Nosocomial Bloodstream Infections Research Articles

Epidemiological and clinical characterization of community, healthcare-associated and nosocomial colonization and infection due to carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in Spain.

Community-acquired (CA) and healthcare-associated (HCA) infections caused by carbapenemase-producing Enterobacterales (CPE) are not well characterized. The objective was to provide detailed information about the clinical and molecular epidemiological features of nosocomial, HCA and CA infections caused by carbapenemase-producing Klebsiella pneumoniae (CP-Kp) and Escherichia coli (CP-Ec). A prospective cohort study was performed in 59 Spanish hospitals from February to March 2019, including the first 10 consecutive patients from whom CP-Kp or CP-Ec were isolated. Patients were stratified according to acquisition type. A multivariate analysis was performed to identify the impact of acquisition type in 30-day mortality. Overall, 386 patients were included (363 [94%] with CP-Kp and 23 [6%] CP-Ec); in 296 patients (76.3%), the CPE was causing an infection. Acquisition was CA in 31 (8.0%) patients, HCA in 183 (47.4%) and nosocomial in 172 (48.3%). Among patients with a HCA acquisition, 100 (54.6%) had been previously admitted to hospital and 71 (38.8%) were nursing home residents. Urinary tract infections accounted for 19/23 (82.6%), 89/130 (68.5%) and 42/143 (29.4%) of CA, HCA and nosocomial infections, respectively. Overall, 68 infections (23%) were bacteremia (8.7%, 17.7% and 30.1% of CA, HCA and nosocomial, respectively). Mortality in infections was 28% (13%, 14.6% and 42.7% of CA, HCA and nosocomial, respectively). Nosocomial bloodstream infections were associated with increased odds for mortality (adjusted OR, 4.00; 95%CI 1.21-13.19). HCA and CA infections caused by CPE are frequent and clinically significant. This information may be useful for a better understanding of the epidemiology of CPE.

Epidemiology and antimicrobial susceptibility profiles of Enterobacterales causing bloodstream infections before and during COVID-19 pandemic: Results of the Study for Monitoring Antimicrobial Resistance Trends (SMART) in Taiwan, 2018–2021

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has contributed to the spread of antimicrobial resistance, including carbapenem-resistant Enterobacterales. MethodsThis study utilized data from the Study for Monitoring Antimicrobial Resistance Trends (SMART) surveillance program in Taiwan. Enterobacterales from patients with bloodstream infections (BSIs) were collected and subjected to antimicrobial susceptibility testing and β-lactamase gene detection using a multiplex PCR assay. Statistical analysis was conducted to compare susceptibility rates and resistance genes between time periods before (2018–2019) and during the COVID-19 pandemic (2020–2021). ResultsA total of 1231 Enterobacterales isolates were collected, predominantly Escherichia coli (55.6%) and Klebsiella pneumoniae (29.2%). The proportion of nosocomial BSIs increased during the COVID-19 pandemic (55.5% vs. 61.7%, p < 0.05). Overall, susceptibility rates for most antimicrobial agents decreased, with Enterobacterales from nosocomial BSIs showing significantly lower susceptibility rates than those from community-acquired BSIs. Among 123 Enterobacterales isolates that underwent molecular resistance mechanism detection, ESBL, AmpC β-lactamase, and carbapenemase genes were detected in 43.1%, 48.8% and 16.3% of the tested isolates, respectively. The prevalence of carbapenemase genes among carbapenem-resistant Enterobacterales increased during the pandemic, although the difference was not statistically significant. Two novel β-lactamase inhibitor combinations, imipenem-relebactam and meropenem-vaborbactam, preserved good efficacy against Enterobacterales. However, imipenem-relebactam showed lower in vitro activity against imipenem-non-susceptible Enterobacterales than that of meropenem-vaborbactam. ConclusionsThe COVID-19 pandemic appears to be associated with a general decrease in antimicrobial susceptibility rates among Enterobacterales causing BSIs in Taiwan. Continuous surveillance is crucial to monitor antimicrobial resistance during the pandemic and in the future.

