ABSTRACT
BACKGROUND: Infections caused by carbapenem resistant K. pneumoniae are increasing and associated with high mortality rates. There are increasing reports of hypermucoviscous/ hypervirulent K. pneumoniae isolated from various sources. However, there is limited data on the prevalence of hypermucoviscous strains among carbapenem-resistant K. pneumoniae from invasive infections in India and its association with mortality. rmpA, rmpA2 and magA genes are associated with these hypervirulent strains. In this study, we investigate the prevalence of hypermucoviscous strains amongst carbapenem resistant K. pneumoniae isolated from blood culture. Association of mortality rate with meropenem minimum inhibitory concentration and hypermucoviscous strains are determined. METHODS: 86 non-repetitive carbapenem resistant K. pneumoniae isolated from bacteremia underwent E-test for meropenem minimum inhibitory concentration (MIC) determination and PCR for detection of carbapenamase genes. String test, PCR for rmpA, rmpA2 and magA were performed for characterisation of hypervirulent strains. Results: 31.3% of the 86 isolates displayed hypermucoviscous phenotype as indicated by a positive string test. Among the two genotypic markers, 7% were positive for rmpA2 and all were negative for rmpA and magA. 74.1% and 67.9% mortality were seen among string test positives and isolates meropenem MIC of ≥16µg/ml respectively (p 0.036 and 0.008 respectively). Isolates with both string positivity and meropenem MIC of ≥16µg/ml had a very high mortality rate of 84.2%. CONCLUSION: String test, aids prediction of disease severity, and is independently associated with increased mortality in invasive carbapenem resistant K.pneumoniae health care-acquired infections. High meropenem MIC is a significant risk factor for mortality. Combination of string positive carbapenem resistant hypermucoviscous K. pneumoniae resulted in mortality rate of 84.2%. It is important to monitor prevalence of carbapenem resistant hypermucoviscous/hypervirulent K. pneumoniae among invasive isolates especially in a setting with high resistance rates as combination of increased virulence and decreased susceptibility to antimicrobials results in worse outcomes.
Subject(s)
Bacteremia/mortality , Drug Resistance, Bacterial , Klebsiella Infections/mortality , Carbapenems , Humans , India , Klebsiella pneumoniaeABSTRACT
Objetivos: La prednisolona y la talidomida se administran frecuentemente en el control del eritema nodoso leproso (ENL) y proporcionan alivio a los pacientes con esta condición en todo el mundo. Sin embargo, tanto el ENL como sus tratamientos causan gran morbilidad. Este trabajo describe el espectro del ENL observado en el Hospital para Enfermedades Tropicales de Londres (HTD), la utilización de esteroides y el uso de esteroides y talidomida en su control y las consiguientes complicaciones. Metodología: Se llevó a cabo una revisión retrospectiva de los pacientes diagnosticados con ENL entre 1996 y 2013. Los datos se obtuvieron de los archivos clínicos, incluyendo la severidad y duración del episodio, además del tratamiento y efectos adversos. Resultados: Entre 1996 y 2013 se diagnosticaron 30 pacientes con ENL. El índice bacteriológico (IB) promedio en el momento del diagnóstico fue > 4.65, superior al aceptado en otros estudios. La mayoría de los pacientes desarrollaron ENL durante el tratamiento (67%) y presentaron ENL crónico (57%). La duración media del ENL fue de 60 meses (rango 9-192); los pacientes con IB > 4.5 presentaron períodos de tiempo más largos. El 87% de los pacientes recibieron prednisolona durante 9 meses; 33% desarrolló efectos adversos, incluyendo diabetes e hipertensión; el 87% de los pacientes recibió talidomida durante 16 meses y el 65% presentó efectos adversos. No hubo casos de embarazo o tromboembolismo. El 77% de los pacientes dejó la prednisolona a los dos meses de iniciar la talidomida. No hubo casos de fallecimiento en nuestro grupo. Conclusión: Describimos el curso clínico del ENL en un país no endémico con acceso a la talidomida y prednisolona. El ENL puede durar mucho más que el tiempo descrito anteriormente y tiene un gran impacto sobre la salud del paciente. En el Reino Unido, la talidomida es esencial para cesar la administración de los esteroides, prevenir efectos adversos y la mortalidad por esteroides, lo cual esté documentado en otros trabajos
Objectives: Prednisolone and thalidomide are commonly used in the management of erythema nodosum leprosum (ENL) and bring relief to patients with this condition worldwide. However, both ENL and its treatments can cause significant morbidity. This study describes the spectrum of ENL seen at The Hospital for Tropical Diseases, London (HTD), the use of steroids and thalidomide in its management and the complications of their use. Study Design: We conducted a retrospective audit of patients diagnosed with ENL between 1996 and 2013. Data were obtained from hospital records including severity and length of disease, together with treatments received and adverse effects. Results: Between 1996 and 2013, 30 patients were diagnosed with ENL. The median bacillary index (BI) at diagnosis was 4.65, higher than in previous studies. Most patients developed ENL during leprosy treatment (67%) and had chronic ENL (57%). The median length of ENL was 60 months (range 9-192); patients with BI. 4.5 had significantly longer duration of disease. 87% patients received prednisolone for median nine months; 35% developed adverse effects including diabetes and hypertension. 87% patients received thalidomide for median 16 months; 65% complained of side effects. There were no pregnancies or venous thromboembolisms. 77% patients stopped prednisolone within two months of starting thalidomide. There were no deaths in our cohort. Conclusion: We describe the clinical course of ENL in a non-endemic country with access to thalidomide and prednisolone. ENL may last far longer than previously described and has significant impact on a patients health. In the UK, thalidomide is essential as a steroid-sparing agent, to prevent the adverse effects and mortality of longterm steroids which have been documented elsewhere
