Utilidad del modelo 5MPB-Toledo para predecir bacteriemia en el paciente anciano / Usefulness of the 5MPB-Toledo model to predict bacteremia in the elderly patient

Resumen Objetivo: Analizar la utilidad del modelo predictivo de bacteriemia (5MPB-Toledo) en los mayores de 65 años atendidos por infección en el servicio de urgencias (SU). Material y Método: Estudio observacional prospectivo y multicéntrico de los hemocultivos (HC) obtenidos en pacientes mayores de 65 años atendidos por infección en 66 SU españoles desde el 1 de diciembre de 2019 hasta el 30 de abril de 2020. Se analizó la capacidad predictiva del modelo con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y se calculó el rendimiento diagnóstico de los puntos de corte (PC) del modelo elegido con los cálculos de la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo. Resultados: Se incluyeron 2.401 episodios de HC extraídos. De ellos, se consideró como bacteriemia verdadera a 579 (24,11%) y como HC negativo a 1.822 (75,89%). Entre los negativos, 138 (5,74%) se consideraron contaminados. Se categorizó a los pacientes en bajo (0-2 puntos), moderado (3-5 puntos) y alto (6-8 puntos) riesgo, con una probabilidad de bacteriemia de 1,2%, 18,1% y 80,7%, respectivamente. El ABC-COR del modelo tras remuestreo fue de 0,908 (IC 95%: 0,897-0,924). El rendimiento diagnóstico del modelo, considerando un PC ≥ 5 puntos, obtiene una sensibilidad de 94% (IC 95%:92-96), especificidad de 77% (IC 95%:76-79) y un valor predictivo negativo de 97% (IC 95%:96-98). Conclusión: El modelo 5MPB-Toledo es de utilidad para predecir bacteriemia en los mayores de 65 años atendidos en el SU por un episodio de infección.

Abstract Objective: To analyse a risk score to predict bacteremia (MPB5-Toledo) in the patients aged older 65 years seen in the emergency departments (ED) due to infections. Patients and Methods: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 66 Spanish ED for patients aged older 65 years seen from December 1, 2019, to April 30, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. Results: A total of 2.401 blood samples wered cultured. True cases of bacteremia were confirmed in 579 (24.11%). The remaining 1.822 cultures (75.89%) wered negative. And, 138 (5.74%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.2%, 18.1%, and 80.7%, respectively. The model´s area under the receiver ope rating characteristic curve was 0.908 (95% CI, 0.897-0.924). The prognostic performance with a model´s cut-off value of ≥ 5 points achieved 94% (95% CI: 92-96) sensitivity, 77% (95% CI: 76-79) specificity, and negative predictive value of 97% (95% CI: 96-98). Conclusion: The 5MPB-Toledo score is useful for predicting bacteremia in the patients aged older 65 years seen in the emergency departments due to infections.

Typhoid fever presenting as acute psychosis in a young adult: case report and literature review of typhoid psychosis

@#The rarity of acute psychosis in typhoid fever can result in delayed and misdiagnosis of the condition. We report a case of a 20-year-old man who presented with fever and acute psychotic symptoms. This was associated with headache, dizziness, and body weakness. There were no other significant symptoms. Neurological examination revealed reduced muscle tone of bilateral lower limbs but otherwise unremarkable. The computed tomography (CT) scan of his brain showed no abnormality. Blood specimens for microbiological culture grew Salmonella Typhi. This isolate was susceptible to chloramphenicol, ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole. He was treated with intravenous ceftriaxone for one week and responded well. He was discharged with oral ciprofloxacin for another week. The repeated blood and stool for bacterial culture yielded no growth of Salmonella Typhi.

Incidence, bacteriological profile and risk factor analysis of neonatal sepsis in a peri urban set up of North India

Background: The high incidence and antimicrobial resistance among the pathogens causing neonatal sepsis is alarming. In addition to substantial immediate mortality, survivors of infections in the neonatal period are at increased risk of long-term disability. The present study was conducted to know the bacteriological profile and risk factors associated with culture proven neonatal sepsis in a peri urban population.Methods: This study was conducted over a period of 4 year (2015-2019). On clinical suspicion, blood culture specimens were sent to microbiology laboratory. The organisms isolated from blood cultures were identified and tested for antimicrobial susceptibility. As part of infection control practices, environmental samples from the neonatal intensive care units were tested.Results: Of 907 blood cultures of neonates received in the microbiology laboratory, 20.7% were culture positive. Majority of the episodes occurred at or before 72 hours of life (81.4%). 54.3% were Gram positive cocci including Coagulase negative Staphylococci, Staphylococcus aureus and Enterococcus spp. The common Gram-negative pathogens included Escherichia coli, Klebsiella spp. and Pseudomonas spp. Common risk factors involved were preterm birth, low birth weight, premature rupture of membrane, prolonged labour and iatrogenic causes.Conclusions: The early signs of sepsis are often subtle and nonspecific. Therefore, a high index of suspicion is needed for early diagnosis. Rapid, reliable detection and appropriate case management can save lives of many new-borns.