Gut barrier dysfunction and the risk of ICU-acquired bacteremia- a case–control study

BackgroundImpaired intestinal barrier function can enable passage of enteric microorganisms into the bloodstream and lead to nosocomial bloodstream infections during critical illness. We aimed to determine the relative importance of gut translocation as a source for ICU-acquired enterococcal bacteremia of unknown origin.MethodsWe conducted a nested case–control study in two mixed medical-surgical tertiary ICUs in the Netherlands among patients enrolled between 2011 and 2018. We selected 72 cases with ICU-acquired bacteremia due to enterococci (which are known gastrointestinal tract commensals) and 137 matched controls with bacteremia due to coagulase-negative staphylococci (CoNS) (which are of non-intestinal origin). We measured intestinal fatty acid-binding protein, trefoil factor-3, and citrulline 48 h before bacteremia onset. A composite measure for Gut Barrier Injury (GBI) was calculated as the sum of standardized z-scores for each biomarker plus a clinical gastrointestinal failure score.ResultsNo single biomarker yielded statistically significant differences between cases and controls. Median composite GBI was higher in cases than in controls (0.58, IQR − 0.36–1.69 vs. 0.32, IQR − 0.53–1.57, p = 0.33) and higher composite measures of GBI correlated with higher disease severity and ICU mortality (p < 0.001). In multivariable analysis, higher composite GBI was not significantly associated with increased occurrence of enterococcal bacteremia relative to CoNS bacteremia (adjusted OR 1.12 95% CI 0.93–1.34, p = 0.22).ConclusionsWe could not demonstrate an association between biomarkers of gastrointestinal barrier dysfunction and an increased occurrence of bacteremia due to gut compared to skin flora during critical illness, suggesting against bacterial translocation as a major vector for acquisition of nosocomial bloodstream infections in the ICU.

Blood-Stream Infections: Causative Agents, Antibiotic Resistance and Associated Factors in Older Patients.

The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance. This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019. Moyen's age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock. The mortality rate was still high, especially for antibiotic-resistant agents.

Clinical and Microbiological Risk Factors for 30-Day Mortality of Bloodstream Infections Caused by OXA-48-Producing Klebsiella pneumoniae.

Bloodstream infections (BSI) caused by carbapenem-resistant Klebsiella pneumoniae are associated with high morbidity and mortality, and the therapy options available for their treatment are frequently scarce. The aim of this study was to analyze risk factors for 30-day mortality in patients with BSI caused by OXA-48-producing K. pneumoniae. The clinical and treatment features of the patients, who attended a single hospital over a five-year period, were retrospectively reviewed. The microbiological features, including the sequence types (ST) and the somatic (O) and capsular (K) antigens, as well as their resistance properties, comprising phenotypes and genetic background, were also considered. To identify the risk factors for 30-day mortality, uni- and multivariate statistical analyses were performed. The univariate analysis revealed statistically significant correlations for age, male gender, lower respiratory system infection, infection by ST147 isolates, and infection by isolates expressing the K64 antigen. The multivariate analysis, applied to variables yielding p-values close to or lower than 0.05 in the univariate analysis, confirmed gender, lower respiratory system infection, and infection with ST147 isolates, but not age or infection with K64 isolates, as risk factors for 30-day mortality. Moreover, the multivariate analysis showed that patients suffering from hematological malignancies or having been treated with inappropriate therapy, both having p-values slightly higher than 0.05 in the univariate analysis, exhibited significantly poorer outcomes in the multivariant analysis. The association of the ST147 clone with an increased risk of mortality is a novel finding that deserves further attention. Studies like the one presented here can certainly benefit the management of patients with nosocomial BSI caused by carbapenemase-producing K. pneumoniae.

Antifungal resistance, combinations and pipeline: oh my!

