Rate Of Bacteremia Research Articles

Fever in Sickle Cell – Is it a One Shot Deal?

Introduction: Children with sickle cell disease (SCD) have an increased risk of bacteremia. Although penicillin prophylaxis and pneumococcal immunizations have significantly reduced this risk, fever remains an indication for emergency evaluation and treatment. Our study aimed to investigate the bacteremia rate for sickle cell patients who presented to the Emergency Department (ED) with fever, as well as the incubation time to positive (TTP) of pathogenic blood cultures. We hypothesized that true pathogens in febrile patients with SCD would be isolated within 24 hours. Methods: A chart review of children (0 …

Rectal colonization with multidrug-resistant gram-negative bacteria in patients with hematological malignancies: a prospective study

ABSTRACT Objectives To investigate the risk factors for rectal colonization with carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) in hematological malignant patients with febrile neutropenia (FN); rate of rectal colonization and infection/colonization with CRE and ESBL-E; whether empirical treatment can be revised. Methods Adult patients receiving chemotherapy were included. Rectal swab cultures of patients were screened for CRE and ESBL-E using selective chromogenic agars. Results Fifty-seven FN episodes of 57 patients were studied. Rectal colonization rates were 40.4% (23/57) and 8.8% (5/57) for ESBL-E and CRE, respectively. ESBL-E bacteremia was diagnosed in 2 (8.6%) ESBL-E colonized patients, while CRE bacteremia was detected in 1 (20%) CRE colonized patient. Amikacin (100%) and carbapenem (93%) were the most effective antibiotics against gram-negative enteric bacteria. Beta-lactam usage within the last 3 months was a significant risk factor for ESBL-E colonization. Conclusions For the treatment of FN patients either colonized with ESBL-E or having significant risk factors for ESBL-E infection, aminoglycoside containing combinations may become an alternative to carbapenems due to their high sensitivity rates. When CRE colonized hematological cancer patients develop FN or if they are hemodynamically unstable, CRE covering empiric antibiotherapy should be preferred due to high mortality rates of CRE bacteremia.

Management and outcomes of Burkholderia cepacia complex bacteremia in patients without cystic fibrosis: a retrospective observational study.

Burkholderia cepacia complex (BCC) is an emerging pathogen of nosocomial infection in chronic or critically ill patients without cystic fibrosis (CF). The objective was to evaluate the management and outcomes of BCC bacteremia in patients without CF. We conducted a retrospective study of non-CF adult patients with BCC bacteremia between January 1997 and December 2016 at 4 tertiary hospitals in South Korea. A total of 216 non-CF patients with BCC bacteremia were identified. Most cases were hospital-acquired (79.2%), and the most common source was a central venous catheter (CVC) (42.1%). The rates of susceptibility to trimethoprim-sulfamethoxazole and piperacillin-tazobactam of BCC isolates were high as 92.8% and 90.3%, respectively. The rates of susceptibility to ceftazidime, meropenem, and levofloxacin were 75.5%, 72.3%, and 64.1%, respectively. The 14-day, 30-day, and in-hospital mortality rate was 19.4%, 23.1%, and 31.0%, respectively. Female (OR = 3.1; 95% CI, 1.4-6.8), liver cirrhosis (OR = 6.2; 95% CI, 1.6-16.6), septic shock (OR = 11.2; 95% CI, 5.1-24.8), and catheter-related infection (OR = 2.6, 95% CI, 1.2-5.8) were the independent risk factors for 30-day mortality. The outcome did not differ according to type of antibiotics used. Among 91 patients with CVC-related BCC bacteremia, delayed CVC removal (> 3days) had a higher rate of persistent bacteremia (54.5 vs. 26.1%; P = 0.03) and lower rate of clinical response (49.0 vs. 71.9%; P = 0.04), compared with early CVC removal (within 3days). BCC bacteremia occurring in non-CF patients was mostly hospital-acquired and CVC-related. Early removal of the catheter is crucial in treatment of CVC-related BCC bacteremia.

Anakinra for patients with COVID-19 - Authors' reply.

Anakinra for patients with COVID-19 - Authors' reply.