Study of the utility of blood culture in febrile children aged between 3 months to 12 years admitted in a tertiary centre

Background: Fever, the most common complaint that led patients to seek healthcare, indicates an underlying infection which could either be simple self-limiting viral infections or life threatening bacterial infections. It's greatest challenge is the risk of occult bacteraemia, for which blood culture is the gold standard for the diagnosis. Objectives was to determine the proportion of blood culture positives among febrile children and to describe the bacteriological profile and antibiogram of blood culture isolates.Methods: A cross sectional study was done in the Department of Paediatrics and Microbiology, RIMS Hospital, Imphal. After obtaining consent (verbal assent in >7 years), blood culture samples were drawn from 200 children aged between 3 months to 12 years. The data was analysed using descriptive statistics. Chi square test was used and p-value of less than 0.05 taken as statistically significant.Results: Culture positivity was seen in 17 cases (8.5%) of which, participants who were less than 1 year of age and without proper immunisation record showed the highest positivity rate. It was higher in fever with localizing signs (9.2%) than those with fever without focus (7.8%). Gram positives constituted 11 (64.7%) of the isolates while 35.3% were Gram negatives. Staphylococcus aureus was the only Gram positive isolate. Of them, 4 were MRSA but all the strains were sensitive to Vancomycin and Linezolid. The most common Gram negative isolate was Acinetobacter spp and 80% of them were sensitive to Aminoglycosides while most of the Gram negatives were resistant to Ampicillin and 3rd generation Cephalosporins. All Acinetobacter spp were sensitive to Carbapenems but the only Pseudomonas spp isolated was sensitive only to Colistin.Conclusions: Blood culture positivity rate is relatively low in this study. However, studies with larger sample sizes are recommended to validate the findings. We emphasise the need for antibiotic stewardship

Bacteraemia in Febrile HIV Patients Hospitalized in a Tertiary Hospital in Abuja, Nigeria

Bacteraemia is significantly associated with underlying Human Immunodeficiency Virus (HIV) infection and is often life-threatening. Streptococcus pneumoniae, non- typhoidal salmonella (NTS), Staphylococcus aureus and Escherichia coli have been shown in various studies to be common organisms that cause bacteraemia in HIV patients in other parts of Sub Saharan Africa (SSA). Methods: The study was a cross sectional analytical study carried out on febrile HIV infected adults who were admitted into the medical wards of the University of Abuja Teaching Hospital (UATH), North Central Nigeria. Blood cultures and other relevant laboratory investigations were carried out on admission. The patients were followed up for a period of one month and outcome thereafter was evaluated. Results: A total of 145 HIV positive patients with a mean age of 37.5 years (range 18-75 yrs.) were studied. The prevalence of bacteraemia was found to be 28.3%. The common causative pathogens were Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumonia, with Streptococcus pneumoniae being the most common isolate. Mortality was higher in the bacteremia group (51.2%) compared to the non bacteraemic group (32.7%) [P-value = 0.04] as well as among those with severe immunosuppression (96.4%) compared to those with CD4 cell counts above 200 cells /ml (3.6%)[p-value=0.004]. Conclusion: Bacteremia is common among febrile HIV patients presenting at the University of Abuja Teaching Hospital and it is associated with a high mortality rate. Streptococcus pneumoniae is the commonest causative organism.

Bacteraemia in Haematopoietic Stem Cell Transplant Recipients in a Single Tertiary Referral Centre

@#Bacteraemia is a common and one of the serious complications in haematopoietic stem cell transplantation (HSCT). To date, there are no published data on antibiotic resistance and clinical outcome among HSCT recipients in Malaysia. The aims of the present study was to analyse the prevalence, antibiotic resistance and clinical outcome of bacteraemia in HSCT recipients within 100 days following transplantation. We retrospectively analysed the prevalence, antibiotic resistance pattern and mortality rate of early bacteraemia among HSCT recipients in a single centre over a 5-year period (2013-2017). Thirty patients of 85 HSCT recipients developed bacteraemia with 40 positive cultures resulting in prevalence of 47% (40/85). Gram negative bacteria (GNB) accounted for 60.5% of total isolates. Enterobacteriaceae and Coagulase negative Staphylococcus (CoNS) were the commonest pathogens isolated. GNB showed a high resistance rate to ciprofloxacin. Only 30% of recipients responded to first line empirical antibiotics for febrile neutropenia (FN). The mortality rate was 13.3% (4/30), of which 50% was attributed to multi-drug resistance (MDR) Acinetobacter and 25% to extended spectrum beta-lactamase (ESBL) Enterobacteriaceae. Bacteraemia is a frequent and life-threatening early complication among HSCT recipients with MDR GNB being the commonest cause of mortality. The high rate of resistance to ciprofloxacin and failure of the first line empirical antibiotics to treat FN calls for a thorough evaluation of the current antibiotic prophylaxis and empirical treatment protocols. These findings have important clinical implications regarding the use and selection of both prophylactic and empiric antibiotic regimens to treat FN.

