Tracheal Aspirate Samples Research Articles

Clinical and microbiological characteristics of Pantoea agglomerans infection in children.

Pantoea agglomerans is an environmental Gram-negative bacterium that rarely is responsible for the infections in humans but it is often a causative factor of a number of occupational diseases. This study evaluated the clinical and microbiological characteristics and pathogenicity of P. agglomerans in children. We retrospectively reviewed microbiological test results for all children (1 month old to 18 years old) who were admitted to our pediatric hospital between January 2000 to June 2015 and had positive clinical specimen cultures for P. agglomerans. Isolates were identified using conventional tests and the BBL Crystal E/NF ID or MALDI-TOF MS systems. Antibiotic susceptibilities were evaluated using the Kirby-Bauer disc diffusion method. We identified fifteen positive cultures from 14 patients with confirmed infections. The positive specimens included pus, urine, tracheal aspirate, blood, and central venous line samples that yielded P. agglomerans. The median patient age was 8.8 years (range: 1.5 months to 16.5 years), and all patients had underlying comorbidities. Five patients had medical devices, and two devices were removed. The most common P. agglomerans infections involved wound infections (35.7%), pneumonia (21.4%), and urinary tract infections (21.4%). Three patients had concomitant infections (Enterococcus faecium, Pseudomonas aeruginosa, and Aspergillus fumigatus). Five patients had anemia. Three patients (21.4%) died, and all three had carbapenem-resistant P. agglomerans that was detected after the first week of hospitalization; two cases involved pneumonia, which was ineffectively treated. P. agglomerans infections may be life-threatening, especially in young patients with pneumonia. Hospital-acquired P. agglomerans may have different pathogenicity and clinical features, compared to community-acquired P. agglomerans, although further studies are needed to understand the drug-resistance patterns in this bacterium.

Correlation Between Lung Injury Score, PvO2/FiO2 Ratio and Oxidative Stress Markers in Tracheal Aspirate Samples in Intubated Infant Patients During Chest Physical Therapy

Background: Pneumonia presents high oxidative stress, which directly affects the lung injury and oxygenation status. Evidence has shown the correlation of oxidative stress markers in tracheal aspirates (TA) in infant patients, however, not before or after chest physical therapy (CPT). Objectives: The objective of this study was to evaluate the correlation between lung injury score (LIS) or PvO2/FiO2 ratio and oxidative stress parameters in TA before and after CPT in infant patients during recovery from pneumonia. Methods: TA samples from 40 intubated patients aged 5.4 ± 0.15 months were collected before and after CPT for evaluating oxidative stress parameters; as a glutathione (GSH), vitamin E, hyarulonic acid (HA), and malondialdehyde (MDA). Furthermore, the LIS and PvO2/FiO2 ratio were recorded. The correlation between oxidative stress markers and LIS or PvO2/FiO2 ratio was evaluated before and after CPT. Results: The results before CPT showed no significant correlation between LIS and all parameters, whereas, the PvO2/FiO2 ratio correlated with the thiol group (r = -0.566, P = 0.000) and HA (r = -0.507, P = 0.000). After CPT, LIS correlated with GSH and HA (r = -0.396 and -0.409, P = 0.01) and the PvO2/FiO2 ratio correlated significantly with the GSH, HA, and MDA (r = 0.609, 0.768, -0.482, P = 0.000). Conclusions: Some oxidative stress markers, such as the GSH, HA, and MDA in TA possibly reflected lung injury and oxygenation and may respond with more correlation after CPT intervention than before it.

Microbial investigations in throat swab and tracheal aspirate specimens are beneficial to predict the corresponding endotracheal tube biofilm flora among intubated neonates with ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in neonatal intensive care units with high morbidity and mortality. Bacterial biofilm in the endotracheal tube (ET) provides a notable and persistent source of pathogens that may cause VAP, and thus is important for VAP detection. However, during intubation microbial investigations in ET, samples are unavailable due to the infeasibility of collecting ET samples during intubation of neonates. It is therefore of great importance to find alternative sources of samples that can help identify the ET biofilm flora. In the present study, the microbial signatures of throat swabs and tracheal aspirates were compared with ET biofilm samples from VAP neonates using 16S ribosomal RNA gene polymerase chain reaction, denaturing gradient gel electrophoresis (DGGE), cloning and sequencing. Sequences were assigned to phylogenetic species using BLAST. Microbial diversity and richness among the three types of specimens were compared based on their DGGE fingerprints, and taxonomic characteristics based on the BLAST results. The microbial richness and diversity of ET biofilms were similar to tracheal aspirate yet significantly different from throat swab samples (P<0.05). Compared with ET biofilms, the overall constituent ratio of microflora was significantly different in throat swab and tracheal aspirate samples (P<0.05). However tracheal aspirate samples were useful for predicting Staphylococcus sp. in ET biofilms with a sensitivity of 85.7% and a specificity of 83.3%. The sensitivity for the combination of tracheal aspirate and throat swab samples to detect Staphylococcus sp. in ET biofilms was 100%. The detection of Pseudomonas sp. in throat swabs assisted its identification in ET biofilms (sensitivity 33.3% and specificity 100%). The results of the present study suggest that microbial investigations in throat swab and tracheal aspirate samples are beneficial for identifying the ET biofilm flora. There may therefore be clinical applications of using substituent samples to identify pathogens in ET biofilms for VAP surveillance among intubated neonates.