1022-P: Efficacy of Sliding Scale Insulin for Inpatient Glycemic Control in a Multinational Propensity-Matched Cohort Study

Sliding scale insulin (SSI) continues to be widely used for glycemic management of inpatients with T2D despite condemnation in clinical guidelines. To confirm the accuracy of this clinical guideline recommendation, we determined the efficacy and safety of using SSI for the management hyperglycemia of non-critical patients with T2D in a large multinational, propensity-matched cohort study. A total of 53,516 patients with ICD 9/10 code of T2D were included in the dataset. Patients were categorized as having received SSI only vs. basal insulin, and were matched according to age, BMI, Charlson Comorbidity Index, and admission blood glucose (BG). Among patients with admission BG <180 mg/dL treated with SSI, 69% achieved and maintained good glycemic control (mean hospital BG <180 mg/dl), compared to 52% of patients treated with basal insulin (p <.001). Patients treated with basal insulin had higher rates of hypoglycemia than patients treated with SSI (30 vs. 16%, p <.001). There were no differences in rates of lactic acidosis, acute MI, pneumonia, or bacteremia (p=NS). A total of 14.93% of patients initially treated with SSI alone failed to achieve adequate glycemic control and were started on basal insulin during the hospital stay. Those who failed SSI had significantly higher admission BG (227.4±90 vs. 175.8±71 mg/dl), greater rates of CKD (31 vs. 24%), CHF (29 vs. 24%), CAD (35 vs. 31%), and higher Charlson score (4.3±2.7 vs. 3.8±2.7) than patients who remained well controlled on SSI alone (all, p<.001). Conclusion: In a multicenter, international, propensity-matched cohort study, 69% of patients with T2D with admission BG <180 mg/dL treated with SSI achieved good glycemic control. Patients admitted with higher BG and greater comorbidities are more likely to fail treatment with SSI alone. These data suggest that SSI may be appropriate for patients with mild/moderate hyperglycemia, thus simplifying recommendations for inpatient glycemic management. Disclosure A. Migdal: None. C. Fortin: None. Y. Guo: None. I. Hochberg: None. M.F. Magee: Consultant; Self; Mytonomy. Employee; Spouse/Partner; U.S. Food and Drug Administration. Research Support; Self; AstraZeneca, Eli Lilly and Company, National Institute of Diabetes and Digestive and Kidney Diseases. Speaker’s Bureau; Self; American Diabetes Association, Pri-Med LLC. Other Relationship; Self; Endocrine Society. F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. G.E. Umpierrez: None. Funding Jacobs Research Foundation