Anti-inflammatory actions and Salmonella typhimurium-bacteraemia clearance by methanol extract of Curcuma longa Linn. (Turmeric)

Aims@#Rhizome of turmeric is known to possess therapeutic activities and has been used in medical practice as an anti-diabetic, hypolipidemic, hepatoprotective, anti-diarrheal, and anti-asthma agent. This study was designed to investigate the anti-inflammatory and antimicrobial activities of Curcuma longa. @*Methodology and results@#Rhizomes of Curcuma longa (Turmeric) purchased from markets in Ado-Ekiti, Nigeria, were analysed for anti-inflammatory and anti-microbial properties, as well as phytochemical constituents. The in vitro anti-inflammatory activities of the C. longa methanol extract (CLME) were evaluated by albumin denaturation, proteinase inhibitory activity, membrane stabilization, and anti-lipoxygenase activity, at different concentrations using Aspirin, Diclofenac sodium and Indomethacin as standard drugs. The in vitro antimicrobial activities of CLME were carried out on five pathogenic microbes namely Escherichia coli ATCC 29929, Staphylococcus aureus ATCC 29293, Salmonella typhimurium ATCC 14028, Klebsiella pneumoniae ATCC 4252 and Candida albicans ATCC 10231, using both agar well diffusion and broth dilution techniques. A S. typhimurium infected rat model was used for in vivo antimicrobial studies. Phytochemical analyses showed that C. longa rhizomes contain high concentrations of alkaloids, flavonoid and saponins, with moderate levels of phenols, tannin and ferric reducing antioxidant power. CLME was found to be rich in alkaloids, tannins, phenols, steroids, saponins, terpenoids, flavonoids and reducing sugars. CLME showed potent anti-inflammatory activities, and the results compared favourably with the standard anti-inflammatory drugs used. C. longa methanol extract significantly inhibited albumin denaturation and proteinase activity, stabilized membrane of red blood cell from haemolysis in heat and hypotonic conditions, as well inhibited lipoxygenase activity; all of which are associated with inflammatory processes. CLME was found to possess high in vitro antimicrobial activities against the five microorganisms tested. Rats orally infected with S. typhimurium, demonstrated bacteraemia five days post infection, with a total clearance of bacteraemia within 3-5 days following oral administration of CLME. The infected rats treated with CLME equally showed significant improvement in some haematological indices compared to infected rats that were not treated with CLME. @*Conclusion, significance and impact of study@#The results also showed that methanol extract of C. longa rhizome effectively cured with S. typhimurium infected rats. The overall results suggest that Curcuma longa is a potential source of anti-inflammatory and antimicrobial agents.

Molecular characterisation for clonality and transmission dynamics of an outbreak of Klebsiella pneumoniae amongst neonates in a tertiary care centre in South India

Purpose: Sepsis is a significant cause of morbidity and mortality amongst neonates. Klebsiella pneumoniae is a common cause of nosocomial outbreaks causing bacteraemia and having potential of acquiring plasmids enhancing antimicrobial resistance. In the present study, we investigate K. pneumoniae outbreak causing bacteraemia amongst neonates over a span of 2 months. Isolates were characterised for antimicrobial resistance, virulence, molecular typing for clonality and plasmid typing for transmission dynamics, and patient outcome was investigated. Methods: Thirteen isolates of K. pneumoniae were obtained during October–November 2016. Antimicrobial susceptibility testing was performed, and multiplex polymerase chain reaction (PCR) for ?-lactamases and PCR for ompK35 and ompK36 were performed. To study hypervirulence, string test and PCR for rmpA and rmpA2 were performed. Multilocus sequence typing and Inc plasmid typing were carried out to study transmission dynamics. Results: Amongst 13 isolates, all isolates harboured blaSHVand blaTEM; 12 isolates carried blaCTX-M-1. ompK35 was present in all, but ompK36 was absent in 12 isolates. Ten isolates belonged to ST48, 6 amongst which contained IncFII (K) plasmid. One isolate each belonged to ST29, ST111 and ST2647 (novel clone). None of the isolates was hypervirulent. Conclusion: Extended-spectrum ?-lactamase K. pneumoniae is commonly seen in Indian hospitals and main mechanisms being production of SHV, TEM and CTX-M enzymes as seen in the present study. Outer membrane porins contribute significantly to antimicrobial resistance. Emergence of new clones such as ST2647 implies continuous evolution of the organism and also potential for rapid genetic recombination leading to multidrug resistance. Outbreaks amongst neonates lead to fatal outcome, and stringent hospital infection control is necessary.