Improving Conditions for Gliotoxin Production by Local Isolates of Aspergillus fumigatus

Thirty two isolates of Aspergillus fumigatus were obtained from a total of 44 samples of sputum, nose swab and tracheal aspirate from suspected patient with aspergillosis were also collected from February 2014 to June 2014. A morphological examination of A. fumigatus was first made with naked eye and at low magnification power of microscope after that detailed examination was done by measuring the dimensions of the microscopic structures, photographing the microscopic structures and using relevant literature. Results appeared conical-shaped terminal vesicles, uniseriate row of phialides on the upper two thirds of the vesicle, conidiophore stipes were short, phialides arrange uniseriate upper vesicle conidia and parallel to axis of conidiophore, produced in chains of spore basipetally from phialides, the chains of spore were borne directly in the absence of metulae and represented by septet and branching hyphae. The ability of A. fumigatus for GT production was investigated using thin layer Chromatography (TLC) and High Performance Liquid Chromatography (HPLC) techniques and results showed that GT was produced by 81.25% of A. fumigatus isolates. Optimum conditions for GT production by A. fumigatus 16 (AF-16) isolate were determined by submerged fermentation using Yeast extract sucrose medium. Results indicated that AF-16 isolate was the highest GT producer on Yeast Exract Sucrose medium with inoculum size 2×107 conidium and incubation at 32ºC for 15 days and the concentration of gliotoxin was (4511µg mL-1).

The evaluation of antibiotic resistance status of Klebsiella pneumoniae

Purpose: Klebsiella species can be found in the nasopharynx and intestine, rare pathogen but causes serious infections. Those kinds isolated from people most frequently from Klebsiella pneumoniae (K. pneumoniae) and Klebsiella oxytoca; like urinary tract, gallbladder, surgical site infection, bacteremia, pneumonia and abscesses in various organs infections bacteria identified as a factor. Urinary tract infections are the most common infections among community acquired and health care related infections. Thus treatment is usually given empirically, it is necessary and important to know the pathogens and the antibiotic susceptibility patterns of these pathogens in urinary tract infections for the success of treatment. Therefore in this study, antimicrobial susceptibility of 871 K. pneumoniae strains isolated from various clinical samples was investigated in our hospital. Material and Method: Between the April 2014-October 2015, sent to Sakarya University Training and Research Hospital medical microbiology laboratory isolated from various clinical specimens 871 K. pneumoniae isolates were included to study. Isolates, eosin methylene blue (EMB) agar and blood agar cultivation was carried out and samples were incubated at 37 °C for 18-24 hours. Vitek 2 (bioMérieux, France) automatised system was used for identification and antibiotic susceptibility tests, and susceptibility results were determined according to the guidelines of CLSI and/or EUCAST. Using the SPSS version 20.0 (SPSS, Inc., USA) program was performed descriptive statistical analysis of the isolates in our study . Results: K. pneumoniae strains were frequently isolated from urine (415, 48%), blood (91, 10%), wound (76, 9%), tracheal aspirate (52, 6%), sputum (19, %2) and (218, %25) other samples. The rates of ESBL production that was detected in all isolated-strain were 55% . The resistance rate was 37% in all isolates-strains for the only beta-lactam antibiotic, carbapenem group that can be used in the treatment of infections caused by ESBL producing strains. Resistance values of ESBL producing strains; for AN, AMC, CRO, CIP, CAZ, FEP, GM, IPM, MEM, SXT, TZP antibiotics respectively were found to be 8%, 34%, 24%, 51%, 28%, 1%, 8%, 5%, 7%, 6%, 3%. Conclusion: There is a high rate of ESBL-producing K. pneumoniae isolates and also to the high rate of resistance to antimicrobial agents of these strains., making ESBL detection tests in the clinical microbiology laboratory and we believe that each hospital should periodically evaluate its own data and concordantly assess its antibiotic use policies.

Airway Microbial Community Turnover Differs by BPD Severity in Ventilated Preterm Infants.

Preterm birth exposes the developing lung to an environment with direct exposure to bacteria, often facilitated by endotracheal intubation. Despite evidence linking bacterial infections to the pathogenesis of bronchopulmonary dysplasia (BPD), systematic studies of airway microbiota are limited. The objective was to identify specific patterns of the early respiratory tract microbiome from tracheal aspirates of mechanically ventilated preterm infants that are associated with the development and severity of BPD. Infants with gestational age ≤34 weeks, and birth weight 500–1250g were prospectively enrolled. Mechanically ventilated infants had tracheal aspirate samples collected at enrollment, 7, 14, and 21 days of age. BPD was determined by modified NIH criteria with oxygen reduction tests; infants without BPD were excluded due to low numbers. Aspirates were processed for bacterial identification by 16S rRNA sequencing, and bacterial load by qPCR. Cross-sectional analysis was performed using 7 day samples and longitudinal analysis was performed from subjects with at least 2 aspirates. Microbiome analysis was performed on tracheal aspirates from 152 infants (51, 49, and 52 with mild, moderate, and severe BPD, respectively). Seventy-nine of the infants were included in the cross-sectional analysis and 94 in the longitudinal. Shannon Diversity, bacterial load, and relative abundance of individual taxa were not strongly associated with BPD status. Longitudinal analysis revealed that preterm infants who eventually developed severe BPD exhibited greater bacterial community turnover with age, acquired less Staphylococcus in the first days after birth, and had higher initial relative abundance of Ureaplasma. In conclusion, longitudinal changes in the airway microbial communities of mechanically ventilated preterm infants may be associated with BPD severity, whereas cross-sectional analysis of airway ecology at 7 days of age did not reveal an association with BPD severity. Further evaluation is necessary to determine whether the observed longitudinal changes are causal or in response to clinical management or other factors that lead to BPD.