P1325VASCULAR ACCESS OUTCOMES IN A FRAIL HAEMODIALYSIS POPULATION

Abstract Background and Aims Current guidelines recommend the pursuit of arteriovenous (AV) access over central venous catheter (CVC) access in haemodialysis (HD) populations. The limitations of this approach are increasingly recognised, and are particularly relevant when considering frail patients with relatively high levels of comorbidity and limited life expectancy. In such patients AV access may incur more invasive procedures, whereas CVC access may incur heightened risks of infection. This study aimed to evaluate the association between HD access modality and access complications, hospitalisation and mortality in a cohort of HD patients with frailty. Method We performed a retrospective analysis of prospectively recorded data from the Strathclyde Electronic Renal Patient Record concerning HD patients from 01/10/2017 to 21/09/2019. HD patients with a Rockwood clinical frailty scale (CFS) ≥6 were identified with baseline demographic data being recorded from date of first CFS ≥6 to census date 21/09/19 or death. We recorded the first vascular access modality at study inception and the modality at the time of census or death. Episodes of TCVC associated sepsis were determined using both clinical diagnosis in patient case records and positive blood cultures. Episodes were regarded as separate where positive blood cultures occurred ≥14 days apart. An inpatient admission was regarded as a discharge date ≥24 hours following admission. These were then further categorised as unscheduled or elective. Results 139 patients were identified with CFS ≥6. Median age was 72 years and 51% were female. Median follow-up was 1.1 years with total 50861 observed HD days. 52.3% patients were deceased at census. Table 1 illustrates vascular access modality at initial CFS. CVC accounted for the greatest proportion of dialysis access days (50.3%) compared to AVF (40.7%) and AVG (8.9 %). There was no significant difference in mortality between vascular access modalities over the follow-up period (50.7% CVC; 55% AVF; 54.5% AVG, p=0.18). In total, 5244 HD exposed days (10.3%) were spent as an inpatient during follow-up, of which 5120 (98%) were unscheduled and 119 (2%) were elective. The AVG group had the highest rate of inpatient bed days (138/1000 HD days) when compared to CVC (107/1000 HD days) and AVF (94/1000 HD days). Both AVG and CVC were associated with more inpatient bed days than AVF (p<0.0001 for each). Patients who started with CVC and transitioned to AV access had a rate of 86/1000 HD days. This was significantly lower than those who remained CVC throughout (p=0.0001). There were 24 recorded events of CVC associated sepsis during follow-up, occurring at a rate of 0.8 per 1000 HD days. Rates of CVC associated sepsis were similar between CFS 6 (0.6 per 1000 HD days) and CFS 7 (1.1 per 1000 HD days), p=0.21. The CVC associated staphylococcus aureus bacteraemia (SAB) rate for the overall population was 0.2 per 1000 HD days. AVG sepsis occurred at a rate of 0.2 per 1000 HD days and there were no incidences of AVF sepsis in those who continued with AVF throughout the follow-up period. Conclusion CVC was the most prevalent access modality in this frail HD population. Rates of CVC associated sepsis and SAB were similar to published bloodstream infection rates and existing local data (Murray et al QJM 2014). Although absolute events were low, increasing frailty from CFS 6 “moderately frail” to CFS 7 “severely frail” did not appear to influence rate of CVC associated sepsis. Patients with CVC and AVG had greater inpatient bed days than those with AVF. Transitioning from CVC to AV access reduced inpatient bed days. However, the choice of vascular access modality did not influence mortality overall.

P1349CATHETER RELATED BACTERAEMIA AND EFFECTIVENESS OF UNIVERSAL MEASURES: 11-YEAR PROSPECIVE STUDY

Abstract Background and Aims Tunnelled catheter-related bacteraemia (BRC) of the patient in chronic hemodialysis program results in high morbidity and mortality. Antibiotic catheter lock has been suggested to reduce the incidence of BRC in clinical trials. Aim: To demonstrate the effectiveness of universal aseptic measures in obtaining an optimal BRC rate in a long-term single-centre study. Method Design: Prospective cohort study, single-centre. Follow-up time: 11 years (2008-2018) Tunneled catheters: Optiflow, Hemostar, Hemosplit, Equistream, Hemoglide (Bard Access Systems, New Jersey, USA) and Palindrome (Covidien, - Medtronic, Mansfield, Massachusets, USA). Days / catheter analyzed: 207,320. Catheter placement: Ultrasound-guided interventional radiology equipment, with fluoroscopy and universal aseptic measures + 1 single dose of Vancomycin / cefazolin. Follow-up: Nursing and Nephrology and Infectious physicians. Universal aseptic measures. Heparin lock. BRC is considered to be the presence of a positive blood culture after discarding another focus and related to the negative catheter or blood culture with no other focus than the catheter. All available samples at the time of bacteraemia are analyzed: blood, sputum, urine, faeces, pleural fluid, peritoneal fluid, cerebrospinal fluid, exudates, smears etc, and their results. The BRC rate x 1000 days / catheter is evaluated Results Results BRC 2008 to 2018: 0.57, 0.47, 0.31, 0.1, 0.43, 0.37, 0.42, 0.16, 0.2, 0.18 and 0.04 respectively. The evaluated catheters, follow-up days, catheter-related bacteraemias, germ typing and treatment are analyzed: antibiotic vs. catheter removal in Table 1. Conclusion 1. The use of universal measures only, without the use in the antibiotics lock or anticoagulants other than heparin, can achieve a bacteraemia rate related to the optimal catheter, being cost / effective and avoiding possible resistance to antibiotics and side effects of other anticoagulant drugs. 2. Antibiotic sealing should be reserved for cases of difficult epidemiological control of BRC.

A clinical approach to non-neutropenic fever in children with cancer.