Cuantificación de citoquinas y su relación con la presencia de bacteriemia en leucemias agudas y neutropenia febril postquimioterapia / Quantification of cytokines and their relationship with the presence of bacteraemia in acute leukaemia and febrile neutropenia after chemotherapy

Resumen Objetivo: En pacientes con leucemia aguda y neutropenia febril, describir el comportamiento de varias citoquinas y su relación con la presencia de bacteriemia mediante la medición de interleuquinas1ß， 6, 8,10,12p70 y factor de necrosis tumoral (TNF) en cuatro tiempos. Métodos: Se almacenaron muestras de plasma obtenidas al momento del diagnóstico de la neutropenia, al inicio de la fiebre y a las 24 y 48 horas posteriores, las cuales se conservaron a -70 °C y luego se descongelaron para su procesamiento mediante citometría de flujo. Se utilizaron medianas junto con sus correspondientes medidas de dispersión. Resultados: No hubo ningún reporte de muerte al egreso. La tasa de hemocultivos positivos fue 25% similar a lo revisado en la literatura, con predominio del aislamiento de gérmenes Gram negativos. Las IL10 y 6 mostraron mayor porcentaje de variación durante el momento de la fiebre, comparando el grupo de bacteriémicos con el de no bacteriémicos. Las IL1, IL12p70 y TNFa arrojaron niveles séricos por debajo del límite de detección de la prueba. Conclusiones: Las citoquinas podrían cumplir un papel promisorio en el seguimiento de los pacientes neutropénicos febriles, dada la potencial asociación con presencia de bacteriemia, desenlace bien conocido como predictor de morbilidad y mortalidad en esta población. Sin embargo, se requieren más estudios con mayor población para definir una recomendación.

Abstract Objectives: To describe the properties of several cytokines and their relationship with the presence of bacteraemia by measuring interleukins1ß, 6, 8,10,12p70, and tumour necrosis factor (TNFa) at four different times in patients with acute leukaemia and febrile neutropenia. Methods: Plasma samples were obtained on diagnosis of neutropenia, at the onset of fever, and at 24 hours and 48 hours thereafter. They were stored at -70° C and then thawed for processing by flow cytometry. Medians were used along with their corresponding dispersion measurements. Results: There were no reports of death at discharge. The rate of positive blood cultures was 25%, which was similar to that reviewed in the literature, with predominance of the isolation of Gram negative bacteria. Interleukins 10 and 6 showed a higher percentage of variation during the time of fever on comparing the bacteraemia group with the non- bacteraemia group. IL1, IL12p70, and TNF a 士showed serum levels below the detection limit of the test. Conclusions: Cytokines could play a promising role in the monitoring of febrile neutropenic patients, given the potential association with the presence of bacteraemia, an outcome well known as a predictor of morbidity and mortality in this population. However, more studies with a larger population are required to define a clear recommendation in the management guidelines for febrile neutropenia after chemotherapy.

Influencia en la evolución de los pacientes con bacteriemia/candidemia de la participación activa del especialista clínico en Patología Infecciosa. Estudio de una cohorte prospectiva / The impact of Infectious Disease specialist active care on the outcome of patients with bacteraemia/candidemia. A prospective cohort study María Encarnación Hernández Contrerasa

Introducción: Nuestro objetivo es evaluar el impacto de la participación activa del especialista en Patología Infecciosa en el pronóstico de los enfermos con bacteriemia/candidemia. Pacientes y métodos: Estudio observacional, longitudinal y prospectivo de una cohorte de pacientes con bacteriemia/candidemia en un hospital de tercer nivel (2010-2011). Se analizaron los factores asociados con fracaso terapéutico (persistencia de la bacteriemia/candidemia o muerte relacionada) mediante análisis bivariante y multivariante. Resultados: Se valoraron un total de 324 episodios de bacteriemia/candidemia significativa, de los que en 252 pacientes (78%) el Servicio de Medicina Interna Infecciosas aplicó un sistema de participación activa (recomendación sobre el tratamiento antibiótico). La adquisición de la bacteriemia se consideró nosocomial o relacionada con cuidados sanitarios en 154 pacientes (47,5%) y comunitaria en 170 (52,5%). Los focos de infección más frecuentemente identificados fueron: urinario (31%), catéter vascular (14%), intraabdominal (12%) y desconocido (15%). El 31,6% era portador de sonda vesical y el 35,4%, de catéter venoso central. El 24% de los pacientes no presentaban fiebre (>38 °C) en el momento de cursar los hemocultivos. La bacteriemia fue persistente en 35 pacientes (11%). La mortalidad global fue del 17,4% y del 15% relacionada ("fracaso" terapéutico, 20%). Se asociaron a un mayor fracaso terapéutico el índice de Pitt ≥ 3 (OR 7,94), McCabe III (OR 3,11), uso previo de antibióticos (OR 2,93) y la ausencia de participación activa de los especialistas clínicos en Patología Infecciosa (OR 2,44). Conclusiones: En la cohorte de pacientes con bacteriemia/candidemia estudiada, la gravedad de la enfermedad de base, la gravedad al inicio, el uso previo de antibióticos y la ausencia de participación activa de los especialistas clínicos en Patología Infecciosa se asociaron a fracaso terapéutico.

