Prevalence of multidrug-resistant Gram-negative bacteria from blood cultures and rapid detection of beta-lactamase-encoding genes by multiplex PCR assay

Introduction This study aimed to determine the prevalence of multidrug-resistant Gram-negative bacteria (GNB) from blood cultures in a tertiary-care hospital and the multiplex PCR assay's ability to detect resistance genes. Methods A total of 388 GNB isolates obtained from hospitalized patients between November 2019 and November 2021 were included in the study. Antimicrobial susceptibility testing was done by VITEK 2 system and broth microdilution method. Beta-lactamase-encoding genes were detected by multiplex PCR assays, BioFire-Blood Culture Identification 2 (BCID2) panel (bioMerieux, France). Extended-spectrum beta-lactamases (ESBLs) were detected phenotypically with VITEK AST-GN71 card (bioMerieux, France). The isolates of GNB were classified into multidrug-resistant, extensively-drug-resistant, and pandrug-resistant categories, and their prevalence and distribution in different wards, including coronavirus diseases 2019 (COVID-19) intensive care units (ICU), were calculated. Results Results revealed that all isolates of Acinetobacter baumannii and Pseudomonas aeruginosa were multidrug-resistant as well as 91.6% of Enterobacter cloacae, 80.6% of Proteus mirabilis, and 76.1% of Klebsiella pneumoniae, respectively. In fermentative bacteria, blaOXA-48-like (58.1%), blaNDM (16.1%), blaKPC (9.7%) and blaVIM (6.5%) genes were detected. More than half of Enterobacter cloacae (58.3%) and Klebsiella pneumoniae (53.7%) produced ESBLs. Among non-fermenters, the blaNDM gene was carried by 55% of Pseudomonas aeruginosa and 19.5% of Acinetobacter baumannii. In the COVID-19 ICU, Acinetobacter baumannii was the most common isolate (86.1%). Conclusions This study revealed high proportions of multidrug-resistant blood isolates and various underlying resistance genes in Gram-negative strains. The BCID2 panel seems to be helpful for the detection of the most prevalent resistance genes of fermentative bacteria.Copyright © GERMS 2022.

Secondary Infections in Patients with Extremely Severe COVID-19 During ECMO Therapy.

Up to 70% of patients hospitalized for COVID-19 need respiratory support, up to 10% need high-flow oxygen therapy, non-invasive and invasive ventilation. However, standard methods of respiratory support are ineffective in 0.4-0.5% of patients. In case of potentially reversible critical refractory respiratory failure that patients may require ECMO. Management of patients with extremely severe COVID-19 associates with numerous clinical challenges, including critical illness, multiple organ dysfunction, blood coagulation disorders, requiring prolonged ICU stay and care, use of multiple pharmacotherapies including immunosuppressive drugs. Pharmacological suppression of immunity is associated with a significant increase in the risk of secondary bacterial and fungal infections. Currently, data on epidemiology of secondary infections in patients with COVID-19 undergoing ECMO is limited. Aim. To study the prevalence and etiology of secondary infections associated with positive blood cultures in patients with extremely severe COVID-19 requiring ECMO. Materials and methods. A single-center retrospective non-interventional epidemiological study including 125 patients with extremely severe COVID-19 treated with ECMO in April 2020 to December 2021. Results. Out of 700 blood culture tests performed in 125 patients during the study, 250 tests were positive confirming bacteremia/fungemia. Isolated pathogens varied depending on the duration of ECMO: gram-positive bacteria (primarily coagulase-negative staphylococci) dominated from the initiation of ECMO support;increased duration of ECMO associated with an increasing the proportion of pathogens common in ICU (Klebsiella pneumoniae and/or Acinetobacter baumannii with extensively drug resistant and pan-drug resistant phenotypes, and vancomycin-resistant Enterococcus faecium). When ECMO lasted more than 7-14 days, opportunistic pathogens (Candida species, Stenotrophomonas maltophilia, Providencia stuartii, non-diphtheria corynebacteria, Burkholderia species and others) prevailed as etiological agents. Conclusion. Longer duration of ECMO resulted in increasing the rates of infectious complications. In patients undergoing ECMO for more than 14 days, the microbiological landscape becomes extremely diverse, which hampers choosing an empirical antimicrobial therapy. Since potential pathogens causing secondary infections in patients during ECMO are difficult to predict, rapid identification of rare opportunistic pathogens and their sensitivity profile, followed by targeted administration of antimicrobials, seems most beneficial.Copyright © 2023, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved.