There are a limited number of studies that address non-neutropenic fever episodes in children with cancer, and no standard approach exists. We opt to retrospectively analyze the efficacy of the current clinical approach for management of non-neutropenic fever episodes and the associated risk factors among children with cancer at the Princess Noorah Oncology Center from May 2016 through December 2017. A total of 480 non-neutropenic fever episodes were identified in 131 children, of which 62 episodes were triaged as high-risk non-neutropenic fever and 418 as low-risk non-neutropenic fever. Of those 480 non-neutropenic fever, 361 episodes (75.2%) were associated with the presence of central venous catheters. The overall failure rate of ceftriaxone mono-therapy was observed in 75.6% (11.7% in high-risk non-neutropenic fever with a mean C-reactive protein level of 21.1 (±23.2) mmol/L and 63.9% in low-risk non-neutropenic fever with a mean C-reactive protein level of 17.6 (±53.9) mmol/L). The overall bacteremia rate was 14.4%. The type of organisms isolated was mainly high-risk organisms in 59 non-neutropenic fever episodes (85.5%), OR 1.78 (95% CI: 0.45-7.04) p = 0.41. Of note, all bacteremia were associated with the presence of central venous catheter (100%). Of all the examined risk factors of outpatient treatment failure in low-risk non-neutropenic fever, only prolonged fever of more than three days were significantly associated with bacteremia OR 8.107 [95% CI: 1.744-37.691], p = 0.008. Noteworthy is that almost 43% of non-neutropenic fever episodes were associated with respiratory symptoms. This study provides a baseline for future prospective research assessing the pattern of non-neutropenic fever by focusing on associated risk factors.

The African Green Monkey Model of Pneumonic Plague and US Food and Drug Administration Approval of Antimicrobials Under the Animal Rule.

Additional treatment options for pneumonic plague, the most severe form of infection by Yersinia pestis, are needed, as past US Food and Drug Administration (FDA) approvals were not based on clinical trials that meet today's standards, and multiple drugs are sought to counter resistance or use in special populations. Due to the sporadic nature of outbreaks and the low number of pneumonic cases of disease, we sought FDA approval of antimicrobials for treatment under the Animal Efficacy Rule, where efficacy can be demonstrated in 1 or more well-characterized animal models that sufficiently represent human disease. A model was developed in African green monkeys (AGMs) after challenge with a lethal dose of Y. pestis delivered as an aerosol, in 4 independent studies in 3 laboratories. The primary data points were bacteremia (daily), body temperature and heart rate (continuously monitored by telemetry), and survival. In antimicrobial efficacy studies, human-equivalent doses of gentamicin, ciprofloxacin, levofloxacin, and doxycycline were administered upon fever onset for 10 days. Disease in AGMs was similar to case reports of human disease. Fever was determined to be a reliable sign of disease and selected as a treatment trigger. Gentamicin was 60%-80% effective depending on the dose given to animals. Ciprofloxacin and levofloxacin were found to be >90% efficacious. These data were submitted to FDA and plague indications were approved. Doxycycline was less effective. The AGM model of pneumonic plague is reproducible, well-characterized, and mimics human disease. It has been used to support plague indications for fluoroquinolones and to test the efficacy of additional antimicrobials.

Malaria in HIV-infected patients in a nonendemic setting.

The impact of HIV infection on malaria is unclear in nonendemic areas. In endemic territories, HIV has been reported to be a risk factor for higher morbidity. Nowadays, as HIV-infected patients travel more, it is important to assess the impact of HIV at the individual level on imported malaria. This retrospective case-control study collected data on HIV-infected patients diagnosed with malaria (2000-2017) and matched them with two controls based on age, sex and ethnicity. Clinical and biological parameters were collected and compared. We identified 47 cases and matched them with 94 controls. Comparing each of the WHO 2014 severity criteria, hyperparasitemia above 10% (P = 0.006; 12.8 versus 1.1%), icterus (P = 0.042; 14.9 versus 4.3%), acute renal failure (P = 0.022; 25.5 versus 9.6%) and bacteraemia (P = 0.014; 6.4 versus 0%) were significantly more present in HIV-infected patients with a trend to more cerebral malaria (12.8 versus 6.4%). HIV- infected patients were hospitalized more frequently and for longer periods. We observed a higher number of severity criteria when CD4 T-cell count was lower, especially below 200 cells/μl. The difference in occurrence of severe malaria disappeared when patients with CD4 T-cell count more than 500 cells/μl and undetectable viral load (n = 9) were compared with controls. De-novo HIV diagnosis was made during the malaria episode in 17% of cases. HIV infection has an impact on the imported malaria profile, although it is unclear whether well controlled HIV-infected patients have a higher risk of severe malaria. HIV-infected patients should be particularly targeted for pretravel advice.