Introduction: Our objective is to evaluate the impact of active care by an Infectious Diseases specialist (IDS) on the outcome of patients with bacteraemia/candidemia. Patients and methods: Observational, longitudinal and prospective study of a cohort of patients with bacteraemia/candidemia in a tertiary level hospital (2010-2011). Factors associated with treatment failure (persistent bacteraemia or related death) were analysed (bivariate and multivariate analysis). Results: A total of 324 episodes of bacteraemia were included, of which surveillance by IDS was implemented in 252 cases (78%). Acquisition was considered nosocomial or healthcare-related in 154 patients (47.5%) and community acquired in 170 (52.5%). More frequent sources of bacteraemia were urinary tract (31%), vascular catheter (14%), intra-abdominal (12%); and unknown (15%); 31.6% had a urinary catheter and 35.4% had a central venous catheter. When blood cultures were processed, 24% of patients had no fever (> 38 °C). Bacteraemia was persistent in 35 patients (11%). Overall mortality was 17.4% and 15% related (therapeutic "failure", 20%). Failure was associated with Pitt ≥ 3 (OR 7.94), McCabe III (OR 3.11), previous use of antibiotics (OR 2.93) and no active care by IDS (OR 2.44). Conclusions: In our study cohort, severity at presentation, underlying medical conditions, previous antibiotic use and no active Infectious Diseases specialist care were statistically associated with mortality or microbiological failure.

Experiencia clínica con infecciones causadas por Klebsiella pneumoniae productora de carbapenemasa, en una institución de enseñanza universitaria en Medellín, Colombia / Clinical experience with infections caused by carbapenemase-producing Klebsiella pneumoniae in a tertiary care teaching institution in Medellin, Colombia

Antecedentes: Las infecciones por Klebsiella pneumoniae productora de carbapenemasa (KPC) son un problema de salud pública mundial. Desde 2008 nuestra institución experimenta casos endémicos de infecciones por KPC posteriores a un brote cuyo caso índice fue un paciente de Israel admitido para trasplante hepático. Objetivo: Describir características clínicas y mortalidad en pacientes hospitalizados con infecciones nosocomiales por KPC. Métodos: Estudio observacional retrospectivo, descriptivo. Resultados: Un total de 52 pacientes fueron incluidos, la edad media fue 45,7 ± 27 años, 65,4% fueron hombres. Uso de inmunosupresores, cirugía gastrointestinal, hepatopatía crónica y trasplante de órgano sólido fueron las comorbilidades importantes. El 100% recibió antibióticos antes de la infección por KPC. Las principales infecciones fueron bacteriemia (30,7%), infección intraabdominal (23,1%) y neumonía (17,3%). El tratamiento fue dirigido por antibiograma en 50,7%. Tigeciclina fue administrada en el 51,9% y colistina en el 32,7%, ambas en terapia combinada con otros antibióticos. En el 15,4% se utilizó tigeciclina más colistina. La duración del tratamiento fue 15,7 ± 7,5 días. El 51,9% desarrolló bacteriemia y falla renal aguda y el 76,9% requirió atención en UCI. La mortalidad fue 48,1% y fue significativamente mayor en pacientes con bacteriemia vs. sin bacteriemia (74,1 vs. 20%; p = 0,01). No hubo diferencias significativas en mortalidad cuando se comparó uso de tigeciclina vs. colistina (45 vs. 52%; p = 0,609). Conclusión: La inmunosupresión, cirugía gastrointestinal, tratamiento previo con antibióticos y estancia en UCI son factores importantes para la infección por KPC. La mortalidad es alta a pesar de la terapia dirigida, especialmente en pacientes con bacteriemia.