EFFECT OF HIGH- VS LOW-DOSE OF DEXAMETHASONE ON INCIDENCE OF HOSPITAL-ACQUIRED INFECTIONS IN ACUTE HYPOXEMIC RESPIRATORY FAILURE IN SARS COV-2 PNEUMONIA

SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: To compare the incidence of hospital acquired infections (HAI) in patients treated with systemic corticosteroids (dexamethasone or equivalent alternative corticosteroid) with high (> 10 mg/day) vs low (6 mg/day) dose for COVID-19 related acute hypoxemic failure METHODS: Observational cohort study of COVID-19 patients from July 25 and Oct 1, 2021 at a tertiary care hospital. 227 hospitalized patients were positive for COVID-19. 168 patients were included in the analysis. Corticosteroid type and dose was analyzed. Comparison of high vs low dose cohorts was done. Primary outcome measure was incidence of HAI in each group. Bloodstream Infections (BSI), Hospital Acquired Pneumonia (HAP) and Urinary Tract Infections (UTI) were included. Secondary measures were number of patients requiring intubation, length of ICU stay and inpatient mortality. Descriptive statistics were used to compare variables between cohorts including body mass index (BMI), severity of illness (SOFA and modified SOFA scores) and glucose control RESULTS: Of 168 patients: 68 (40%) received high dose (> 10 mg dexamethasone) & 100 patients (60%) received low dose (6 mg dexamethasone) corticosteroids. High vs Low dose: Demographics: Age (57 vs. 64 years;p 0.21), sex (51% vs. 57% female;p 0.77) & chronic comorbidities including BMI (29.2 vs 33.1;p 0.45). Severity of illness scores at day of corticosteroid use were similar (SOFA 4.7 vs 4.1;p 0.71 & mSOFA 2.6 vs 2.3;p 0.07) despite difference in rates of patients that required intubation (56% vs 18%;p<0.001). 45% of intubated died in high dose compared to 18% in low dose group. Overall mortality was 29.4% vs 11%;p 0.011. Glucose control (insulin > 50 u/day) was worse in high dose group (35% vs 14%;p<0.01). Baricitinib or tocilizumab used in 60% vs 44% of intubated;p0.62). HAI data: BSI- High dose 18/68 (26.5 %) vs low dose group 13/10 (13%);p 0.07. UTI-High dose 4/68 (6%) vs low dose group 5/100 (5%);p 1.00. HAP-High dose 27/68 (39.7%) vs low dose group 11/100 (11%);p <0.001. High dose group HAP > 1 organism: 15/27 (MSSA 44%, Aspergillus 18%, MRSA 18%, Streptococcus 26%, Pseudomonas 18%, rest were Enterobacter, H Influenzae, Acinetobacter, Serratia, E coli, Klebsiella, Providencia and Citrobacter species at 3% each). Low dose group HAP > 1 organism: 2/11 (Streptococcus 36%, MSSA 27%, H Influenzae 18%, rest were pseudomonas, E coli, stenotrophomonas and acinetobacter species) CONCLUSIONS: In hospitalized COVID-19 patients with acute respiratory failure, high dose dexamethasone use was associated with significantly higher HAP rates compared to low dose dexamethasone. Moreover the high dose group had higher BSI, worse glucose control, higher intubations and deaths in the intubated cohort despite similar severity of illness in either group CLINICAL IMPLICATIONS: High dose dexamethasone may increase susceptibility to HAIs and negatively impact outcomes in COVID-19 associated hypoxemic failure DISCLOSURES: No relevant relationships by Beenish Bhutta No relevant relationships by Rosalyn Chi No relevant relationships by Jason Graf No relevant relationships by mohsin iqbal No relevant relationships by Rajat Kapoor No relevant relationships by Rachel Kruer No relevant relationships by Connor Parker No relevant relationships by Omar Rahman No relevant relationships by James Skinner