Invasive fungal infections are a strong contributor to healthcare costs, morbidity and mortality, especially amongst hospitalized patients. Historically, Candida was responsible for approximately 15% of all nosocomial bloodstream infections. In the past 10 years, the epidemiology of Candida species has altered, with increasing prevalence of resistant species. With rising fungal resistance, especially in Candida spp., the demand for novel antifungal therapies has exponentially increased over the last decade. Newer antifungal agents have become an attractive option for patients needing long-term therapy for infections or those requiring antifungal prophylaxis. Despite advances in coverage of non-Candida pathogens with newer agents, clinical scenarios involving multidrug-resistant fungal pathogens continue to arise in practice. Combination antifungal therapy can lead to a host of side-effects, some of which can be drug limiting. Additional antifungal therapies with enhanced fungal spectrum of activity and decreased rates of adverse effects are warranted. Fosmanogepix, ibrexafungerp, olorofim and rezafungin may help fill some of these gaps in the antifungal armamentarium. This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Application of Next-Generation Sequencing to Enterobacter Hormaechei Subspecies Analysis during a Neonatal Intensive Care Unit Outbreak.

The Enterobacter cloacae complex (ECC) species are potential neonatal pathogens, and ECC strains are among the most commonly encountered Enterobacter spp. associated with nosocomial bloodstream infections. Outbreaks caused by ECC can lead to significant morbidity and mortality in susceptible neonates. At the molecular level, ECC exhibits genomic heterogeneity, with six closely related species and subspecies. Genetic variability poses a challenge in accurately identifying outbreaks by determining the clonality of ECC isolates. This difficulty is further compounded by the limitations of the commonly used molecular typing methods, such as pulsed field gel electrophoresis, which do not provide reliable accuracy in distinguishing between ECC strains and can lead to incorrect conclusions. Next-generation sequencing (NGS) offers superior resolution in determining strain relatedness. Therefore, we investigated the clinical pertinence of incorporating NGS into existing bundle measures to enhance patient management during an outbreak of ECC in a level-3 neonatal intensive care unit (NICU) in Germany. As the standard of care, all neonates on the NICU received weekly microbiological swabs (nasopharyngeal and rectal) and analysis of endotracheal secretion, where feasible. During the 2.5-month outbreak, colonisation with ECC was detected in n = 10 neonates. The phylogenetic relationship and potential antimicrobial resistance genes as well as mobile genetic elements were identified via bacterial whole-genome sequencing (WGS) using Illumina MiSeq followed by in silico data analysis. Although all ECC isolates exhibited almost identical antimicrobial susceptibility patterns, the WGS data revealed the involvement of four different ECC clones. The isolates could be characterised as Enterobacter hormaechei subspecies steigerwaltii (n = 6, clonal), subsp. hoffmannii (n = 3, two clones) and subsp. oharae (n = 1). Despite the collection of environmental samples, no source of this diffuse outbreak could be identified. A new standardised operating procedure was implemented to enhance the management of neonates colonised with MRGN. This collaborative approach involved both parents and medical professionals and successfully prevented further transmission of ECC. Initially, it was believed that the NICU outbreak was caused by a single ECC clone due to the similarity in antibiotic resistance. However, our findings show that antibiotic susceptibility patterns can be misleading in investigating outbreaks of multi-drug-resistant ECC. In contrast, bacterial WGS accurately identified ECC at the clonal level, which significantly helped to delineate the nature of the observed outbreak.

The Fourier-transform infrared spectroscopy-based method as a new typing tool for Candida parapsilosis clinical isolates.

The Fourier-transform infrared spectroscopy-based IR Biotyper is a straightforward typing tool for bacterial species, but its use with Candida species is limited. We applied IR Biotyper to Candida parapsilosis, a common cause of nosocomial bloodstream infection (BSI), which is aggravated by the intra-hospital spread of fluconazole-resistant isolates. Of 59 C. parapsilosis isolates studied, n = 56 (48 fluconazole-resistant and 8 fluconazole-susceptible) and n = 3 (2 fluconazole-resistant and 1 fluconazole-susceptible) isolates, respectively, had been recovered from BSI episodes in 2 spatially distant Italian hospitals. The latter isolates served as an outgroup. Of fluconazole-resistant isolates, n = 40 (including one outgroup) harbored the Y132F mutation alone and n = 10 (including one outgroup) harbored both Y132F and R398I mutations in the ERG11-encoded azole-target enzyme. Using a microsatellite typing method, which relies on the amplification of genomic short tandem repeats (STR), two major clusters were obtained based on the mutation(s) (Y132F or Y132F/R398I) present in the isolates. Regarding IR Biotyper, each isolate was analyzed in quintuplicate using an automatic (i.e., proposed by the manufacturer's software) or tentative (i.e., proposed by us) cutoff value. In the first case, four clusters were identified, with clusters I and II formed by Y132F or Y132F/R398I isolates, respectively. In the second case, six subclusters (derived by the split of clusters I and II) were identified. This allowed to separate the outgroup isolates from other isolates and to increase the IR Biotyper typeability. The agreement of IR Biotyper with STR ranged from 47% to 74%, depending on type of cutoff value used in the analysis. IMPORTANCE Establishing relatedness between clinical isolates of Candida parapsilosis is important for implementing rapid measures to control and prevent nosocomial transmission of this Candida species. We evaluated the FTIR-based IR Biotyper, a new typing method in the Candida field, using a collection of fluconazole-resistant C. parapsilosis isolates supposed to be genetically related due to the presence of the Y132F mutation. We showed that IR Biotyper was discriminatory but not as much as the STR method, which is still considered the method of choice. Further studies on larger series of C. parapsilosis isolates or closely related Candida species will be necessary to confirm and/or extend the results from this study.

