. Of the 2384 screened patients, 298 fulfilled two or more SIRS criteria. Among these were 28.2 % SIRS patients without infection, 46.3 % non-bacteremic/fungemic sepsis patients and 25.5 % bacteremic/fungemic sepsis patients. Occurrence of a malignant disease and chills were associated with a higher risk of patients having bacteremic/fungemic sepsis, whereas other described risk factors remained insignificant. In total, 91.1 % of suspected sepsis patients received empirical antimicrobial therapy, but 41.1 % of bacteremic sepsis patients received inappropriate therapy. Non-surviving bacteremic sepsis patients received a higher proportion of inappropriate therapy than those who survived (p = 0.022). A significant proportion of bacteremic sepsis patients receive inappropriate empiric antimicrobial therapy. Our results indicate that rapid availability of microbiological results is vital, since inappropriate antimicrobial therapy tended to increase the hospital mortality of sepsis patients.

Febrile Neutropenic Infection Occurred in Cancer Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation

ObjectiveThe objective of this study was to investigate the incidence, risk factors, and clinical and prognostic characteristics of febrile infection that occurred during the neutropenic period in cancer patients who underwent autologous peripheral blood stem cell transplantation (APBSCT). MethodsClinical data of all the APBSCT cases from 2007 to 2009 in Sun Yat-sen University Cancer Center were collected and retrospectively analyzed. ResultsEighty-nine APBSCT subjects were investigated. Neutropenia usually occurred on the 4th day (range, 0–15) after transplantation and lasted 6 (range, 3–27) days. Febrile neutropenia occurred in 78.7% patients and lasted around 3 (range, 1–20) days and no infection-related deaths were observed. For febrile episodes, 12 patients (17.1%) were diagnosed as having microbiologically documented infections (MDI). Initial empirical antimicrobial therapy was given to all cases of post-APBSCT febrile neutropenia, of which 44 cases (62.9%) were effective. Febrile neutropenia occurred in 25/34 (73.5%) patients who were given antifungal drugs for prophylaxis. ConclusionsNeutropenic infection is still the major complication in APBSCT patients and duration of neutropenia is one of the major risk factors. Prophylactic administration of antifungal drugs seems to be invalid to reduce post-APBSCT infection. Sufficient doses of broad-spectrum antibiotics at the early stage lead to better results of initial antimicrobial treatment.

Accuracy of tracheal aspirate gram stain in predicting Staphylococcus aureus infection in ventilator-associated pneumonia

BackgroundThe Gram stain can be used to direct initial empiric antimicrobial therapy when complete culture is not available. This rapid test could prevent the initiation of inappropriate therapy and adverse outcomes. However, several studies have attempted to determine the value of the Gram stain in the diagnosis and therapy of bacterial infection in different populations of patients with ventilator-associated pneumonia (VAP) with conflicting results. The objective of this study is to evaluate the accuracy of the Gram stain in predicting the existence of Staphylococcus aureus infections from cultures of patients suspected of having VAP.MethodsThis prospective single-center open cohort study enrolled 399 patients from December 2005 to December 2010. Patients suspected of having VAP by ATS IDSA criteria were included. Respiratory secretion samples were collected by tracheal aspirate (TA) for standard bacterioscopic analysis by Gram stain and culture.ResultsRespiratory secretion samples collected by tracheal aspirates of 392 patients were analyzed by Gram stain and culture. When Gram-positive cocci were arranged in clusters, the sensitivity was 68.4%, specificity 97.8%, positive predictive value 88.1% and negative predictive value 92.8% for predicting the presence of Staphylococcus aureus in culture (p < 0.001).ConclusionsA tracheal aspirate Gram stain can be used to rule out the presence of Staphylococcus aureus in patients with a clinical diagnosis of VAP with a 92.8% Negative Predictive Value. Therefore, 7.2% of patients with Staphylococcus aureus would not be protected by an empiric treatment that limits antimicrobial coverage to Staphylococcus aureus only when Gram positive cocci in clusters are identified.