Effect of a “handshake” stewardship program versus a formulary restriction policy on High-End antibiotic use, expenditure, antibiotic resistance, and patient outcome

This study reports the effect of implementing an antibiotic stewardship program (ASP) based on the “handshake” strategy for 2 years on multiple endpoints compared with that in a preceding period when an antimicrobial restriction policy was only applied in the absence of a complete program in a tertiary-care Lebanese hospital. The studied endpoints were broad-spectrum antibiotic consumption, antibiotic expenditure, nosocomial bacteremia incidence rate, and patient outcome.An interrupted time series analysis was undertaken to assess the changes in the trend (ΔT) and level (ΔL) of the aforementioned endpoints among adult inpatients before (October 2013 to September 2015) and after the introduction of the ASP (October 2016 to September 2018).After the implementation of the “handshake” ASP, marked changes were observed in the consumption of broad-spectrum antibiotics. The mean use density levels for imipenem and meropenem decreased by 13.72% (P = 0.017), coupled with a decreasing rate of prescription (ΔT = −24.83 defined daily dose [DDD]/1,000 patient days [PD]/month; P = 0.02). Tigecycline use significantly decreased in level by 69.19% (P < 0.0001) and in trend (ΔT = −25.63 DDD/1,000 PD/month; P < 0.0001). A reduction in the use of colistin was also documented but did not reach statistical significance (ΔL = −8.71%, P = 0.56; ΔT = −5.51 DDD/1,000 PD/month = −5.5; P = 0.67). Antibiotic costs decreased by 24.6% after ASP implementation (P < 0.0001), and there was a distinct change from an increasing rate to a decreasing rate of expenditure (ΔT = −12.19 US dollars/PD/month; P = 0.002). The incidence rate of nosocomial bacteremia caused by carbapenem-resistant gram-negative bacteria (CRGNB) decreased by 34.84% (P = 0.13) coupled with a decreasing trend (ΔT = −0.23 cases/1,000 PD/month, P = 0.08). Specifically, a noticeable reduction in the incidence rate of bacteremia due to carbapenem-resistant Acinetobacter baumannii was documented (ΔL = −54.34%, P = 0.01; ΔT = −0.24 cases/1000 PD/month, P = 0.01). Regarding patient outcome, all-cause mortality rates did not increase in level or in rate (ΔL = −3.55%, P = 0.59; ΔT = −0.29 deaths/1000 PD/month, P = 0.6). The length of stay and 7-day readmission rate remained stable between the two periods.In conclusion, the “handshake” ASP succeeded in controlling the prescription rates of antibiotics and in decreasing the nosocomial bacteremia rates caused by CRGNB without compromising patient outcome in our facility. It also had an economic effect in reducing antibiotic costs compared with the previous restriction policy on antimicrobial dispensing.

Escherichia coli ST131 clones harbouring AggR and AAF/V fimbriae causing bacteremia in Mozambican children: Emergence of new variant of fimH27 subclone

Multidrug-resistant Escherichia coli ST131 fimH30 responsible for extra-intestinal pathogenic (ExPEC) infections is globally distributed. However, the occurrence of a subclone fimH27 of ST131 harboring both ExPEC and enteroaggregative E. coli (EAEC) related genes and belonging to commonly reported O25:H4 and other serotypes causing bacteremia in African children remain unknown. We characterized 325 E. coli isolates causing bacteremia in Mozambican children between 2001 and 2014 by conventional multiplex polymerase chain reaction and whole genome sequencing. Incidence rate of EAEC bacteremia was calculated among cases from the demographic surveillance study area. Approximately 17.5% (57/325) of isolates were EAEC, yielding an incidence rate of 45.3 episodes/105 children-years-at-risk among infants; and 44 of isolates were sequenced. 72.7% (32/44) of sequenced strains contained simultaneously genes associated with ExPEC (iutA, fyuA and traT); 88.6% (39/44) harbored the aggregative adherence fimbriae type V variant (AAF/V). Sequence type ST-131 accounted for 84.1% (37/44), predominantly belonging to serotype O25:H4 (59% of the 37); 95.6% (35/44) harbored fimH27. Approximately 15% (6/41) of the children died, and five of the six yielded ST131 strains (83.3%) mostly (60%; 3/5) due to serotypes other than O25:H4. We report the emergence of a new subclone of ST-131 E. coli strains belonging to O25:H4 and other serotypes harboring both ExPEC and EAEC virulence genes, including agg5A, associated with poor outcome in bacteremic Mozambican children, suggesting the need for prompt recognition for appropriate management.