Low serum IGF-1 and increased cytokine levels in tracheal aspirate samples are associated with bronchopulmonary dysplasia.

Yılmaz C, Köksal N, Özkan H, Dorum BA, Bağcı O. Low serum IGF-1 and increased cytokine levels in tracheal aspirate samples are associated with bronchopulmonary dysplasia. Turk J Pediatr 2017; 59: 122-129. Despite developments in the perinatal and neonatal care, bronchopulmonary dysplasia (BPD) is still the most frequently seen long-term complication in preterm infants. The aim of this prospective study is to investigate the association between the development of BPD and serial measurements of IGF-1 levels and their relationship with levels of IGF-1 and cytokine in tracheal aspirate fluids. A total of 40 premature infants, born at a gestational age of ≤ 32 weeks, were enrolled in the study. On postnatal day-1, 3, 7, 21 and 28 serum IGF-1 levels and IGF-1 levels, IL-6, IL-8, IL-10 and TNF-alpha levels in tracheal aspirate fluid samples of intubated cases were examined. Mean gestational age of 40 patients included in the study was 29.41 ± 2.23 weeks, and their mean birth weight was 1,256.85 ± 311.48 g. BPD was detected in 35% of cases. Mean gestational week and birth weight of the cases that developed BPD were 30 ± 3 weeks and 1,150 ± 295 g, respectively. Serum IGF-1 levels on postnatal day-1, 3, 7, 21 and 28 in cases who developed BPD were significantly lower when compared with those without BPD (p < 0.01). Levels of IL-6, IL-8, IL-10, and TNF-alpha in tracheal aspirate samples were significantly higher in cases with BPD compared to those without BPD (p < 0.05). IGF-1 levels in tracheal aspirate fluid samples did not differ significantly based on the presence of BPD (p > 0.05). Severity of BPD was associated with decreased serum IGF-1 levels and increased cytokine levels in tracheal aspirate samples.

The First Enterobacter cloacae Co-Producing NDM and OXA-48 Carbapenemases and Interhospital Spread of OXA-48 and NDM-Producing Klebsiella pneumoniae in Turkey.

The aim of this study was to investigate the occurrence of carbapenemase-producing Enterobacteriaceae. A total of 54 carbapenem nonsusceptible Enterobacteriaceae (CRE) isolates were recovered from clinical samples sent to the Dr. Lutfi Kirdar Kartal Training and Research Hospital from the period 2011 through 2014. Forty-four isolates were Klebsiella pneumoniae (CRKP) and the other 10 were Enterobacter cloacae (CREC).The isolate identifications and antibiotic sensitivity tests were performed using a Vitek2 automatic system. The clonality of isolates was determined using rep-PCR Diversilab. Presence of blaOXA-48, blaNDM, blaVIM, blaIMP, and blaKPC genes were screened using polymerase chain reaction (PCR) with specific primers. CRKP were isolated from blood, urine, wounds, catheter tips, and tracheal aspirate samples; a total 44 isolates were evaluated. All isolates were nonsusceptible to ertapenem/imipenem or meropenem. Eighteen percent of the isolates were resistant to colistin. CREC were isolated from blood, urine, cerebrospinal fluid and sputum; a total of 10 isolates were evaluated. They were resistant to all carbapenems and 90% were resistant to cefoperazone/sulbactam and trimethoprim/sulfamethoxazole, and 50 - 70% isolates were resistant to gentamicin, amikacin, and ciprofloxacin. Thirty-three (75%) OXA-48 producing CRKP were identified. Thirteen (29.5%) were positive and two (4.5%) NDM-producing K. pneumoniae were co-producing OXA-48. Of the ten CREC strains tested, eight were positive for blaNDM, one isolate was positive for blaVIM and another for blaIMP genes. rep-PCR typing revealed the presence of a clonal dissemination in CRKP and CREC in the hospital. To our knowledge, this is the first identification of blaNDM in E. cloacae isolates in Turkey. These findings describe an interhospital spread of CRKP-producing OXA-48 and NDM carbapenemases that started in 2011. Continuous monitoring is necessary to better understand their dissemination in the hospital, which probably occurred as a result of transmission from an environmental reservoir. These findings emphasize the need for intensive surveillance and precautions.

Association between pathogens from tracheal aspirate and oral biofilm of patients on mechanical ventilation.