Identification of risk factors and development of a predictive model for bloodstream infection in intensive care unit COVID-19 patients

To identify risk factors for nosocomial bloodstream infections (BSIs) in intensive care unit (ICU) patients with COVID-19 and to build a predictive model for BSIs. The retrospective case-control study included 236 ICU COVID-19 patients with BSIs group and 234 patients in the control group. Demographic and laboratory data, comorbidities, drug use, invasive procedures and identified pathogens were recorded separately for patients directly admitted and transferred to ICU. Fine and Gray's multi-variate competing risk model was used to build a predictive model for patients transferred to ICU. The risk factors were: interleukin inhibitors (HR= 6.1 (95% CI: 2.0-18.5)) and dexamethasone (HR= 3.0 (95% CI: 1.3-7.1)) use in previous hospitalization, glomerular filtration rate <60mL/min per 1.73m2 (HR= 4.0 (95% CI: 2.1-7.6)) and blood glucose >9mmol/L (HR= 2.5 (95% CI: 1.4-4.6)) in patients directly admitted to ICU; and dexamethasone use in previous hospitalization (HR= 4.5 (95% CI: 1.8-11)), the total dexamethasone dose before transfer to ICU (HR= 1.2 (95% CI: 1.06-1.37)), diabetes mellitus (HR= 1.4 (95% CI: 1.1-1.9)), alanine transaminase (ALT) ≥35.5 U/L on hospital admission (HR= 1.5 (95% CI: 1.1-2.1)), and the use of low-flow oxygen versus high-flow oxygen therapy or non-invasive mechanical ventilation on admission to ICU ((HR= 2.7 (95% CI: 5.6-11.1)) in patients transferred to ICU. A predictive model had sensitivity of 63-73% and specificity of 71-83% at different times of ICU stay. Our findings may help clinicians detect patients at high risk of developing BSIs.

The incidence of nosocomial bloodstream infection and urinary tract infection in Australian hospitals before and during the COVID-19 pandemic: an interrupted time series study

BackgroundThe COVID-19 pandemic has had a significant impact on healthcare including increased awareness of infection prevention and control (IPC). The aim of this study was to explore if the heightened awareness of IPC measures implemented in response to the pandemic influenced the rates of healthcare associated infections (HAI) using positive bloodstream and urine cultures as a proxy measure.MethodsA 3 year retrospective review of laboratory data from 5 hospitals (4 acute public, 1 private) from two states in Australia was undertaken. Monthly positive bloodstream culture data and urinary culture data were collected from January 2017 to March 2021. Occupied bed days (OBDs) were used to generate monthly HAI incidence per 10,000 OBDs. An interrupted time series analysis was undertaken to compare incidence pre and post February 2020 (the pre COVID-19 cohort and the COVID-19 cohort respectively). A HAI was assumed if positive cultures were obtained 48 h after admission and met other criteria.ResultsA total of 1,988 bloodstream and 7,697 urine positive cultures were identified. The unadjusted incident rate was 25.5 /10,000 OBDs in the pre-COVID-19 cohort, and 25.1/10,000 OBDs in the COVID-19 cohort. The overall rate of HAI aggregated for all sites did not differ significantly between the two periods. The two hospitals in one state which experienced an earlier and larger outbreak demonstrated a significant downward trend in the COVID-19 cohort (p = 0.011).ConclusionThese mixed findings reflect the uncertainty of the effect the pandemic has had on HAI’s. Factors to consider in this analysis include local epidemiology, differences between public and private sector facilities, changes in patient populations and profiles between hospitals, and timing of enhanced IPC interventions. Future studies which factor in these differences may provide further insight on the effect of COVID-19 on HAIs.