Should Buttonhole Cannulation of Arteriovenous Fistulas Be Used? CON.

Fistulas continue to be promoted as the vascular access of choice due to their lower complication rates as compared with catheters (1,2). However, depending on the fistula cannulation method, the infection risk can compared with that of a catheter. Traditionally, cannulation is an area most physicians tend to ignore; instead, the choice and technique of cannulation is routinely left to nurses. However, given the pain, fear, and anxiety with cannulation that most hemodialysis patients experience (3–⇓5), all health care providers should pay more attention to needling. Furthermore, cannulation and its associated mishaps can lead to fistula complications of infection, and decreased patency. The most common method of cannulation among maintenance hemodialysis patients is the rope ladder technique, which rotates needling sites along the full length of the fistula. The area wall technique, where favored regions are repeatedly needled, is actively discouraged due to progressive weakness in the vessel wall and subsequent aneurysm formation (6). Buttonhole cannulation is more often used in home hemodialysis and it was first introduced as a measure to cannulate a fistula with a limited area for needling (7). Buttonhole involves a constant site of needling that, over time, leads to an epithelized track into which a blunt needle is inserted. Since its first introduction almost 50 years ago by Dr Twardoski and his head nurse (Sister Kumara), buttonhole has continued to garner widespread enthusiasm. Support for its use has been mostly promoted by observational data and poor-quality methodology studies showing beneficial effects on pain and fewer needling complications. Nephrology societies (8,9) (renal.org/guidelines) still recommend buttonhole use as a means to reduce pain and increase longevity. In order to promote a novel cannulation technique over the standard of care, there should be evidence of benefit and a lack of demonstrable …

Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) randomised clinical trial: study protocol

IntroductionBloodstream infections are a leading cause of mortality and morbidity; the duration of treatment for these infections is understudied.Methods and analysisWe will conduct an international, multicentre randomised clinical trial of...

Utility of Blood Cultures and Empiric Antibiotics in Febrile Pediatric Hemophilia Patients With Central Venous Access Devices.

Children with hemophilia frequently require long-term central venous access devices (CVADs) for regular infusion of factor products. Hemophilia patients are not immunocompromised, but the presence and use of CVADs are associated with infections including bacteremia. Currently, the utility of blood cultures in evaluation of the febrile hemophilia patient with an indwelling CVAD is unknown, nor is optimal empiric antibiotic use. We performed a retrospective cross-sectional study of febrile immunocompetent hemophilia patients with CVADs presenting to a large academic urban pediatric emergency department from 1995 to 2017. We used a natural language processing electronic search, followed by manual chart review to construct the cohort. We analyzed rate of pathogen recovery from cultures of blood in subgroups of hemophilia patients, the pathogen profile, and the reported pathogen susceptibilities to ceftriaxone. Natural language processing electronic search identified 181 visits for fever among hemophilia patients with indwelling CVADs of which 147 cases from 44 unique patients met study criteria. Cultures of blood were positive in 56 (38%) of 147 patients (95% confidence interval, 30%-47%). Seventeen different organisms were isolated (10 pathogens and 7 possible pathogens) with Staphylococcus aureus and coagulase-negative Staphylococcus species as the most common. Thirty-four percent of isolates were reported as susceptible to ceftriaxone. Positive blood cultures were more common in cases involving patients with inhibitors (n = 71) versus those without (n = 76), odds ratio, 7.4 (95% confidence interval, 3.5-15.9). This was observed irrespective of hemophilia type. Febrile immunocompetent hemophilia patients with indwelling CVADs have high rates of bacteremia. Empiric antimicrobial therapy should be targeted to anticipated pathogens and take into consideration local susceptibility patterns for Staphylococcus aureus.