Tracheobronchopathia Osteochondro-What? A Rare Disorder of the Airway

Airway abnormalities may be due to a multitude of conditions. Symptoms do not occur until there is very significant narrowing, and therefore these conditions are often incidentally found. It is important to consider a broad differential.This case is a 47 year old woman with history of mild intermittent asthma and chronic sinusitis who presented to the emergency department with four weeks of malaise, shortness of breath, cough, and two days of hemoptysis. On CT imaging she was found to have tracheal wall thickening, calcifications and projections along the trachea, as well as extensive right upper and middle lobe, and lingular ground glass opacities as seen in figure 1. With hindsight, similar tracheal abnormalities were noted on chest x-ray in 2019. During admission, ENT was consulted and she was noted to have saddle nose deformity. Nasal biopsy was performed and revealed evidence of chronic inflammation, but no other abnormalities. Extensive workup was performed including rheumatologic workup with mildly positive ANA, mildly elevated ESR and CRP, negative ANCAs, MPO, PR3, RF. Bronchoscopy was pursued and direct visualization of nodules were noted along the anterior and lateral aspects of the trachea, as well as narrowing of the right upper lobe segmental bronchi, also seen in figure 1. Bronchoalveolar lavage cultures revealed Citrobacter freundii complex, Group G beta hemolytic streptococcus, Providencia rettgeri, Enterococcus avium, Pseudomonas aeruginosa, Klebsiella pneumoniae, in addition to rhinovirus and COVID-19. Biopsy was not performed due to patient intolerance of the procedure and desaturation. Ultimately, the pulmonary infiltrates were felt to be a separate process from the tracheal nodules. She improved clinically, and was discharged on antibiotic therapy with a plan for close outpatient follow up.Tracheobronchopathia osteochondroplastica (TO) is a rare condition. Imaging is often the first clue, as symptoms come late in disease course. The differential diagnosis of imaging findings consistent with TO include relapsing polychondritis, granulomatosis with polyangiitis, amyloidosis, along with a host of others. Diagnosis of TO often requires multidisciplinary involvement to evaluate other etiologies,and ultimately bronchoscopy for direct visualization. (Table Presented).

Providencial Progression: Time to be Intolerant.

How to cite this article: Gopal P. Providencial Progression: Time to be Intolerant. Indian J Crit Care Med 2022;26(4):409-410.

SÍNDROME DE MOÜNIER-KUHN E ASPEGILOSE PULMONAR

Introdução: A Traqueobroncomegalia ou Síndrome de Moünier-Kuhn (SMK) é uma doença rara, observada principalmente em homens de meia idade antes da 5ª década de vida. Caracteriza-se por perda ou atrofia das fibras musculoesqueleticas da parede da traqueia e dos brônquios principais, levando a um comprometimento respiratório significativo devido a bronquiectasias, alterações que facilitam as infecções por agentes como o Aspergillus. Descrição do caso: Masculino, 54 anos, Hepatite C, Diabetes Mellitus tipo 2, usuário de drogas inalatórias, ex-tabagista. Admitido por febre, tosse, hemoptise e dispneia. RT-PCR SARS-CoV-2, BAAR de escarro/Genexpert e hemocultura todos negativos. Tomografia cumputadorizada (TC) de tórax: Traqueobroncomegalia, calibre de traqueia 3,6 cm e brônquios com calibre de até 2,8 cm, bronquiectasias císticas / cavidades preenchidas por material sugestivo de bola fúngica (Fig. 1). Broncoscopia: Providencia (tratada com Piperacilina-Tazobactam). Imunodifusão para Aspergillus fumigatus e Galactomanana em sangue positivo, tratado com Anfotericina B liposomal por 13 dias, suspenso por comprometimento renal e hepático, aos 50 dias de internação começou a apresentar Delirium por encefalopatia hepática, foi recomendado tratamento cirúrgico (bola fúngica) e embolização de artéria endobrônquica (hemoptise massiva intermitente requerendo transfusão de concentrado de hemácias), enquanto aguardava vaga para procedimento cirúrgico, evolui-o com ascite severa, derrame pleural a esquerda, sobre infecção pulmonar e choque séptico, foi intubado, transferido a Unidade de Cuidados Intensivos, 72 horas depois evoluiu a óbito, completando 70 dias de internação hospitalar. Comentários: A SMK caracteriza-se pelo aumento do diâmetro da traqueia e dos brônquios principais associado à redução do clearance mucociliar, o que facilita as infecções respiratórias. O diagnóstico é feito por TC de tórax. O tratamento só é realizado nos sintomáticos, objetivando tratar o fator desencadeante da descompensação. No caso apresentado deve ser tratada a bola fúngica (Aspergillose pulmonar). Se a traqueobroncomegalia coexistir com condições como: necessidade de ventilação mecânica, asma, DPOC e tabagismo, a síndrome torna-se fator agravante, como é o caso do nosso paciente. A cirurgia não é realizada na maioria dos casos, sua indicação é individualizada, sendo que a implantação de stent traqueal foi benéfica em alguns casos avançados.

Pan-drug resistant Providencia rettgeri contributing to a fatal case of COVID-19.

Following prolonged hospitalization that included broad-spectrum antibiotic exposure, a strain of Providencia rettgeri was cultured from the blood of a patient undergoing extracorporeal membrane oxygenation treatment for hypoxic respiratory failure due to COVID-19. The strain was resistant to all antimicrobials tested including the novel siderophore cephalosporin, cefiderocol. Whole genome sequencing detected ten antimicrobial resistance genes, including the metallo-ß-lactamase bla NDM-1, the extended-spectrum ß-lactamase bla PER-1, and the rare 16S methyltransferase rmtB2.