The aim of this study was to detect possible associations between respiratory pathogens from tracheal aspirate and oral biofilm samples in intubated patients in an intensive care unit (ICU), and to identify the most common respiratory pathogens in oral biofilm, particularly in patients that developed ventilator-associated pneumonia (VAP). Two oral biofilm samples were collected from the tongue of intubated patients (at admission and after 48 hours) and analyzed by culture with the Antibiotic Sensitivity Test. The results from the tongue biofilm samples were compared with the tracheal secretions samples. A total of 59.37% of patients exhibited the same species of pathogens in their tracheal aspirate and oral biofilm, of which 8 (42.1%) developed VAP, 10 (52.63%) did not develop pneumonia and one (5.26%) had aspiration pneumonia. There was a statistically significant association between presence of microorganisms in the tracheal and mouth samples for the following pathogens: Klebsiella pneumoniae, Candida albicans, Pseudomonas aeruginosa, Enterobacter gergoviae, Streptococcus spp and Serratia marcescens (p < 0.05). Pathogens that are present in tracheal aspirates of intubated patients can be detected in their oral cavity, especially in those who developed VAP or aspiration pneumonia. Thus, the results indicate that an improved oral care in these patients could decrease ICU pneumonia rates.

Analysis of biofilm production by clinical isolates of Pseudomonas aeruginosa from patients with ventilator-associated pneumonia.

ObjectiveTo phenotypically evaluate biofilm production by Pseudomonas aeruginosa clinically isolated from patients with ventilator-associated pneumonia.MethodsTwenty clinical isolates of P. aeruginosa were analyzed, 19 of which were from clinical samples of tracheal aspirate, and one was from a bronchoalveolar lavage sample. The evaluation of the capacity of P. aeruginosa to produce biofilm was verified using two techniques, one qualitative and the other quantitative.ResultsThe qualitative technique showed that only 15% of the isolates were considered biofilm producers, while the quantitative technique showed that 75% of the isolates were biofilm producers. The biofilm isolates presented the following susceptibility profile: 53.3% were multidrug-resistant, and 46.7% were multidrug-sensitive.ConclusionThe quantitative technique was more effective than the qualitative technique for the detection of biofilm production. For the bacterial population analyzed, biofilm production was independent of the susceptibility profile of the bacteria, demonstrating that the therapeutic failure could be related to biofilm production, as it prevented the destruction of the bacteria present in this structure, causing complications of pneumonia associated with mechanical ventilation, including extrapulmonary infections, and making it difficult to treat the infection.

Microbial investigation of biofilms recovered from endotracheal tubes using sonication in intensive care unit pediatric patients

ObjectivesTo compare cultured microorganisms identified on endotracheal tubes biofilms through sonication technique with traditional tracheal aspirate collected at extubation of pediatric intensive care unit patients. MethodsDemographic and epidemiological data were analyzed to identify factors possibly related with the microbiological profile of the two collection methods. Associations between categorical and continuous variables were analyzed using the chi-square or Fisher's exact test, or Student's t test. p-Value <0.05 were considered significant. ResultsThirty endotracheal tubes and tracheal aspirates samples from 27 subjects were analyzed. Only one patient presented the clinical diagnosis of ventilator-associated pneumonia. Overall, 50% of bacteria were Gram-negative bacilli, followed by Gram-positive bacteria in 37%, and fungi in 10%. No statistically significant difference on the distribution of Gram-positive or Gram-negative bacteria (p=0.996), and fungi (p=0.985) were observed between the collection methods. Pseudomonas spp. was the most frequent microorganism identified (23.8%), followed by Streptococcus spp. (18.5%), Acinetobacter spp. (15.9%), coagulase-negative staphylococci (11.2%), and Klebsiella spp. (8.6%). Concordant results between methods amounted to 83.3%. Pseudomonas aeruginosa and Acinetobacter baumannii showed carbapenem resistance in 50% and 43.7% of the isolates, respectively. In general, cultures after endotracheal tubes sonication (non-centrifuged sonication fluid and centrifuged sonication fluid) yielded bacteria with higher rates of antimicrobial resistance compared to tracheal aspirates cultures. Additionally, in 12 subjects (40%), we observed discrepancies regarding microbiologic profiles of cultures performed using the collection methods. ConclusionsOur study demonstrated that sonication technique can be applied to ET biofilms to identify microorganisms attached to their surface with a great variety of species identified. However, we did not find significant differences in comparison with the traditional tracheal aspirate culture approach.

Prevalence and Anti-Microbial Susceptibility of Methicillin Resistant &amp;lt;i&amp;gt;Staphylococcus aureus&amp;lt;/i&amp;gt; at Moi Teaching and Referral Hospital Eldoret