Staphylococcus aureus and Coagulase-Negative Staphylococci from Bloodstream Infections: Frequency of Occurrence and Antimicrobial Resistance, 2018-2021.

The abuse of antibiotics during the SARS-CoV-2 pandemic might have disrupted efforts to curb the further development and spread of the antimicrobial resistance of Staphylococcus aureus infection and Staphylococcus spp. coagulase-negative (CoNS) agents of nosocomial bloodstream infections (NBSIs). The purpose of our work was to study the resistance patterns of Staphylococcus aureus and CoNS through the analysis of blood cultures in hospitalized SARS-CoV-2-positive and SARS-CoV-2-negative patients (pts.). During the period January 2018-June 2021, a retrospective case-control study was performed on blood cultures positive for Staphylococcus spp. detected in 177 adult pts. (≥18 years old) hospitalized for >48 hours at Sant'Elia Hospital, Caltanissetta. Staphylococcus aureus was isolated in 33.9% of blood culture samples, and among CoNS, the most frequent strains were Staphylococcus capitis (18.6%) and Staphylococcus hominis (18.1%). Patients aged ≥ 65 years, with a greater number of males, comprised the SARS-CoV-2-negative pts. (71.8% vs. 52.2%, p = 0.0154). Among the SARS-CoV-2-positive patients, the significant resistance of Staphylococcus aureus was only observed for erythromycin (57.1%). The oxacillin resistance of Staphylococcus capitis was higher in SARS-CoV-2-positive than in negative pts. (90% and 78.3%, respectively). Comparing the two groups, we found an increase in resistance in SARS-CoV-2-negative patients for the following antibiotics: gentamicin for Staphylococcus aureus (p = 0.007), clindamycin and erythromycin (p = 0.012) for Staphylococcus hominis and oxacillin and rifampicin for Staphylococcus haemoliticus (p = 0.012). Our study confirms the relevance of oxacillin-resistant Staphylococcus aureus in being responsible for bloodstream infection and draws attention to highly oxacillin-resistant CoNS such as Staphylococcus capitis. The presence of resistant strains of CoNS in hospitals can be worrying, as it limits treatment options and worsens outcomes. The Infection Control Committee (ICC) recommends new treatment strategies to decrease colonization and infections. As part of the implementation of a bloodstream infection prevention program, the authors encourage the introduction of a report on the antimicrobial resistance of hospital bacteremia due to CoNS.

Risk Factor for Superimposed Nosocomial Bloodstream Infections in Hospitalized Patients with COVID-19.

Corticosteroids are a component of the standard therapy for patients with coronavirus disease 2019 (COVID-19) because of the immunological dysregulation and hyperinflammation associated with the condition. This study aimed to evaluate the potential risk factors for nosocomial bloodstream infections in hospitalized patients with COVID-19, including the exploration of corticosteroid dosage and treatment duration. A retrospective cohort study of hospitalized patients with COVID-19 was conducted in a tertiary care hospital. We performed univariate and multivariate analyses of various parameters to identify risk factors for nosocomial bloodstream infection. Of 252 patients, 19% had nosocomial bloodstream infections. The mortality rate of nosocomial bloodstream infections was 62.5%. Multivariate analysis revealed that male sex (odds ratio [OR] 3.43; 95% confidence interval [CI]: 1.60-7.33), receiving methylprednisolone (OR: 3.01; 95% CI: 1.24-7.31), receiving an equivalent dexamethasone dose of 6-12 mg/day (OR: 7.49; 95% CI: 2.08-26.94), and leukocytosis on admission (OR: 4.13; 95% CI: 1.89-9.01) were significant predictors of nosocomial bloodstream infections. Unmodified risk variables for nosocomial bloodstream infections included male sex and leukocytosis at admission. Using methylprednisolone and obtaining a cumulative dosage of dexamethasone were adjusted risk variables associated with superimposed nosocomial bloodstream infections in hospitalized patients with COVID-19.

