Secondary Bacteremia Research Articles

Bacteremia Due to <i>Bacillus subtilis</i>：A Case Report and Clinical Evaluation of 10 Cases

A 59-year-old male presented with fever, and was admitted for bacteremia due to gram-positive rod. All 5 sets of blood cultures obtained prior to the initiation of vancomycin tested positive for Bacillus subtilis. Based on the susceptibility test result, the antibiotics were changed to levofloxacin to complete a total of fourteen days treatment. The patient recovered without relapse over one year. Despite thorough examinations, the portal of entry of B. subtilis remained unclear. We retrospectively reviewed ten cases of bacteremia due to B. subtilis over 5 years in our hospital. The cases with positive B. subtilis blood cultures which were evaluated as contamination were excluded from the review. The most common portal of entry of B. subtilis was secondary bacteremia due to perforation or ileus (70%), followed by an unknown site (30%). B. subtilis should be considered not only as a contaminant but also as a true pathogen of bacteremia.

Double-carbapenem combination as salvage therapy for untreatable infections by KPC-2-producing Klebsiella pneumoniae.

We report our experience using the double-carbapenem combination as salvage therapy for patients with untreatable infections caused by KPC-2- producing Klebsiella pneumoniae. A total of 27 patients in two institutions in Athens, Greece suffering from complicated urinary tract infections (16) with or without secondary bacteraemia (four and 12 respectively), primary (six) or catheter-related bloodstream infections (two), HAP or VAP (two) and external ventricular drainage infection (one) were treated exclusively with ertapenem and high-dose prolonged infusion meropenem because in-vitro active antimicrobials were unavailable (19) or failed (four) or were contraindicated (six). Most patients presented with severe infections with median APACHE II score of 17 and 11 of those patients (40.7%) had severe sepsis (five) or septic shock (six). The clinical and microbiological success was 77.8 and 74.1% respectively. Crude mortality was 29.6% with attributable mortality of 11.1%. Adverse events, none of them severe, were reported in four patients (14.8%). The double-carbapenem combination as an exclusive regimen represents a safe and valid salvage therapy for untreatable infections by extensively- or pandrug-resistant KPC-producing K.pneumoniae.

Cholangiohepatitis: Radiological spectrum of the disease amid the rising prevalence in India: A case study in a tertiary institute in South India

Introduction: There is a rising incidence of Oriental cholangiohepatitis (OCH) also known as recurrent pyogenic cholangitis (RPC), in Indian population. The condition which presents with classical triad of recurrent upper abdominal pain, obstructive jaundice and fever is characterized by biliary sludge, intrahepatic bile duct calculi, strictures, duct dilatation and cholangitis resulting from chronic biliary parasitic infestation and associated chronic secondary portal bacteremia. Aim: The purpose of this retrospective study was to understand the spectrum of radiological manifestations of oriental cholangiohepatitis by MRI which helps in differentiating it from other differential causes of biliary obstruction and cholangitis. Materials and Methods: This was a retrospective study of cases of oriental pyogenic cholangitis diagnosed by MRI over a period of 3 years in department of radio diagnosis who were referred from gastroenterology department with clinical suspicion of cholangitis and diagnosed as having OCH based on MRI finding’s and later confirmed by ERCP or biochemical parameters. Results: Out of the total 950 MRCP scans evaluated, 150 cases were of suspected cholangitis and only 9 cases had features of oriental pyogenic cholangitis. These patients showed the characteristic MRCP finding’s like ductal changes including intraductal calculi with dilatation and strictures in RHD and LHD, segmental and subsegmental IHBRs and in extrahepatic biliary tree i.e. CHD and CBD with decreased arborization of peripheral biliary radicals; wall thickening in biliary tree and pneumobilia; and parenchymal abnormalities like fatty liver, hepatomegaly, segmental atrophy or diffuse liver atrophy. Complications like portal hypertension, splenomegaly and ascites that occur were also observed. Though literature mentions complications like hepatic mass/SOL i.e. hepatic abscess or malignancy, we didn’t have any in our case series. Conclusion: To summarise, presence of hepatolithiasis and choledocholithiasis with significant biliary duct dilatation and short segment strictures in the biliary tree with peripheral IHBR pruning, usually in the absence of gallstones on MRCP is nearly pathognomonic of oriental pyogenic cholangitis in patients presenting with classical clinical triad of abdominal pain, jaundice and fever and obviates the need for diagnostic ERCP.