Background: Methicillin-resistant Staphylococcus aureus (MRSA) are pathogens that have major negative impact in all aspects of patient care and are increasingly being recognized as troublesome pathogens in the community. The MRSA are multi-drug resistant bacteria responsible for higher morbidity, mortality and cost of treatment in the affected patients. Research on MRSA antimicrobial susceptibility and resistance in developing countries is limited; hence accurate burden is not certain. Objective: To determine the prevalence and susceptibility pattern of MRSA in S. aureus isolates from patients treated in various units at Moi Teaching and Referral Hospital. Study Design: Cross-sectional design was used to conduct the study. Methods and Materials: Staphylococcus aureus stored isolates from patients at various units at Moi Teaching and Referral Hospital (MTRH) were identified by laboratory conventional methods. Methicillin resistant Staphylococcus aureus was determined using cefoxitin and oxacillin, discs and confirmed by Penicillin Binding Protein (PBP2a’) latex agglutination test. Susceptibility testing was performed according to the Clinical Laboratory Standards Institute procedures. Control strains used were: ATCC 43300 for Methicillin resistant S. aureus (MRSA) strains and ATCC 29213 for methicillin susceptible S. aureus (MSSA) strains. Nine anti-microbials (Erythromycin, Gentamycin, Tetracycline, Vancomycin, Rifampin, Linezolid, Ciprofloxacin, Clindamycin and Fucidicacid) were used to test the anti-microbial susceptibility patterns. Control organisms were run along with the isolates for quality Assurance. The data was analyzed using STATA version 11. Categorical variables were summarized as frequencies and the corresponding percentages. Results were presented using tables and graphs. Results: A total of 107 isolates of S. aureus were obtained, of which 39 (37%) were MRSA. Most of the MRSA, 13 (33%) and 7 (17%), were found in pus and tracheal aspirate samples respectively. Majority of the MRSA isolates were from surgical wards and intensive care unit. The MRSA isolates were highly resistant to erythromycin (92%; 36/39) and tetracycline (92% 36/39) and moderately susceptible to linezolid (77% 30/39), Vancomycin (75% 29/39) and fucidic acid (67% 26/39). A total of 28 (74.4%) MRSA isolates were Clindamycin inducible resistant. Conclusions and Recommendations: This study showed that MRSA is a significant pathogen at MTRH. The MRSA were most detected in pus specimens and least in peritoneal aspirates. Routine Screening of S. aureus isolates for MRSA strains at MTRH is therefore imperative. Infection control measures should be put in place to reduce prevalence and prevent the spread of MRSA at MTRH.

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Resistant pathogens are an important challenge to hospitals, especially to stablish the correct treatment and prophylactic measures. Once in the environmental Gram-negative strains can acquire resistance genes from the soil, water and hospital effluent and so transmit it to other genus. The objective of this study was to quantify and to qualify the bacterial strains present in patients with suspected of nosocomial infection and the environment in which they are admitted in the Palmas General Hospital. 14 different bacterial species from 141 samples, being 123 from patients and 18 from hospital environment. In patient samples highlights were Klebsiella pneumoniae (21.9%), Acinetobacter baumannii (13.82%), Pseudomonas aeruginosa (12.2%), Escherichia coli (11.4%), Serratia marcescens (10.6 %) and Staphylococcus aureus (9.0%), From this total, 80 strains were multiresistant to antibiotics, whichever Klebsiella pneumoniae (26.3%) and A. baumannii (20.0%). The tracheal aspirate samples showed a greater number of multidrug-resistant strains. The environment prevailed Serratia marcescens, Staphylococcus aureus and Staphylococcus sp. both with 22.2%, collected from different locations and ICU materials such as tracheal tube, Ambu, mattress and monitors. Administrative and educational strategies are necessary to reduce the spread of multi-resistant germs.

Patterns of Antimicrobial Resistance Among Intensive Care Unit Patients of A Private Medical College Hospital in Dhaka

Because of importance of Hospital acquired infections (HAIs), it is critical to conduct surveillance studies to obtain the required data about the regional microorganisms and their susceptibility to antibiotics. This study to investigate antimicrobial resistance pattern among Intensive Care Unit (ICU) patients in a private medical college hospital setup. In a cross sectional study, 100 specimens from patients admitted in the ICU who had signs or symptoms of nosocomial infection were collected from 2012 - 2013. For each patient, samples of blood, urine, tracheal aspirate, sputum, wound swab, pus, and endotracheal tubes were obtained, cultured and analyzed with antibiogram. The most common primary diagnosis were aspiration pneumonia (49%) and UTI (20%) respectively. The most common locations for infection were tracheal aspirate (54%). The most frequent gram negative microorganisms derived from samples were Acinetobacter spp (29%), Klebsiella spp (26%) and Pseudomonas spp (18%). Klebsiella spp, Acinetobacter spp and Pseudomonas spp were most common resistant organisms among all. Klebsiella spp were resistant against Ceftriaxone (84.6%), Ceftazidime (82.6%), Amikacin (46.1%), Gentamicin (66.6%) and Quinolones (65-66.6%) respectively. Acinetobacter spp were resistant against Ceftriaxone (85%), Ceftazidime (88.8%), Cefotaxime (85.7%), Meropenem (79.3%),Amikacin (86.2%), Gentamicin (84.5%) and Quinolons (86.2-89.2%) respectively. Pseudomonas spp were resistant against Ceftriaxone (70.5%), Ceftazidime (66.6%), Amikacin (68.7%), Gentamicin (58.8%), Meropenem (52.9%) and Quinolones (81.2-86.6%) respectively. Meropenem was the most sensitive antibiotic against Klebsiella spp (84.6%) but Cotrimoxazole in case of Acinetobacter spp (60%) respectively. Escherichia coli were mostly isolated from urine, which was sensitive to Amikacin (73.3%) and Meropenem (86.6%) respectively. Gram-negative pathogens obtained from ICU patients in our settings show high resistance to antibiotics. Regular monitoring of the pattern of resistance of common pathogens in the ICUs is essential to up-to-date the use of rational antibiotics regiments.Bangladesh J Medicine Jul 2014; 25 (2) : 47-51

Cytological evaluation of tracheal aspirate and broncho-alveolar lavage fluid in comparison to endoscopic assessment of lower airways in horses with recurrent airways obstruction or inflammatory airway disease.