Pharmacological options for Candida albicans Endocarditis at the roadblock with irrecoverable prosthetics and drug interactions: a case report and review of literature

BackgroundCandidemia is the fourth most common nosocomial bloodstream infection. Endocarditis from candidemia is a rare but possibly fatal complication. The efficacy of amphotericin and echinocandins for induction and azoles for suppression has been well studied. Source control of infection, including removal of foreign bodies, remains the cornerstone for the success of any antifungal therapy.Case PresentationWe are describing a case of a 63-years old patient with multiple comorbidities who developed candidemia secondary to Candida albicans. The prospect of curing the fungemia was made difficult by prosthetic devices, including prosthetic heart valves, intracardiac defibrillator, and inferior vena filter, which could not be extracted due to poor cardiovascular status and higher postoperative mortality risk. Combination therapy with amphotericin and 5-Flucytosine (5FC) was used with the first recurrence. Suppression with fluconazole was contraindicated due to prolonged corrected QT (QTc) interval. Isavuconazole was employed for chronic lifelong suppression.ConclusionRetaining prosthetics in higher surgical risk patients presents us with unique clinical and pharmacological challenges regarding breakthrough infections, drug interaction, and side effects from prolonged suppressive therapies.

Health-economic modelling of cost savings due to the use of rezafungin based on a German cost-of-illness study of candidiasis.

Candida species are responsible for fungal diseases and the development of nosocomial bloodstream infections. Treatment is resource-intensive and economically challenging for healthcare systems. Cost analyses of drugs against candidiasis, such as rezafungin, are thus of great interest to healthcare payers. We conducted a cost-of-illness study of patients with Candida infections based on real-word data of the Department I of Internal Medicine, University Hospital Cologne (Germany) between 2016 and 2021. Health-economic parameters were analysed to describe the economic impact of Candida infections. Potential cost savings due to the administration of rezafungin were modelled for patients with invasive candidiasis or candidaemia based on a 5 day reduction of ICU length of stay (LOS) shown by the STRIVE study. We found 724 cases (652 patients) with Candida infections, of which 61% received ICU treatment (n = 442) and 29% were mechanically ventilated (n = 207). Twenty-six percent died during hospitalization (n = 185). Median LOS was 25 and 15 days, on normal wards and ICU, respectively. Median total treatment costs per case accounted for €22 820. Based on the ICU LOS reduction, the retrospective model showed a median cost-saving potential of €7175 per hospital case with invasive candidiasis or candidaemia. Accumulated cost savings for 37 patients of €283 335 were found. Treatment of candidiasis is cost intensive due to increased hospital LOS. The ICU LOS reduction rezafungin showed in STRIVE would lead to sustainable cost savings.

Risk Factors and Outcome Analysis of Gram-Positive Bacteremia in Critically Ill Patients.

Introduction Bloodstream infection (BSI) is a common problem for patients in the intensive care unit (ICU). Nearly 60% of primary bloodstream infections are caused by Gram-positive cocci. Gram-positive bacteria gain access to the bloodstream through invasive procedures and various patient care equipment like catheters, intravenous lines, and mechanical ventilators.S. aureus is considered to be the major cause of septicemia. Knowledge of healthcare-associated infections and the antimicrobial susceptibility patterns of the isolates are crucial in guiding empirical treatment. Methods This prospective observational study was conducted in Medical ICU, Dayanand Medical College & Hospital, Ludhiana over a period of one year (December 2015 to November 2016). Patients whose blood cultures tested positive for Gram-positive bacteria were included in the study. This study was carried out to assess the implications and risk factors for nosocomial BSI and several factors, including the age of the patient, the severity of illness, the presence of catheters, and the microorganisms causing the BSI to independently predict mortality. Chief complaints and risk factors were evaluated. APACHE-II scores were calculated for all patients and outcomes were analyzed. Results In our study, the mean age of patients was 50.93±14.09 years. Central line insertion was found as the most common risk factor (58.7%). A statistically significant correlation was obtained between APACHE-II scores and the presence of risk factors i.e. central line insertion (p-value=0.010) and diabetes mellitus (p-value=0.003). The most common Gram-positive pathogen isolated by blood culture was methicillin-sensitive S. aureus (44.2%). For management, the majority of the patients were prescribed teicoplanin (58.7%). The 28-dayoverall mortality rate in our study was 52.9%. Conclusion We conclude that independent risk factors like diabetes mellitus, central line insertion, and acute pancreatitis in adult patients with Gram-positive bacteremia were associated with higher mortality. We have also concluded that the administration of early appropriate antibiotics improves patient outcomes.