Treatment of Carbapenem-Resistant Enterobacteriaceae Infections with Ceftazidime-Avibactam

BackgroundCRE is an urgent threats to public health with a high mortality estimated at >30–50%. Until recently, polymyxin-based antibiotics were the only available options. However, a new therapeutic option has become available: ceftazidime-avibactam. We sought to describe outcomes from these infections treated with ceftazidime-avibactam.MethodsFrom 9/2015 to 12/ 2016, we reviewed charts of 11 patients infected with CRE who received ceftazidime-avibactam at USC (Los Angeles, CA). Sixteen isolates analyzed. All isolates were resistant to meropenem (MIC ≥ 16). Carbapenemase production confirmed by detection of blaKPC. Clinical success defined as clinical improvement, lack of recurrence, and survival in 90 days. Recurrence defined as clinical signs of infection and recovery of CRE after ≥ 7 days of treatment.ResultsThe median age was 49 (35-89); 73% (7/11) female; and 27% (3/11) solid organ transplants. All CRE infections caused by Klebsiella pneumoniae. All sequence type 258, 7/11 harboring blaKPC-2 and 4/11 blaKPC-3. Nine capsular type wzi-154 and 2 wzi-29. qSOFA score was 0 (0–2) predicting mortality of 3%. Seven had intraabdominal infections; 2 pyelonephritis, 1 skin and soft-tissue infection, and 1 primary bacteremia. There were five episodes of secondary bacteremia. The patients were treated for a median duration of 15 (3-43) days. All received other antibiotics prior to ceftazidime-avibactam. Eighty-seven percent (9/11) treated with monotherapy and 13% (2/11) in conjunction with colistemethate sodium. 27% (3/11) were receiving CRRT or hemodialysis during treatment. No incidents of renal toxicity observed using RIFLE criteria. Clinical success was 73% (8/11); 30 day survival rate 82% (9/11); 90 day survival rate 73% (8/11); and in hospital mortality 27% (3/11). Patients receiving CRRT or hemodialysis had 75% (3/4) mortality (P = 0.02). Recurrence occurred in 18% (2/11). Decreased sensitivity to ceftazidime-avibactam noted in one patient. 27% (3/11) had CRE isolated after ≥ 7 days treatment.ConclusionIn CRE-infected patient treated with ceftazidime-avibactam, the overall mortality rate was 27% with the highest mortality among those receiving renal replacement therapy which was comparable to a prior studies. Additional research is needed to optimize the use of ceftazidime-avibactam to treat CRE infections.Disclosures All authors: No reported disclosures.

Hookworm Infection in South American Fur Seal ( Arctocephalus australis) Pups.

Tissues of South American fur seal pups naturally infected with hookworms ( Uncinaria sp) were examined. Hookworm infection was found in nearly all pups examined (132/140, 94%), and hookworm enteritis with secondary bacteremia was considered the cause of death in 46 (35%) pups. Common findings in these pups included severe hemorrhagic enteritis and numerous (mean intensity = 761.8) hookworms in the jejunum. Hookworms were recovered from the abdominal cavity in 12 of 55 pups (22%) examined through peritoneal wash; these pups had an average of 1343.3 intestinal hookworms and marked fibrinohemorrhagic peritonitis. In all pups that died as a consequence of hookworm infection, the intestinal villi were short, blunt, and fused, and there were variable numbers of free and intrahistiocytic gram-negative bacteria in submucosal hookworm feeding tracks, mesenteric lymph nodes, spleen, blood vessels, and liver sinusoids. Pups that died of causes unrelated to the hookworm infection (trauma) had hookworm feeding tracks confined to the apical portions of the mucosa, and moderate to marked catarrhal eosinophilic enteritis. The number of hookworms was negatively correlated with intestinal villous length and number of leukocytes in the intestine. Pups with hookworm peritoneal penetration had nematodes with little or no blood in the hookworm intestine, suggesting that lack of food for the nematode could be associated with peritoneal penetration. Findings suggest that the initial burden of larval infection, the level of the host tissue response, or a combination determine the number of nematodes in the intestine, the severity of hookworm tissue damage, and pup mortality.