The aim of the present study was to compare the grade of discharge accumulation in the tracheal lumen, area of tracheal bifurcation, main bronchi and the tracheal septum thickness with the cytology of the tracheal aspirate (TA) and broncho-alveolar lavage fluid (BALF) in horses with recurrent airways obstruction and inflammatory airway disease from those horses. This study was conducted on 96 horses with RAO, 139 horses with IAD and 10 control horses. In all the horses, both clinical and endoscopic examinations were performed. During endoscopy, a score of mucus accumulation was estimated in 3/4 lower of the trachea and in the tracheal bifurcation. In addition, thickening of the tracheal septum was also assessed; tracheal aspirates and broncho-alveolar lavage were performed. An estimate of cell percentage was done in TA and BALF samples. In horses suffering from RAO and IAD, there was a positive correlation between the percentage of neutrophils and the accumulation of discharge, and in the IAD group, there was a negative correlation between the percentage of eosinophils and the accumulation of discharge. There was no correlation between tracheal septum thickening and the percentage of neutrophils and/or eosinophils.

Burden of tuberculosis in intensive care units in Cape Town, South Africa, and assessment of the accuracy and effect on patient outcomes of the Xpert MTB/RIF test on tracheal aspirate samples for diagnosis of pulmonary tuberculosis: a prospective burden of disease study with a nested randomised controlled trial

There are few prospective data about the incidence and mortality associated with pulmonary tuberculosis in intensive care units (ICUs), and none on the accuracy and clinical effect of the Xpert-MTB/RIF assay in this setting. We aimed to measure the frequency of culture-positive tuberculosis in ICUs in Cape Town, South Africa and to assess the performance and effect on patient outcomes of Xpert MTB/RIF versus smear microscopy for diagnosis of tuberculosis. We did a prospective burden of disease study with a randomised controlled substudy at the ICUs of four hospitals in Cape Town. Mechanically ventilated adults (≥18 years) with suspected pulmonary tuberculosis admitted between Aug 1, 2010, and July 31, 2013 (irrespective of the reason for admission), were prospectively investigated by culture, and by Xpert-MTB/RIF testing or smear microscopy, of tracheal aspirate samples. In the substudy, patients were randomly assigned (1:1), via a computer-generated allocation list, to smear microscopy or Xpert MTB/RIF. Participants, caregivers, and outcome assessors were not masked to group assignment. Only the laboratory staff were blinded to the clinical details of the participants. In November, 2012, Xpert MTB/RIF was adopted as the initial diagnostic test for respiratory samples in Western Cape province. Thereafter, patients received Xpert MTB/MIF and culture as standard of care. For the whole study cohort, the primary outcome was the frequency of bacteriologically confirmed tuberculosis. The primary endpoint of the randomised substudy was the proportion of culture-positive patients on treatment at 48 h after enrolment. The randomised substudy is registered with ClinicalTrials.gov, number NCT01530568. We investigated 341 patients for suspected pulmonary tuberculosis out of a total of 2309 ICU admissions. 46 (15%) of 317 patients included in the final analysis had a positive test for tuberculosis (Xpert MTB/RIF or culture). Culture-positive patients who failed to initiate treatment (adjusted HR 4·49, 95% CI 1·45-13·89) or who received inotropes (4·33, 1·49-12·60) were more likely to die. However, tuberculosis status was not associated with 28-day or 90-day mortality. In the substudy, we randomly assigned 115 patients to smear microscopy and 111 to Xpert MTB/RIF. Smear microscopy detected six (43%) of 14 culture-positive patients, and Xpert MTB/RIF detected 11 (100%) of 11 culture-positive patients (p=0·002). The proportion of culture-positive patients on treatment at 48 h was higher in the Xpert MTB/RIF group than in the smear microscopy group (11 [92%] of 12 vs nine [53%] of 17; p=0·043), although use of Xpert MTB/RIF had no effect on mortality or other patient outcomes. Tuberculosis is fairly common in ICUs in high-burden settings, and clinicians should screen and test patients for tuberculosis with Xpert MTB/RIF where available. This test improves diagnostic yield and rates of treatment initiation, and reduces unnecessary treatment, but might not increase the total number of patients on treatment when empirical treatment is widely used. A suspected diagnosis of pulmonary tuberculosis should not exclude patients from ICU care in resource-limited settings because mortality is unaffected by the presence of this disease. European and Developing Countries Clinical Trials Partnership, South African Medical Research Council, and the Discovery Foundation.