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: A NBSIs frontline ownership intervention.

Nosocomial bloodstream infections (NBSIs) are adverse complications of hospitalization. Most interventions focus on intensive care units. Data on interventions involving patients' personal care providers in hospitalwide settings are limited. To evaluate the impact of department-level NBSI investigations on infection incidence. Beginning in 2016, positive cultures, classified as suspected of being hospital acquired, were prospectively investigated by patients' unit-based personal healthcare providers using a structured electronic questionnaire. After analyzing the conclusions of the investigation, a summary was sent quarterly to the departments and to hospital management. NBSI rates and clinical data during a 5-year period (2014-2018) were calculated and compared before and after the intervention (2014-2015 versus 2016-2018), using interrupted time-series analysis. Among 4,135 bloodstream infections (BSIs), 1,237 (30%) were nosocomial. The rate of NBSI decreased from 4.58 per 1,000 admissions days in 2014 and 4.82 in 2015, to 3.81 in 2016, 2.94 in 2017 and 2.86 in 2018. Following a 4-month lag after introducing the intervention, the NBSI rate per 1000 admissions dropped significantly by 1.33 (P = .04; 95% CI, -2.58 to -0.07). The monthly NBSI rate continued to decrease significantly by 0.03 during the intervention period (P = .03; 95% CI, -0.06 to -0.002). Detailed department-level investigations of NBSI events performed by healthcare providers, increased staff awareness and frontline ownership and were associated with a decrease in NBSI rates hospitalwide.

Cefiderocol, a Siderophore Cephalosporin, as a Treatment Option for Infections Caused by Carbapenem-Resistant Enterobacterales.

Carbapenem-resistant Enterobacterales (CRE) remain a significant public health threat, and, despite recent approvals, new antibiotics are needed. Severe infections caused by CRE, such as nosocomial pneumonia and bloodstream infections, are associated with a relatively high risk of morbidity and mortality. The recent approval of ceftazidime-avibactam, imipenem-relebactam, meropenem-vaborbactam, plazomicin, eravacycline and cefiderocol has broadened the armamentarium for the treatment of patients with CRE infections. Cefiderocol is a siderophore cephalosporin with overall potent in vitro activity against CRE. It is taken up via iron transport channels through active transport, with some entry into bacteria through traditional porin channels. Cefiderocol is relatively stable against hydrolysis by most serine- and metallo-beta-lactamases, including KPC, NDM, VIM, IMP and OXA carbapenemases-the most frequent carbapenemases detected in CRE. The efficacy and safety of cefiderocol has been demonstrated in three randomised, prospective, parallel group or controlled clinical studies in patients at risk of being infected by multidrug-resistant or carbapenem-resistant Gram-negative bacteria. This paper reviews the in vitro activity, emergence of resistance, preclinical effectiveness, and clinical experience for cefiderocol, and its role in the management of patients with CRE infections.

Multicentre surveillance of epidemiologically important pathogens causing nosocomial bloodstream infections and pneumonia trials in Brazilian adult intensive care units.