Risk Factors for Bacteremia in Patients With Urinary Catheter-Associated Bacteriuria.

Catheter-associated bacteriuria is complicated by secondary bacteremia in 0.4% to 4.0% of cases. The directly attributable mortality rate is 12.7%. To identify risk factors for bacteremia associated with catheter-associated bacteriuria. Data were acquired from a large electronic clinical and administrative database of consecutive adult inpatient admissions to 2 acute care hospitals during a 7-year period. Data on patients with catheter-associated bacteriuria and bacteremia were compared with data on control patients with catheter-associated bacteriuria and no bacteremia, matched for date of admission plus or minus 30 days. Urine and blood cultures positive for the same pathogen within 7 days were used to define catheter-associated bacteriuria and bacteremia. Multivariable conditional logistic regression was used to determine independent risk factors for bacteremia. The sample consisted of 158 cases and 474 controls. Independent predictors of bacteremia were male sex (odds ratio, 2.76), treatment with immunosuppressants (odds ratio, 1.68), urinary tract procedure (odds ratio, 2.70), and catheter that remained in place after bacteriuria developed (odds ratio, 2.75). Patients with enterococcal bacteriuria were half as likely to become bacteremic as were patients with other urinary pathogens (odds ratio, 0.46). Odds of secondary bacteremia increased 2% per additional day of hospital stay (95% CI, 1.01-1.04) and decreased 1% with each additional year of age (95% CI, 0.97-0.99). The results add new information about increased risk for bacteremia among patients with catheters remaining in place after catheter-associated bacteriuria and confirm evidence for previously identified risk factors.

Lactobacillus bacteremia: Pathogen or prognostic marker?

ObjectiveLactobacillus bacteremia is a rare event and its epidemiology is poorly known. Whether Lactobacillus bacteremia is a contaminant, a risk factor, or a risk marker of death remains an open question. Patients and methodsWe conducted a retrospective study of patients presenting with Lactobacillus bacteremia (LB), between January 2005 and December 2014, at the Grenoble University Hospital. ResultsLB was observed in 38 patients (0.34% of all positive blood cultures). Cancer (40%), immunosuppression (37%), and use of central venous devices (29%) were frequently associated with LB. We observed a significant increase with time in the number of Lactobacillus positive blood cultures among all blood cultures performed (P=0.04). LBs were divided into two clinical-biological presentations: secondary bacteremia with a known portal of entry (n=30) and isolated bacteremia (n=8). Case fatality was 31% at D28, 55.2% at 1 year in the secondary bacteremia group, and 12.5% (both at D28 and 1 year) in the isolated bacteremia group. Secondary bacteremia with a known portal of entry was significantly associated with case fatality after adjustment for age, co-infection, cancer, immunosuppression, diabetes, and sex (OR 14.9 [1.04–216] P=0.047) for fatality at one year, but not for D28 fatality (P=0.14). ConclusionLactobacillus bacteremia may be an important marker of disease severity rather than a pathogen, suggesting comorbidities. It should not be considered a contaminant, but should lead physicians to screen for associated infections and underlying diseases.

Impacts of Hypervirulence Determinants on Clinical Features and Outcomes of Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae.