Multicentre study of risk factors for mortality in patients with Acinetobacter bacteraemia receiving colistin treatment

Colistin remains a last-line antibiotic for the treatment of infections by multidrug-resistant Acinetobacter species. However, mortality rates are high in patients with Acinetobacter infection receiving colistin treatment. This multicentre study evaluated whether colistin susceptibility, additional antimicrobial agents or other prognostic factors influenced the clinical outcomes of patients receiving colistin treatment for Acinetobacter bacteraemia. This retrospective study enrolled 122 adults receiving colistin for monomicrobial Acinetobacter bacteraemia at six medical centres in the ACTION Study Group over an 8-year period. Clinical information, antimicrobial susceptibility and colistin resistance determinants were analysed. The primary outcome measure was 14-day mortality. Among 122 patients, 18 and 104 were infected with colistin-resistant (ColR) isolates [minimum inhibitory concentration (MIC) ≥4 mg/L] and colistin-susceptible (ColS) isolates (MIC ≤2 mg/L), respectively. Patients infected with ColR and ColS isolates did not differ significantly with regard to Charlson comorbidity index, invasive procedures, sources of bacteraemia, disease severity and 14-day mortality rate (44.4% vs. 34.6%; P=0.592). No specific additional antimicrobial agent was independently associated with higher or lower mortality. Coronary artery disease, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and bacteraemia caused Acinetobacter baumannii were independent risk factors associated with 14-day mortality. Mechanisms of colistin resistance were associated with amino acid variants in the pmrCAB operon. Finally, previously unreported Acinetobacter nosocomialis amino acid variants related to colistin resistance were identified. In conclusion, colistin susceptibility and colistin combination antimicrobial treatment were not associated with decreased 14-day mortality in patients with Acinetobacter bacteraemia receiving colistin treatment.

Brain Abscess and Esophageal Dilatation: Where is the Link? - Case Report

Abstract Introduction Caustic substance ingestion is a common cause of esophageal stricture in children. The primary treatment is esophageal dilatation. Although it is known that endoscopic esophageal dilatation is a procedure associated with a high rate of bacteremia, current guidelines do not recommend routine throat swab cultures or antibiotic prophylaxis for the general children population. Case Report We describe a case of a 7-year-old boy presenting with refractory headaches who was diagnosed with cranial abscess after multiple esophageal dilatations due to stenosis caused by caustic soda ingestion. The patient was subjected to neurosurgical intervention and intravenous antibiotic treatment for 6 weeks. Streptococcus viridans culture was positive in purulent abscess content. Conclusion We highlight this condition that, although rare, needs immediate diagnosis and proper treatment. We also recommend routine testing of throat swabs and antibiotics prophylaxis to children undergoing esophageal dilatation.

Preoperative abnormal body composition is closely related to bacteremia after living donor liver transplantation.

Infection is the most critical cause of early death after liver transplantation (LT). However, the effect of preoperative body composition on bacteremia after LT is unclear. The aim of this study was to examine the effects of preoperative body composition on bacteremia after living donor LT (LDLT). The study comprised 277 patients who underwent LDLT at Kyoto University, Kyoto, Japan, between January 2008 and June 2016. We evaluated body composition parameters including skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR) using preoperative plain computed tomography at the L3 level. We compared the incidence of bacteremia, species, period of antibiotic administration, mortality due to bacteremia, and survival rates according to the number of abnormal body composition factors (low SMI, high IMAC, and high VSR). Moreover, risk factors for post-transplant bacteremia were examined. Incidence of bacteremia was significantly higher in patients with three abnormal factors (47.1%), two factors (42%), or a single factor (37%) than in patients with no factors (22.5%; P=0.027). Species of bacteremia did not differ significantly among the four groups. The period of antibiotic administration was significantly shorter (P=0.039) and mortality of patients with bacteremia and survival rates were significantly better (P < 0.001, each) in patients with no factors. Multivariate analysis identified ABO incompatibility (P=0.002) and low SMI (P=0.045) as independent risk factors for bacteremia after LT. Preoperative abnormal body composition was closely related to bacteremia after LDLT.