Molecular diagnosis and phylogenetic analysis of the first MERS case in Turkey

Coronaviruses (CoV) are enveloped, spherical, single-stranded positive-sense RNA viruses causing mainly respiratory and intestinal infections in animals and humans. Until recently five types of human coronaviruses (HCoV-OC43, HCoV-HKU1, HCoV-NL63, HCoV-229E, SARS-CoV) have been known, however a novel CoV has been identified in 2012 in Saudi Arabia. This virus, namely MERS-CoV (Middle East Respiratory Syndrome Coronavirus), was classified within Coronaviridae family, Coronavirinae sub-family, Betacoronavirus genus, clade C. It causes acute respiratory infections in humans and transmits via respiratory route and close contact between humans. The aim of this study was to present the first MERS case from Turkey identified by molecular methods and the results of viral sequence analysis. A 42-year-old male Turkish citizen who worked as an employee in Jeddah, Kingdom of Saudi Arabia, admitted to hospital with the complaints of fever and malaise on 25-26 September 2014. Since his symptoms went on and got worse, he returned to Turkey, and hospitalized in a hospital's intensive care unit in Hatay on 6th of October with the symptoms of fever, malaise, sweating, cough and respiratory distress. He transferred to a university hospital on 8th of October and died on 11th October. The tracheal aspirate sample obtained before he died was sent to Virology Unit of Reference Laboratories of the Turkish Public Health Institution. Detection of viral RNA was performed by using a commercial real-time PCR kit (hCoV-EMC Real-Time RT-PCR, Fast Track Diagnostics, Luxembourg) targeting the MERS-CoV E protein (upE), ORF1a and ORF1b gene regions. The reference method Superscript III One Step RT-PCR (Invitrogen, USA) recommended by World Health Organization (WHO) was also applied for confirmation. Both of the methods yielded positive results for MERS-CoV RNA. For the amplification of nucleocapsid (N) and RNA-dependent RNA polymerase (RdRp) genes, hemi-nested PCR (Invitrogen, ABD) was conducted, followed by sequence analysis of 204 nucleotide part of N gene. Phylogenetic tree of N gene was obtained with the use of MEGA6 software. N gene was chosen as it comprised a two aminoacid deletion in the corresponding published sequence from the patient treated in London, United Kingdom. There was no nucleotide or aminoacid change in our isolate, namely ANK/1079/2014 when compared with human Betacoronavirus 2c EMC/2012 reference strain found in Genbank database. The target gene regions selected in our study (UpE, ORF1a, ORF1b, N and RdRp) which were also recommended by WHO, shown to have high specificity and sensitivity for the diagnosis and confirmation of MERS-CoV, and also recommended by WHO. The previous studies indicated that, the viral genomes detected in the earliest cases of humans (clade A) are genetically distinct from the others (clade B) which were isolated from dromedary camels and humans. In our study, according to phylogenetic analysis of partial N gene segment, isolate ANK/1079/2014 has taken place within clade A. In conclusion, MERS-CoV appears to have limited circulation in Arabian Peninsula and Middle-Eastern countries, it should be considered in mind that travel-related cases may export the virus outside these regions leading autochtonous infections in the other parts of the world.

Management of Severe Paroxysmal Sympathetic Hyperactivity Following Hypoxic Brain Injury.

Dear Editor, Paroxysmal sympathetic hyperactivity (PSH) is the autonomic dysfunction characterized by tachypnea, tachycardia, hypertension, hyperthermia, sweating and motor features such as dystonia. It is the leading cause of higher morbidity and mortality in an intensive care unit setting. The main etiologic factors of PSH are traumatic brain injury (79%), hypoxic ischemic encephalopathy (10%) and stroke (1, 2). Presence of hypoxia, diffuse axonal injury and younger age facilitates the development of PSH (3). Treatment of PSH is comprised of reducing sympathetic and motor hyperactivity. Opioids, gabapentin, benzodiazepines, bromocriptin, β-blockers and centrally acting α2-agonists are recommended (1, 4). We described our management for a case of severe PSH, which occurred after hypoxic brain injury, and orally administered baclofen is effective in motor symptoms of PSH, contrary to that reported before (1). A 19-year-old boy with a history of hypoxic brain injury due to cardiopulmonary resuscitation after a thoracic penetrating trauma was admitted to our intensive care unit. He was unconscious and the Glasgow Coma Score was 5/15; thus, informed consent was obtained from his parents. He experienced episodes of increased body temperature (>38.5°C), blood pressure (>140/90 mmHg), heart rate (>100 m−1) and respiration rate (>35 m−1) with decerebrate posturing and excessive sweating. Morphine 2 mg intravenous (IV), dexmedetomidine 1 μg kg−1 h−1 IV infusion and remifentanil 0.5 μg kg−1 h−1 IV infusion were administered during episodes; symptoms were controlled for a while, but not totally. On the other hand, blood, tracheal aspirate and urine sample cultures were collected and appropriate antibiotics were administered. Blood leukocyte count, CRP and procalcitonin values decreased following antibiotherapy; however, fever could not be controlled despite antipyretic therapy (such as paracetamol and metamizole). Moreover, liver enzymes were increased; therefore, antipyretic drugs were stopped and intravenous cooling was performed by the Alsius Coolgard 3000®, USA. Fever was controlled, but tachypnea, tachycardia, hypertension and extensor contractions were persistent. In PSH cases that were managed in our clinic before, we observed limited episodes, including one extremity or one half of the body on the opposite side of the lesion and one half of the head on the lesion side. In this case, episodes occurred in the whole body, including four extremities and the head. We used β-blocker propranolol (160 mg d−1) and α2-agonist clonidine (0.2 mg d−1); thus, the frequency and the intensity of sympathetic episodes were diminished. It is suggested that baclofen cannot cross the blood-brain barrier efficiently when administered orally (5). Although it has been reported that oral baclofen is ineffective to treat motor spasticity in PSH, we observed that the intensity of spasticity was reduced from the Modified Ashworth Scale (MAS) 5 to MAS 2 following oral baclofen therapy (90 mg d−1) (1, 5). In conclusion, β-blocker treatment is efficient in cases that present only sympathetic hyperactivity. In severe cases like our patient, β-blockers, centrally acting α2-agonists and gamma-amino butyric acid (GABA)-B agonist baclofen should be incorporated in PSH therapy. We emphasize that oral baclofen administration could be effective to treat spasticity, contrary to the earlier reports.