We investigated the implications of hypervirulence determinants on clinical features of 48 adult patients with bacteremia caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae. Isolates in the hypervirulence group included any of the following virulence determinants: K1/K2 capsule serotypes, hypermucoviscosity phenotype, rmpA gene, or rmpA2 gene. Nonhypervirulence group isolates were negative for all of the above virulence factors. In this study, all isolates used were non-K1/K2 strains. Statistically significant differences were observed in clinical features of patients between the two groups. The hypervirulent isolates (n = 19), including 11 isolates with the hypermucoviscosity phenotype, 15 with the rmpA gene, and 16 with the rmpA2 gene, were more commonly recovered from diabetic patients and mainly manifested as secondary bacteremia (such as pneumonia, urinary tract infections, or other localized infections). The nonhypervirulent isolates (n = 29) were more commonly recovered from patients after prolonged hospital stays (>30 days) and mostly manifested as primary bacteremia. The overall in-hospital mortality was 56.3%. Hazard ratio (HR) analysis revealed the following positive predictors for mortality: nosocomial infection, stay in an intensive care unit, no removal of the central venous catheter, Charlson comorbidity score, and APACHE II score (≧15). The negative predictors were initial appropriate antibiotic therapy (HR 0.42) and urinary tract infection (HR 0.19). Charlson score was an independent confounder based on multivariate analysis (HR 1.43, 95% confidence interval 1.04-1.99). In conclusion, hypervirulence determinants played a role in causing secondary infections in diabetic patients; however, the presence of morbidity cofactors could themselves influence mortality, despite the absence of hypervirulence determinants.

Levothyroxine soft capsules demonstrate bioequivalent pharmacokinetic exposure with the European reference tablets in healthy volunteers under fasting conditions.

To assess the bioequivalence (BE) potential under fasting conditions between levothyroxine soft capsules and the European reference tablet formulation. Two studies were conducted to assess the BE potential as per European regulations. Study 1 was a two-way crossover BE study comparing a high strength of levothyroxine soft capsules versus levothyroxine tablets (200 μg), while study 2 was a three-way crossover dosage form proportionality study between low, medium, and high strengths of soft capsules. 70 healthy adult subjects participated in the two studies. Each treatment consisted of a 600-μg dose of levothyroxine sodium, administered under fasting conditions. Blood samples were collected for levothyroxine (T4) assay prior to dosing and up to 72 hours post dose. A washout of 35 days separated treatments in each study. Pharmacokinetics was assessed using noncompartmental methods. A total of 61 subjects completed the studies. Baseline-adjusted total T4 ratios (test/reference) and 90% confidence intervals (CIs) between soft capsules and tablets were within 80.00 - 125.00%. Comparison of the three strengths of soft capsules indicated pharmacokinetic equivalence between them (ratios and 90% CIs were contained within 80.00 - 125.00%). Overall, levothyroxine sodium was well tolerated with all products when given as single oral doses of 600 μg, except for 1 serious adverse event of secondary bacteremia reported in study 2, deemed not to be related to treatment. Levothyroxine soft capsules meet BE criteria in terms of systemic exposure when compared to a European reference tablet under fasting conditions in healthy volunteers.

The efficacy of noble metal alloy urinary catheters in reducing catheter-associated urinary tract infection.

Background:Catheter-associated urinary tract infection (CAUTI) is the most common device-related healthcare-acquired infection. CAUTI can be severe and lead to bacteremia, significant morbidity, prolonged hospital stay, and high antibiotic consumption.Patients and Methods:In this study, we evaluated the CAUTI-reducing efficacy of noble metal alloy catheters in sixty patients (thirty per group) in the Intensive Care Unit (ICU) at the King Fahad Hospital in Saudi Arabia. The study was a single-blinded, randomized, single-centered, prospective investigation that included patients using urinary catheters for 3 days.Results:A 90% relative risk reduction in the rate of CAUTI was observed with the noble metal alloy catheter compared to the standard catheter (10 vs. 1 cases, P = 0.006). When considering both catheter-associated asymptomatic bacteriuria and CAUTI, the relative risk reduction was 83% (12 vs. 2 cases, P = 0.005). In addition to CAUTI, the risk of acquiring secondary bacteremia was lower (100%) for the patients using noble metal alloy catheters (3 cases in the standard group vs. 0 case in the noble metal alloy catheter group, P = 0.24). No adverse events related to any of the used catheters were recorded.Conclusion:Results from this study revealed that noble metal alloy catheters are safe to use and significantly reduce CAUTI rate in ICU patients after 3 days of use.