Background: Carbapenemase-producing Klebsiella pneumoniae (KPC) infections are a worldwide public health problem. Since 2008, our institution has experienced endemic cases of KPC infection after an outbreak whose index case was a patient from Israel admitted for liver transplantation. Objective: To describe the clinical characteristics and mortality of inpatients with nosocomial KPC infections. Methods: Retrospective, descriptive observational study. Results: A total of 52 patients were included, with an average age of 45.7 ± 27 years; 65.4% were men. Use of immunosuppressants, gastrointestinal surgery, chronic liver disease and solid organ transplantation were significant comorbidities. All the patients had received antibiotics before the KPC infection. The primary infections were bacteraemia (30.7%), intra-abdominal infections (23.1%) and pneumonia (17.3%). Treatment was directed by antibiogram in 50.7% of cases. Tigecycline was administered in 51.9% of cases and colistin in 32.7%, both in combination therapy with other antibiotics. Colistin plus tigecycline was used in 15.4% of cases. The treatment duration was 15.7 ± 7.5 days, with 51.9% of patients developing bacteraemia and acute renal failure and 76.9% requiring ICU care. Mortality was 48.1% and was significantly higher in the patients with bacteraemia compared with those without (74.1 vs. 20%, respectively, p = 0.01). There were no significant differences in mortality between tigecycline and colistin use (45 vs. 52%, respectively, p = 0.609). Conclusion: Immunosuppression, gastrointestinal surgery, previous treatment with antibiotics and ICU stay are important factors for infection with KPC. Mortality is high despite targeted therapy, particularly in patients with bacteraemia.

Community-acquired bacteremia in Paediatrics:Epidemiology, aetiology and patterns of antimicrobial resistance in a tertiary care centre, Malaysia

Introduction: bacteremia continues to be one of the major causes of morbidity and mortality despite the existence of numerous antimicrobial agents. this study aimed to provide a Malaysian perspective on paediatric community-acquired bacteraemia based on the documentation of epidemiology and antimicrobial profile of the isolated pathogens. Method: A retrospective study was conducted by analysing clinical details, blood cultures and antimicrobial susceptibility testing results in children between the ages of 0 to 13 years old, who were admitted to selayang Hospital over an 11-year period from 2001 until 2011. there were 222 bacteraemia cases and the median age was 11.7 months. the highest number (39%) of bacteraemia cases occurred between ages one month to one year. the three most commonly isolated aetiological agents were Staphylococcus aureus (17.1%), nontyphoidal Salmonella (16.2%), and Streptococcus pneumoniae (12.6%). Almost 8% of the Staphylococcus aureus isolates were methicillin resistant, while nontyphoidal Salmonella (Nts) isolates demonstrated 18.4%, 10.5% and 2.6% resistance towards ampicillin, trimethoprim-sulfamethoxazole and ciprofloxacin respectively. All Nts isolates were sensitive to ceftriaxone. Streptococcus pneumoniae isolates showed 17.9% resistance to penicillin. skin and soft tissue infections as well as lower respiratory tract infections (63.2%) were the main foci of infections in Staphylococcus aureus bacteraemia. Acute gastroenteritis (80.0%) and pneumonia (60.8%) were the main presentations of Nts and Streptococcus pneumoniae bacteraemia respectively. Overall mortality rate was 8.1%. Conclusion: Knowledge on the local epidemiology and antibiotic resistance pattern serves as a significant platform in improving the empiric antibiotic therapy for patients with community acquired bacteraemia.

Role of blood culture in critically sick paediatric patients and its clinical impact: a tertiary care hospital based study.

Background: Blood cultures form a critical part of evaluation of patients with suspected sepsis. The present study was undertaken to study the risk factors, duration of incubation for obtaining positive cultures, and the clinical impact of the culture report. Methods: A total of 224 samples from 110 critically sick pediatric patients presenting with suspected bacteraemia were processed aerobically. Results: Cultures were positive in 25.45% of the Patients. Most of the positive cultures were obtained after 24 hours of incubation of the broth and no isolates were obtained beyond day 4 of incubation. Therapy was modified in 52.73% of the patients after receipt of culture report. Conclusions: Incubation beyond four days (unless with specific indication like enteric fever) may be unnecessary for issuing a negative culture report. Repeated isolation of doubtful pathogens confirms true bacteraemia. Early culture report increases therapeutic compliance.

Profi le of fatal Streptococcal bacteraemia at a tertiary care Indian hospital.

Streptococcus pyogenes causes mild to acutely life-threatening diseases. Herein, we report our experience with fi ve cases of fatal bacteraemia due to various groups of Streptococci, three of them due to Group G Streptococcus and one case each due to Group A Streptococcus and Group F Streptococcus. The peculiarity of all these cases was the rapidity of deaths occurring in these patients despite all the strains being sensitive to Penicillin. Hence, timely intervention in all suspected cases is strongly advocated. All isolates of beta-haemolytic Streptococci should be identifi ed up till the species level and antimicrobial susceptibility be performed so that proper and early management can be done.

Sphingomonas paucimobilis bacteraemia and shock in a patient with rheumatic carditis.

