Severe infection with H1N1 requiring intensive care--lessons for preparedness programmes

<p><b>INTRODUCTION</b>The influenza pandemic has generated much interest in the press and the medical world. We report our experience with 15 cases of severe novel influenza A H1N1 (2009) infections requiring intensive care. The aim of this review is to improve our preparedness for epidemics and pandemics by studying the most severely affected patients.</p><p><b>CLINICAL PICTURE</b>During the epidemic, hospitals were required to provide data on all confirmed H1N1 cases admitted to an intensive care unit (ICU) to the Ministry of Health. We abstracted information from this dataset for this report. To highlight learning points, we reviewed the case notes of, and report, the fi ve most instructive cases.</p><p><b>TREATMENT</b>There were 15 cases admitted to an ICU from July 4, 2009 to August 30, 2009. Two patients died.</p><p><b>CONCLUSIONS</b>The lessons we wish to share include the following: preparedness should include having intermediate-care facilities that also provide single room isolation and skilled nursing abilities, stringent visitor screening should be implemented and influenza may trigger an acute myocardial infarction in persons with risk factors.</p>

"Future" threat of gram-negative resistance in Singapore

The emergence of multidrug-resistant gram-negative bacteria is challenging the treatment of serious nosocomial infections. This is an international trend that is mirrored in Singapore too. Reports of strains resistant to all currently available agents have surfaced here and possibly have taken root here as well. The direst situation is among the non-fermenters, Pseudomonas aeruginosa and Acinetobacter baumannii. This is followed closely by the Enterobacteriaceae family with their array of extended-spectrum beta-lactamases, AmpC beta-lactamases and carbapenemases. There are also resistance mechanisms such as efflux pumps and porins downregulation that effect resistance against multiple classes of agents. Potentiating these developments is the dwindling "pipeline" of new agents. Hence, there is a real concern that we are running out of options for our patients. Novel antibiotic combinations, enhanced infection control, antibiotic cycling, computer-assisted programmes, and maybe in the distant future, non-antimicrobial agents is all that we have.