Clinical Characteristics of Group D Streptococcal Bacteremia in a University Hospital in Thailand

Materials and Methods Conclusions Acknowledgements • Background: Group D streptococci (GDS) are indigenous in the gastrointestinal tracts of humans and animals. Currently, S. bovis, the most common GDS, has been re-classified into 4 different species (Streptococcus gallolyticus, Streptococcus pasteurianus, Streptococcus infantarius and Streptococcus lutetiensis). However, clinical characteristics and the association between gastrointestinal diseases and these species have not been well studied. The objective of this study is to investigate the clinical characteristics of patients with GDS bacteremia. • Methods: We conducted a retrospective review of adult patients with GDS bacteremia who were hospitalized at Siriraj Hospital between 1 January 2009 and 30 June 2011. Clinical characteristics including predisposing factors and microbiological data were analyzed. • Results: One hundred and forty-seven episodes of bacteremia caused by GDS were included. Seventy-eight patients (58.2%) were male. Patients’ mean age was 63 years. Of 147 GDS isolates, 134 (91.2%) were identified as S. pasteurianus, 6 (4.1%) were S. gallolyticus, 2 (1.4%) were S. infantarius, 1 (0.7%) was S. lutetiensis and 4 isolates (2.7%) were unidentifiable. Cirrhosis was identified as underlying disease in 87 patients (59.2%). Eighty-three patients (56.5%) had primary bacteremia and 49 patients (33.3%) had secondary bacteremia from spontaneous bacterial peritonitis. Thirty patients (20.9%) underwent colonic evaluation and colonic polyps were the most common finding found in 8 patients. Colonic cancer was diagnosed in 5 patients with GDS bacteremia in which 4 of 5 patients were diagnosed previously and before the bacteremic episodes. Bacteremia due to S. pasteurianus was associated with patients who had cirrhosis (p = 0.041), whereas S. gallolyticus was more likely to be associated with non-cirrhotic patients (p = 0.031). Overall mortality of patients with GDS bacteremia was 22%. • Conclusion: S. pasteurianus was the most common species isolated in patients with GDS bacteremia and is associated with chronic liver disease. • Group D streptococci (GDS) are indigenous in the gastrointestinal tracts of humans and animals. The association between bacteremia caused by Streptococcus bovis (the most common species of GDS) and colonic malignancies has been documented. Currently, S. bovis has been re-classified into 4 different species (Streptococcus gallolyticus, Streptococcus pasteurianus, Streptococcus infantarius and Streptococcus lutetiensis). The prevalence and clinical characteristics of infections caused by different GDS species and the association between gastrointestinal lesions and those species has not been well studied. • S. pasteurianus was the most common species isolated in patients with GDS bacteremia. GDS infection was significantly associated with liver diseases including cirrhosis and hepatocellular carcinoma. S. pasteurianus is likely to be linked to colon cancer, especially in those without chronic liver diseases. Our study suggested that patients with S. pasteurianus bacteremia who do not have cirrhosis should be appointed for colonic evaluation and considered to search for endocarditis. Finally, beta-lactam antibiotic, especially penicillin, should be used as a drug of first choice for treatment of GDS bacteremia. • We thank the staffs of Department of Microbiology for their collaborations and Ms. Khemajira Karaketklang, Department of Medicine, Siriraj Hospital for assistance of data analysis. Poster number 831

Prevalence of rotaviral diarrhoea in under-five hospitalized children in a tertiary care hospital of Eastern India

BackgroundTo monitor the prevalence of rotaviral diarrhoea in under-5 children (U5C) as a retrospective study in a tertiary care hospital during 1year. MethodsSuspected stool samples were diagnosed for rotavirus by an enzyme immunoassay kit. The same stool samples were diagnosed for the detection of any secondary bacterial infection through routine microbiological diagnosis. Results and conclusionsOf the total 265 stool samples, 123 were diagnosed positive with rotaviral infection, of which, 59 (50.86%) samples were from children in the age group of 0–12months; further, 28 (41.79%), 17 (58.52%), 14 (35.71%) and 5 (46.41%) were from age groups, 13–24, 25–36, 37–48 and 49–60months, respectively. Cases of secondary bacteremia were with Klebsiella sp., Enterobacter sp., Escherichia coli and Shigella sp. in the stool samples in age groups as given: 14 (0–12month), 3 (13–24month), 2 (37–48month) and 1 (25–36month). Of the total 123 rotaviral positive infants, 62 patients had fever and 100 patients had vomiting; while, 57, 47 and 10 patients had ‘mild’, ‘moderate’ and ‘severe’ dehydration, respectively. Further, 34 and 89 rotaviral positive children were with malnutrition and normal nutrition, respectively; while, 19, 89 and 15 patients were hospitalized for ⩽2, 3–6, and ⩾7days, respectively. Data sets for ‘severity of dehydration’ and ‘days of hospitalization’ were statistically significant, with Kruskal–Wallis H-test, independently. Of 142 rotaviral negative patients, 27 with bacterial diarrhoea, 6 with parasitic infections, 20 with antibiotic intolerance and 31 with lactose intolerance were recorded.