A Randomized Double-Blind Placebo-Controlled Dose-Escalation Phase 1 Study of Aerosolized Amikacin and Fosfomycin Delivered via the PARI Investigational eFlow® Inline Nebulizer System in Mechanically Ventilated Patients

This clinical trial evaluated the pharmacokinetics and safety/tolerability of amikacin/fosfomycin solution using a vibrating plate nebulizer, in mechanically ventilated patients with ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP). Nine adult patients were consented to receive three escalating doses of a combination of 50 mg/mL amikacin and 20 mg/mL fosfomycin; doses were separated by 24±2 hr. On day 3, patients received two blinded, randomized treatments (amikacin/fosfomycin and volume-matched placebo), separated by 2 hr. All treatments were administered with a single-patient, multitreatment nebulizer (Investigational eFlow(®) Inline Nebulizer System; PARI Pharma GmbH, positioned in the inspiratory limb tubing between the ventilator and the patient. The nebulizer remained in-line until all treatments had been delivered. Concentrations of amikacin and fosfomycin were measured in tracheal aspirate and plasma samples obtained during the 24 hr after each dose. Fifteen minutes after dosing with the 300/120 mg amikacin/fosfomycin combination, tracheal aspirate amikacin concentrations±SD were 12,390±3,986 μg/g, and fosfomycin concentrations were 6,174±2,548 μg/g (n=6). Airway clearance was rapid. Plasma concentrations were subtherapeutic; the highest observed amikacin plasma concentration was 1.4 μg/mL, and the highest observed fosfomycin plasma concentration was 0.8 μg/mL. Administration time was approximately 2 min/mL. No adverse effects on respiratory rate, peak airway pressures, or oxygenation were observed during or following drug or placebo administration. High tracheal aspirate concentrations of amikacin and fosfomycin were achieved in mechanically ventilated patients with VAT or VAP after aerosolized administration with an inline nebulizer system. Airway clearance was rapid. No adverse respiratory effects were noted during or following drug administration.

Prevalence of microorganism and emergence of bacterial resistance in ICU of Bangabandhu Sheikh Mujib Medical University of Bangladesh

Background Antibiotic resistant bacterial nosocomial infections are a leading problem in intensive care units (ICU). Objective To study the pattern of microorganism and bacterial resistant to antibiotic in ICU of Bangabandhu sheikh Mujib Medical University of Bangladesh. Methods This retrospective study was conducted in ICU of Bangabandhu Sheikh Mujib Medical University, Bangladesh from January 2010 to December 2012. Total number of samples were 448. The samples of tracheal aspirate, blood and urine for culture and sensitivity was collected from the patient admitted in ICU. Analysis of tracheal aspirate, blood and urine culture was done from hospital record. All bacteria was identified by standard microbiological methods, and their antibiotic sensitivity was performed using disk diffusion method. Results Total number of samples 448. Samples of tracheal aspirate was 159, positive culture 121(76%), most frequent identified organism was acenetobacter 45.45%, followed by pseudomonas 32.23%, proteus 11%, klebsiella 10% and E.coli 3%, samples of blood culture was 148, positive culture 22(14.86%), most frequent identified organism was pseudomonas 63.63%, followed by acenetobacter 22.72%, salmonella 4.54% and E.coli 4.54% and samples of urine culture was 141, positive culture 36 (25.53% ) most frequent identified organism was enterococcus 22.22%, followed by acenatobacter 19.44%, candida16.66%, klebsiella 13.88% and E.coli 13.88%. Drug resistant organism of tracheal aspirate was 12(20.33%) in 2010, 2(20%) in 2011 and 13(25%) in 2012. only collistin sensitive organism identified was 28(23.14%). Conclusion From this study we concluded that most common site of infection was respiratory tract and most prevailing organism was acinetobacter &amp; pseudomonas and antibiotic resistant infection is increasing and at present around one fourth organisms were resistant to all antibiotics. DOI: http://dx.doi.org/10.3329/jbsa.v26i1.19811 Journal of Bangladesh Society of Anaesthesiologists 2013; 26(1): 20-26