Acute rheumatic fever (ARF) carditis is treated with steroids, which can cause changes in the cellular immune response, especially decreased CD3 (+) T cells. Nosocomial infections due to steroid use for treatment of ARF carditis or secondary to the changes in the cellular immune response have not been reported in the literature. Sphingomonas paucimobilis is a Gram‑negative bacillus causing community‑ and hospital‑acquired infections. It has been reported as causing bacteraemia/sepsis, pneumonia or peritonitis in patients with malignancies, immunosuppression or diabetes. We present a case with S. paucimobilis bacteraemia/sepsis and shock after administration of steroids for treatment of ARF carditis. We suggest early identification of the causative agent and appropriate adjustments of the treatment plan to avoid shock and possible mortality. This is the first reported case of S. paucimobilis bacteraemia/sepsis in the setting of steroid use for ARF carditis.

Morbidity pattern in hospitalized under five children with sickle cell disease.

Background & objectives: Children with sickle cell disease require more frequent hospital care and younger children (<5 yr of age) are more vulnerable to mortality. There are limited data on the events leading to hospitalizations and death in younger children with sickle cell disease from India. This study was, therefore, undertaken to evaluate the morbidity pattern in hospitalized under five children with sickle cell disease in a tertiary care hospital in Maharashtra, India. Methods: This was a prospective observational study carried out from July 2007 to June 2009. Hospitalized children below five years of age with sickle cell disease were enrolled for the study and evaluated for morbid event/s leading to hospitalization. Haematological indices were noted at baseline (most recent past when patient was not acutely sick) and at the time of hospitalization. Results: Eighty five children with sickle cell disease were hospitalized during the study period. Hospitalization with acute febrile illness (31%) was the most common morbid event followed by severe anaemia (30%) and acute painful events (20%). Majority (62%) of the events occurred between August and October. Forty five patients had foetal haemoglobin (HbF) more than 20 per cent (26.80±4.81%) and morbidity was significantly less in these patients. Interpretation & conclusion: Acute febrile illness was the most common morbid event followed by severe anaemia and acute painful event hospitalized children with sickle cell disease. There was significant seasonal variation with maximum events occurring in the monsoon season.

Factors influencing the early mortality in haematological malignancy patients with nosocomial Gram negative bacilli bacteraemia: a retrospective analysis of 154 cases

BACKGROUND: The aim of this study is to assess the factors influencing the early mortality (7- day after index blood culture) in haematological malignancy patients with Gram negative bacilli (GNB) bacteraemia. METHODS: Infection control committee records were reviewed to identify the cases between March 2006 and June 2011. Only one bacteraemic episode per patient was included in the study. RESULTS: A total of 154 patients with GNB bacteraemia were identified. The early mortality rate was 19.5% (30 out of 154). Blood cultures revealed Enterobacteriacea in 120 patients (Escherichia coli; 86, Klebsiella spp.; 28, Enterobacter cloacea; 6) and glucose non-fermenting GNB in 34 patients (Pseudomonas aeruginosa; 15, Acinetobacter baumannii; 11, Stenotrophomonas maltophilia; 7, Burkholderia cepacia; 1). Forty (33.3%) out of 120 Enterobacteriaceae were extended spectrum beta-lactamase (ESBL) producers and 18 (52.9%) out of 34 glucose non-fermenting GNB were multidrug resistant. Carbapenems were administered as first line therapy in 139 out of 154 patients. In univariate analysis Pitt's bacteraemia score, presence of aplastic anaemia, bacteraemia caused by glucose non-fermentating GNB, inappropriate empirical antibacterial treatment, presence of severe sepsis or septic shock, unable to achieve microbiological cure, and intensive care unit (ICU) acquired bacteraemia were associated with mortality. Multivariate analysis showed ICU acquired bacteraemia (OR, 12.55; 95% CI, 2.34-67.38, p = 0.003) as an independent factor associated with early mortality. CONCLUSION: Haematological malignancy patients who require ICU care are at high risk for early mortality related to GNB bacteraemia. Based on the local findings pointing out high rate of multidrug resistance, carbapenems combined with colistin seems to be a reasonable approach as empirical treatment of these patients. However, increasing carbapenem resistance rate is of concern.

Bacteriemia por Shigellaflexneri serotipo 6 en pacientes con SIDA: Presentación de dos casos clínicos / Bacteraemia due to Shigella flexneri serotype 6 in two patients with AIDS

Infections due to Shigella usually remain localized to the digestive tract and are self-limited. Bacteremia is a potentially lethal complication that can occur in immunocompromised patients. We describe two episodes of bacteremia caused by Shigella in two adults with AIDS. In both patients, S. flexneri was recovered from stool and blood samples. The isolates belonged to serotype 6, were resistant only to trimethoprim-sulfamethoxazole and showed a similar band profile by pulsed-field gel electrophoresis. Patients received prolonged antimicrobial treatment with a favorable outcome. There were no cases of diarrhea in other individuals admitted to the emergency room. We hypothesized that patient No. 2 was infected at the hospital from patient No. 1. However, we could not establish the way of transmission. Although rare, it is important to take into account the possible occurrence of bacteremia due to Shigella or other bacterial enteropathogens in immunocompromised patients with diarrhea.