Efficacy of tigecycline for secondary Acinetobacter bacteremia and factors associated with treatment failure.

We describe the clinical outcome of 17 patients with secondary Acinetobacter bacteremia whose isolates had a tigecycline MIC of ≤2 mg/liter and who received tigecycline within 2 days of bacteremia onset. The 14-day mortality rate of the tigecycline cohort was 41.2% (7/17), which was significantly higher than that of those receiving other appropriate antimicrobial agents (13.8%, 9/65; P = 0.018). However, the percentages of end-stage renal disease and congestive heart failure were higher in the tigecycline cohort. The efficacy of tigecycline was contingent upon the illness severity and bacterial species. Tigecycline should be applied cautiously for treatment of Acinetobacter bacteremia.

Secondary bacteraemia in adult patients with prolonged dengue fever.

Although dengue management guidelines do not advice on use of antibiotics in dengue shock syndrome, unrecognised bactraemia is likely to contribute to morbidity and mortality. To assess the occurance of secondary bacteraemia in adult patients with prolonged dengue fever. A prospective study was conducted recruiting patients with confirmed acute dengue infection who had prolonged fever (>5 days). Two sets of blood cultures were taken in such patients prior to institution of antibiotic therapy. Demographic, clinical, haematological and biochemical parameters were recorded. Development of ascites and pleural effusions were detected using ultrasonography. Fourty patients (52.5% males) with a mean age of 29.8 years (SD 13.6) were studied. The average duration of fever was 7.9 days (SD 1.8). Ten patients (25%) had bacterial isolates in their blood cultures; Staphylococcus aureus (n=2), coliforms (n=3), pseudomonas (n=1) and 4 had mixed growths. The culture positive group had severe body aches at admission and higher fever, third space fluid accumulation, a significant drop in platelets and a higher CRP. A quarter of dengue patients with prolonged fever had a bacterial isolate. Culture positive patients appeared more ill with body aches and had higher degrees of fever during the latter part of the illness. Increased vascular permeability may predispose to bacterial seepage into blood. Although white cell count is not helpful in detecting bacteraemia, low platelet count and elevation of CRP seem to be helpful.

EVALUATION OF ANTIBIOTIC TREATMENT AND ANTIBIOTIC DE-ESCALATION IN A INTENSIVE CARE UNIT WITH SELECTIVE DIGESTIVE DECONTAMINATION