Community Acquired Urosepsis: A surgical intensive care Experience.

Urosepsis contributes significantly to the epidemiology of sepsis. Urosepsis can be classified as community acquired or hospital acquired, depending upon the origin of infection acquisition: either from the community or from a healthcare facility. A great deal of literature is available about nosocomial urosepsis, but the literature regarding community-acquired urosepsis (CAUs) is limited, and studies are underpowered. The aim of our study was to determine the epidemiology, bacteriology, severity, and outcome of CAUs. Methods and Patients: All patients admitted from the emergency department to the surgical intensive care unit (SICU) with urosepsis over a period of 10 years were identified and included retrospectively from the SICU registry. The study was retrospective. Data were entered into the SPSS program version 23, and groups were compared by using chi-square and t-tests. Results were considered statistically significant at p ≤ 0.05. Results: During the study period, 302 patients with CAUs were admitted to the SICU. The common etiology was obstructive uropathy (60%). The Local Arab population outnumbered the non-Arab population (164/54.3%), and there were equal numbers of patients of both genders. Diabetes mellitus and hypertension together were the common comorbidities. Seventy-five percent of patients had acute kidney injury (AKI). Thirty-eight percent of patients had percutaneous nephrostomy, and 24.8% of patients underwent endoscopic stent insertion to relieve the obstruction. Ninety-three percent of patients were admitted with septic shock, and 71.5% had bacteremia. The common bacteria (36.1%) was extended-spectrum beta-lactamase-(ESBL)-producing bacteria, with a predominance of Escherichia coli (31.5%). Fifty-four percent of patients required a change of antibiotics to carbapenem. Eighty-two percent of patients had acute respiratory distress syndrome (ARDS). Patients with bacteremia had a statistically significant AKI, ARDS, and septic shock (p < 0.001). Male patients had a significantly higher incidence of oliguria, intubation, and ARDS (p < 0.05). Eight patients died of urosepsis during the study period, giving a mortality rate of 2.6%. Conclusion: In our patients, obstruction of urine flow was the most common cause of CAUs. Our urosepsis patients had a higher bacteremia rate, which led to higher incidences of organ dysfunction and septic shock. ESBL bacteria were a frequent cause of urosepsis, requiring a change of the initial antibiotic to carbapenem. Male patients had a significantly higher rate of organ dysfunction. Mortality in our urosepsis patients was lower than mentioned in the literature.

Risk of bacteremia in hospitalised patients with inflammatory bowel disease: a 9-year cohort study.

Patients with inflammatory bowel disease might be at increased risk of invasive bacterial infections. The objective of this study was to identify the rate of bacteremia in hospitalised patients with inflammatory bowel disease and risk factors. An observational cohort of hospitalised patients with inflammatory bowel disease, aged 16-80 years, from 2008 to 2017 in a large tertiary hospital. Patients with Charlson comorbidity index of 2 or greater were excluded. Patients with one or more positive blood culture were reviewed. Logistic regression was used to evaluate risk factors for bacteremia. Of 5522 admitted patients, only 1.3% had bacteremia (73/5522) (39, Crohn's disease; 25, ulcerative colitis; nine, unclassified inflammatory bowel disease). The most common pathogen was Escherichia coli (19/73 patients). The mortality rate at 30 days of patients with bacteremia was 13.7% (10/73). Longer hospitalisations (mean length of stay (21.6 ± 31.0 vs. 6.4 ± 16.0 days; P < 0.0001) and older age (mean age 47.5 ± 18.0 vs. 40.2 ± 15.4 years, P < 0.0001)) were associated with an increased risk of bacteremia. In multivariate analysis, treatment with either anti-tumour necrosis factor α, purine analogues, steroids or amino salicylates was not associated with an increased risk of bacteremia. Risk was greatest among patients aged 65 years or older (relative risk 2.84, 95% confidence interval 1.6-4.8; P = 0.0001) relative to those under 65 years. Age over 65 years, but not inflammatory bowel disease-related medications, is associated with an increased risk of bacteremia in hospitalised patients with inflammatory bowel disease.