Las infecciones por Shigella spp., en general, permanecen localizadas en el tracto digestivo y tienen una evolución autolimitada. La bacteriemia es una complicación potencialmente letal que ocurre en pacientes con algún tipo de inmunocompromiso. Presentamos dos casos de bacteriemia causadas por Shigella en dos adultos con SIDA. En ambos pacientes, se recuperó Shigella flex-neri en muestras de deposiciones y sangre. Los aislados correspondieron al serotipo 6, fueron resistentes sólo a cotrimoxazol y mostraron un perfil de bandas similar por PFGE. Los pacientes recibieron tratamiento antimicrobiano prolongado y la evolución fue favorable. No se registraron otros casos de diarrea en individuos admitidos en el servicio de emergencia. La hipótesis fue que el paciente 2 adquirió la infección en el hospital a partir del paciente 1. Sin embargo, no pudimos establecer el modo de transmisión. Aunque poco frecuente, es importante tener presente la ocurrencia de bacteriemia por Shigella spp. o por otros enteropatógenos bacterianos en pacientes inmunocomprometidos con diarrea.

A Multicentre Study about Pattern and Organisms Isolated in Follow-up Blood Cultures / 대한임상미생물학회지

BACKGROUND: This study analysed patterns of requests for repeated blood cultures and the microorganisms isolated in follow-up cultures. METHODS: The frequencies and intervals of repeated blood cultures performed during January and February of 2010 at seven university-affiliated hospitals in Korea were evaluated. Results of microbiological cultures at follow-up were analysed with respect to pathogen replication, immune clearance, appearance of new pathogens, and skin contaminants. RESULTS: Among 3,072 patients who received repeated blood cultures, the average number of requests was 3.2. Of the 5,241 follow-up blood culture events recorded, durations of 1, 2, and 3 days between cultures were identified for 23.1%, 21.4%, and 15.0% of events, respectively. Relative to each initial culture, persistent pathogen growth in subsequent culture(s) accounted for 2.3% of events, whereas immune clearance was confirmed in 8.5% of events. Previously undetected pathogens were isolated in 5.2% of the follow-up cultures, the majority of which grew after an interval of six days. Skin contaminants were detected in 7.6% of the repeated cultures, and 76.1% of the follow-ups displayed no growth of microorganisms. CONCLUSION: The most common numbers of repeat culture requests were two and three, and these were typically performed within three days of the initial culture. Among the follow-up cultures, new pathogens were identified in 5.2%, and the majority of this group likely presented for follow-up during a new disease episode.

Peritonitis bacteriana espontánea asociada a bacteriemia por Vibrio cholerae no O1, no O139 / Spontaneous bacterial peritonitis associated with Vibrio cholerae non-O1, non-139 bacteremia

Vibrio cholerae is a Gram-negative bacilli with curved, comma shape that belongs to the family Vibrionaceae. The antigenic structure consists of a flagellar H antigen and a somatic O antigen (used to classify V cholerae in various serogroups). Serogroups 01 and 0139 have caused epidemics of cholera. Vibrio cholerae non-01 non-139 has been isolated from patients with bacteremia, acute secretory diarrhea, dysentery, abdominal pain, nausea, vomiting, fever and cellulitis. Invasive forms such as meningitis, spontaneous bacterial peritonitis (SBP) and encephalitis are uncommon. Immunosuppression and cirrhosis are risk factors for developing invasive disease. This case report describes a cirrhotic patient from Salta, Argentina, consulting for abdominal pain and fever. He was diagnosed with SBP and Vibrio cholerae non-01 non-139 bacteremia. He received antibiotic treatment with third generation cephalosporins for fourteen days with favorable clinical outcome.

Vibrio cholerae es un bacilo gramnegativo, curvo y móvil, perteneciente a la familia Vibrionaceae, que presenta antígenos flagelares H y somático O; este último permite clasificarlo en numerosos serogrupos. Los serogrupos O1 y O139 han causado epidemias de cólera. Vibrio cholerae serogrupo no O1, no O139 es no aglutinable con el antisuero específico y se manifiesta clínicamente como bacteriemias, diarrea acuosa, disentería, dolor abdominal, náuseas, vómitos, fiebre y celulitis. Raramente se describen formas invasoras tales como meningitis, peritonitis bacteriana espontánea (PBE) y cerebritis, entre otras. Dentro de los factores de riesgo para desarrollar enfermedad invasora se encuentran la inmunodepresión y la cirrosis hepática. Comunicamos el caso de un paciente procedente de la provincia de Salta, Argentina, con antecedentes de cirrosis hepática, que consulta por dolor abdominal y fiebre, en el que se diagnóstica PBE asociada a bacteriemia por Vibrio cholerae no 01, no 0139. Recibió tratamiento con cefalosporinas de tercera generación iv, por catorce días con una evolución clínica favorable.