Method In a polyvalent ICU of 30 beds from October 1, 2011 to September 30, 2014 nosocomial infections (pneumonia, urinary tract infections, catheter-related bacteremia (BRC) and of unknown origin and secondary nosocomial bacteremia) were prospectively collected. ENVIN-HELICS diagnostic criteria were applied. Etiology, inflammatory response to infection, antibiotic treatment (ATB T), and treatment modifications according to culture results, was analyzed. SDD was applied to all admitted patients requiring endotracheal intubation over 48 hours. For each of the groups categorical variables were summarized as frequencies and percentages and number in means and standard deviations (SD) or median with interquartile ranges (IQR). Percentages were compared, as appropriate, with the Fisher s exact test.or X test and medians with the Wilcoxon test for independent samples. For those variables that were associated with DE in the univariate analysis were entered into a logistic multidimensional analysis. The model obtained was expressed by p-values and odd-ratios, which were estimated by confidence intervals at 95%. A hypothesis test was considered statistically significant when p-value was less than .05. Results Fifty-seven patients had ATB DE and 126 did not. There were no significant differences in demographics or type of admission (Figure 1) Mortality was lower in patients receiving DE antibiotic (ATB) (22.9%, p: 0.095). In the multivariate study of urinary tract infection, septic shock or severe sepsis and secondary bacteremia were significant (Figure 2). Of the 253 nosocomial infections ATB DE were performed at least in one of ATB in 131 (51.8%) of them. The inflammatory response and the type of infection did not show any decrease in the group with DE compared to all infections. The ATB T was inadequate in 43 infections (16.9%) (15 pneumonias, 11 urinary tract infections, 14 CRB and 3 secondary bacteremias). Targeted therapy was performed at least 1 time out of 109 infections (43.1% of infections), 28 pneumonias, 35 urinary tract infections, 38 CRB and 10 BRC secondary bacteremias. The number of antibiotics used was 483 and in 156 occasions ATB DE was performed. Frequency of use and DE is shown in Figure 3.

THREE YEARS APPLICATION OF SELECTIVE DIGESTIVE DECONTAMINATION IN A MIXED INTENSIVE CARE UNIT IN A UNIVERSITY HOSPITAL: IMPACT ON COLONIZATION, INFECTION AND ANTIBIOTIC CONSUMPTION

Methods This study was conducted in a 30-bed-medical-surgical ICU. All consecutive patients admitted to the from October 1, 2011 to September 30, 2014 expected to require tracheal intubation for longer than 48 hours were given SDD (SDD study group) with a 4-day course of intravenous cefotaxime, plus enteral colistin, tobramycin, nystatin in an oropharyngeal paste and in a digestive solution. Oropharyngeal and rectal swabs were obtained on admission and once weekly. Nosocomial infections were diagnosed by CDC criteria. We compared all patients admitted to ICU who acquired nosocomial ICU colonization and infection from October 1, 2010 to September 30, 2011 (non-SDD group) to SDD group. In both groups, categorical variables were summarized as frequencies and percentages and the continuous ones as means and standard deviations when the data followed the normal distribution or medians and interquartile ranges when they did not. The percentages were compared using the test of chisquare test or Fisher exact test, means with the t-test and medians with the Wilcoxon test for independent samples. Those variables that showed statistical significance in the univariate analysis were introduced in a multivariate logistic regression analysis. For each one of the acquired infections (catheter-related and other secondary bacteremias, pneumonia and urinary infections and antibiotic resistant bacteria (ARB) infection) the incidences per 1000 days of exposure in each cohort and the corresponding relative risks were obtained using the Poisson regression. Statistical significance was set at p ≤ 0.05. We also analized colistin and tobramycin resistant colonization and antibiotic consumption (Defined Antibiotics daily Doses (DDD)).

STATISTICAL STUDY OF FOUR YEARS OF URINARY INFECTIONS (UTI) RELATED TO URETHRAL CATHETER IN OUR INTENSIVE CARE UNIT (ICU)

UTI is the most common nosocomial infection, accounting for 23 to 30% of all infections acquired during hospitalization, with a prevalence of 2%. Increases hospital stay by an average of 4 days, with a consequent increase in hospital costs. Mortality is low and is particularly associated with secondary bacteremia, which occurs from 0.5 to 4% of these patients. Bladder catheterization (CV) is the most influential factor for developing an UTI. Approximately 75% of UTIs, affect patients that have required catheterization. Through the application of some of medical and sanitary steps,UTI may decrease about 30%, infectious complications of bladder catheterization.