Introduction. Healthcare-associated infections (HAIs) are the most recurrent adverse event in hospitals worldwide and represent an important public health problem.Gap statement. There are a paucity of multicentric data describing severe HAIs such as bloodstream infection (BSI) and pneumonia in Brazil.Aim. To provide an up-to-date picture of the extent and patterns of HAIs in adult intensive care units (ICUs), as well as to identify variables associated with the risk of development of severe infections.Methodology. Point prevalence surveys were conducted using standardized protocols in 35 ICUs from Minas Gerais state, Brazil. Medical records of eligible inpatients at or before 8 am on the survey day were reviewed to identify HAIs present at the time of the survey. A matched-pairs case-control study was performed on a total of 66 pairs for BSI and 115 pairs for pneumonia according to the selection criteria developed.Results. Overall, 171 patients (45.7%) had at least one HAI, with most (78.4%) acquired in the ICU. These patients presented a total of 240 infections; including 123 pneumonia (51.3%) and 66 BSI (27.5%), and 78.9 and 80.3 %, respectively, were acquired in the ICU. Their aetiology showed a predominance of Gram-negative bacteria versus Gram-positive bacteria (48.9 versus 43.3 %), with Acinetobacter baumannii (13.7%) and Pseudomonas aeruginosa (12.8%) being prominent. One striking observation from our data was the higher prevalence of Staphylococcus aureus (14.5%) and coagulase-negative staphylococci (10.2%) observed in the overall HAIs.Conclusion. A high severe ICU-acquired HAI burden was found when compared with findings from other low- and middle-income countries. These data can be utilized for better planning of nosocomial infection surveillance programmes in our hospitals.

IS PROCALCITONIN AN ACCURATE MARKER IN THE DIAGNOSIS OF ACINETOBACTER-INDUCED BACTEREMIA?

Nosocomial bloodstream infections are common in intensive care units, and a significant portion results in mortality. Procalcitonin is a biomarker used in the early diagnosis of bloodstream infections. Since different pathways release it, its level in the blood may differ in bloodstream infections caused by different agents. The present study was designed to demonstrate whether procalcitonin was an accurate marker in nosocomial bloodstream infections caused by Acinetobacter spp. The present study evaluated 214 bacteremia episodes of 145 patients diagnosed with nosocomial bloodstream infection. Nosocomial bloodstream infection agents were divided into four groups gram-positive bacteria, gram-negative bacteria, Acinetobacter spp., and Candida spp. At the time of diagnosis, procalcitonin, C-reactive protein, neutrophil/lymphocyte ratio, and leukocyte values were measured on the 3rd and 7th days. The mean procalcitonin value measured at the time of diagnosis was 11.7±21.8 ng/ml, the highest in the gram-negative bacteria group. The mean procalcitonin value in the gram-positive bacteria group was 2.8±6.44 ng/ml, 2.5±3.35 ng/ml in the Candida spp. group, and 3.5±12.1 ng/ml in the Acinetobacter spp. group. A significant difference was determined between the four groups regarding procalcitonin values. It was determined that the blood procalcitonin level at the time of diagnosis did not increase as expected in Acinetobacter spp.-induced nosocomial bloodstream infections. In this respect, caution should be exercised in the early diagnosis of nosocomial bloodstream infections.

Peripheral Parenteral Nutrition Solutions and Bed Bath Towels as Risk Factors for Nosocomial Peripheral Venous Catheter-related Bloodstream Infection by Bacillus cereus

In Japan, China, and Singapore, several studies have reported increased incidences of peripheral venous catheter-related bloodstream infection by Bacillus cereus during the summer. Therefore, we hypothesized that bed bathing with a B. cereus-contaminated "clean" towels increases B. cereus contact with the catheter and increases the odds of contaminating the peripheral parenteral nutrition (PPN). We found that 1) professionally laundered "clean" towels used in hospitals have B. cereus (3.3×104 colony forming units (CFUs) / 25cm2), 2) B. cereus is transferable onto the forearms of volunteers by wiping with the towels (n=9), and 3) B. cereus remain detectable (80∼660 CFUs /50cm2) on the forearms of volunteers even with subsequent efforts of disinfection using alcohol wipes. We further confirmed that B. cereus grow robustly (102 CFUs /mL to more than 106 CFUs /mL) within 24hours at 30°C in PPN. Altogether we find that bed bathing with a towel contaminated with B. cereus leads to spore attachments to the skin, and that B. cereus can proliferate at an accelerated rate at 30°C compared to 20°C in PPN. We therefore highly recommend ensuring the use of sterile bed bath towels prior to PPN administration with catheter in patients requiring bed bathing.