Clinical outcomes of elderly patients with bloodstream infections due to extended-spectrum ß-lactamase-producing Enterobacteriaceae in an Italian Internal Medicine ward.

PURPOSE: Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. METHODS: We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7±10years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). RESULTS: At multivariate risk analysis, we found that urinary tract as primary infection site (RR=0.181 [0.037-0.886], p=0.035) and definitive antibiotic therapy (RR=0.517 [0.147-0.799], p=0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR=2.788 [1.407-9.228], p=0.025). Also regarding 30days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR=0.098 [0.011-0.743], p=0.025) and definitive antibiotic therapy (RR=0.236 [0.058-0.961], p=0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR=4.241 [1.040-17.295], p=0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. CONCLUSIONS: Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia.

Breakthrough Lactobacillus rhamnosus GG bacteremia associated with probiotic use in an adult patient with severe active ulcerative colitis: case report and review of the literature.

BACKGROUND: Probiotics are widely investigated in the treatment of various bowel diseases. However, they may also have a pathogenic potential, and the role of Lactobacillus spp. as opportunistic pathogens, mostly following disruption of the intestinal mucosa, is emerging. CASE REPORT: We report on a case of bacteremia caused by L. rhamnosus GG in an adult patient affected by severe active ulcerative colitis under treatment with corticosteroids and mesalazine. Lactobacillus bacteremia was associated with candidemia and occurred while the patient was receiving a probiotic formulation containing the same strain (as determined by PFGE typing), and was being concomitantly treated with i.v. vancomycin, to which the Lactobacillus strain was resistant. L. rhamnosus GG bacteremia, therefore, was apparently related with translocation of bacteria from the intestinal lumen to the blood. CONCLUSIONS: Pending conclusive evidence, use of probiotics should be considered with caution in case of active severe inflammatory bowel diseases with mucosal disruption.