Central line-associated bloodstream infections (CLABSI): Microbiology and antimicrobial resistance pattern of isolates from the Pediatric ICU of a tertiary care Indian hospital

ObjectivesCentral line-associated bloodstream infections (CLABSIs) are important and serious healthcare-associated infections (HAI), with a reported mortality of 12–25%. We conducted this study to determine incidence of CLABSI in our Pediatric Intensive Care Unit (PICU), and to study the profile (gram positive or negative) of organisms causing these infections and also their antimicrobial resistance pattern. MethodsA prospective cohort study was conducted in our PICU for a period of one and a half years from 1st August 2011 to 31st January 2013. Blood samples were collected for culture when primary or secondary bacteremia was suspected. A CLABSI was defined as per CDC guidelines. Antimicrobial susceptibility testing was done by Disk diffusion Technique using Kirby Bauer's method and interpretation was as per CLSI guidelines. ResultsThere were 13 episodes of CLABSI, of which, 5 (38.5%) were caused by Klebsiella spp., 3 (23.1%) by Pseudomonas spp., 1(7.7%) by Acinetobacter spp., 1 (7.7%) by Proteus spp., 1 (7.7%) by Enterococcus faecium, and 2 (15.3%) by Staphylococcus epidermidis. All the Pseudomonas spp. isolates were sensitive to Ciprofloxacin whereas Acinetobacter spp. was resistant to it. Four of 5 Klebsiella spp. isolates were resistant to carbapenems and all were resistant to 3rd generation cephalosporins. Both the S. epidermidis isolates were methicillin resistant. ConclusionsGram-negative organisms continue to predominate HAIs in the developing countries, reflecting the suboptimal infection control. More worrisome is the rise of multidrug-resistant gram-negative bacilli, which are resistant to quinolones, 3rd and 4th generation cephalosporins, and carbapenems. Preventive and control measures are the most cost-effective parameters to help contain the rising antimicrobial resistance.

Characteristics, risk factors and outcomes of carbapenem-resistant Klebsiella pneumoniae infections in the intensive care unit

To study the characteristics, risk factors and outcomes of intensive care unit (ICU) patients with carbapenem-resistant (CRKp) and carbapenem-susceptible (CSKp) Klebsiella pneumoniae infections. A retrospective cohort of patients with K. pneumoniae infections in an eight-bed ICU between January 2006 and October 2009. During the study period, 104 patients were diagnosed with K. pneumoniae infection (80 CRKp and 24 CSKp). Isolation of CRKp increased gradually during the study period, while isolation of CSKp remained constant. The mean age of patients was 66.3 ± 14.3 years. The mean APACHE II score was 17.9 ± 6.9. The median duration of ICU stay until the infection was 15 days. Thirty five patients (33.7%) had primary and 30 (28.8%) had secondary bacteremia. Seventy-two patients (69.2%) died in the ICU. No independent risk factors for development of CRKp infections were identified in the multivariate analysis. Treatment failure (p = 0.001) was the only independent predictor of mortality in the multivariate analysis (APACHE II, shock, multi-organ failure, respiratory failure, acute renal failure, acidosis and extensive-drug resistance were included in the model). No difference in mortality was found between patients with CRKp and CSKp isolates. Infection due to K. pneumoniae in the ICU was associated with high mortality. Control of the infection was the most important determinant of the outcome of critically ill patients.

Injectional anthrax - new presentation of an old disease.

Bacillus anthracis infection (anthrax) has three distinct clinical presentations depending on the route of exposure: cutaneous, gastrointestinal and inhalational anthrax. Each of these can lead to secondary bacteraemia and anthrax meningitis. Since 2009,anthrax has emerged among heroin users in Europe,presenting a novel clinical manifestation, 'injectional anthrax', which has been attributed to contaminated heroin distributed throughout Europe; before 2009 only one case was reported. During 2012 and 2013,new cases of injectional anthrax were diagnosed in Denmark, France, Germany, and the United Kingdom.Here we present a comprehensive review of the literature and information derived from different reporting systems until 31 December 2013. Overall 70 confirmed cases were reported, with 26 fatalities (37% case fatality rate).The latest two confirmed cases occurred in March 2013. Thirteen case reports have been published,describing 18 confirmed cases. Sixteen of these presented as a severe soft tissue infection that differed clinically from cutaneous anthrax, lacked the characteristic epidemiological history of animal contact and ten cases required complimentary surgical debridement. These unfamiliar characteristics have led to delays of three to 12 days in diagnosis, inadequate treatment and a high fatality rate. Clinicians' awareness of this recently described clinical entity is key for early 'and successful management of patients.