Global epidemiology and clinical outcomes of carbapenem-resistant Pseudomonas aeruginosa and associated carbapenemases (POP): a prospective cohort study.

BACKGROUND: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a global threat, but the distribution and clinical significance of carbapenemases are unclear. The aim of this study was to define characteristics and outcomes of CRPA infections and the global frequency and clinical impact of carbapenemases harboured by CRPA. METHODS: We conducted an observational, prospective cohort study of CRPA isolated from bloodstream, respiratory, urine, or wound cultures of patients at 44 hospitals (10 countries) between Dec 1, 2018, and Nov 30, 2019. Clinical data were abstracted from health records and CRPA isolates were whole-genome sequenced. The primary outcome was 30-day mortality from the day the index culture was collected. We compared outcomes of patients with CRPA infections by infection type and across geographic regions and performed an inverse probability weighted analysis to assess the association between carbapenemase production and 30-day mortality. FINDINGS: We enrolled 972 patients (USA n=527, China n=171, south and central America n=127, Middle East n=91, Australia and Singapore n=56), of whom 581 (60%) had CRPA infections. 30-day mortality differed by infection type (bloodstream 21 [30%] of 69, respiratory 69 [19%] of 358, wound nine [14%] of 66, urine six [7%] of 88; p=0·0012) and geographical region (Middle East 15 [29%] of 52, south and central America 20 [27%] of 73, USA 60 [19%] of 308, Australia and Singapore three [11%] of 28, China seven [6%] of 120; p=0·0002). Prevalence of carbapenemase genes among CRPA isolates also varied by region (south and central America 88 [69%] of 127, Australia and Singapore 32 [57%] of 56, China 54 [32%] of 171, Middle East 27 [30%] of 91, USA ten [2%] of 527; p<0·0001). KPC-2 (n=103 [49%]) and VIM-2 (n=75 [36%]) were the most common carbapenemases in 211 carbapenemase-producing isolates. After excluding USA patients, because few US isolates had carbapenemases, patients with carbapenemase-producing CRPA infections had higher 30-day mortality than those with non-carbapenemase-producing CRPA infections in both unadjusted (26 [22%] of 120 vs 19 [12%] of 153; difference 9%, 95% CI 3-16) and adjusted (difference 7%, 95% CI 1-14) analyses. INTERPRETATION: The emergence of different carbapenemases among CRPA isolates in different geographical regions and the increased mortality associated with carbapenemase-producing CRPA infections highlight the therapeutic challenges posed by these organisms. FUNDING: National Institutes of Health.

Prevalence and associated factors of mental health outcomes among healthcare workers in Northern Colombia: A cross-sectional and multi-centre study.

Background: Mental health outcomes in Healthcare Workers (HCWs) has been few evaluated during COVID-19 pandemic in low-and middle-income countries. Our aim was carry-out a study to identify the prevalence of stress, anxiety, depressive symptoms in HCWs and associated factors to severe illness in a northern region in Colombia. Method: A cross-sectional, hospital-based survey was conducted to assess mental health outcomes in 1,149 HCWs in Colombia. The study used Perceived Stress Scale (PSS-10), 7-item Generalized Anxiety Disorder (GAD-7), and 9-item Patient Health Questionnaire (PHQ-9) to evaluate stress, anxiety, and depression symptoms, respectively. Results: 682 HCWs completed the questionnaire. The 58,21% (397/682) were nurses, 31,23% were physicians (213/682), and 10,56% (72/682) were other health professionals. The proportion of HCWs with stress, anxiety, and depressive symptoms were 59,97%, 44,87%, and 23,02%, respectively. HCWs in emergency room and Intensive Care Units (ICU) have 2-3-fold increase risk to have severe symptoms of stress. Staff in ICU have 64% more likely to have severe anxiety symptoms, and 97% more likely to have severe depression symptoms. Limitations: Including HCWs only in the northern region in Colombia; a non-probabilistic sample, and a cross-sectional design to identify causality. Conclusion: A higher proportion on mental health outcomes has been reported in HCWs in Colombia. There are work areas related with severe mental symptoms such as ICU and emergency room. Hospitals and patient-care institutions in Latin-America needs consider the mental and physical health of HCWs during outbreaks and identify health staff at-risk to implementing support strategies to mitigate adverse mental outcomes.

Impact of antimicrobial stewardship programs on antibiotic consumption and antimicrobial resistance in four Colombian healthcare institutions.

BACKGROUND: Antimicrobial stewardship programs (ASPs) have become a fundamental pillar in optimizing antimicrobial usage, improving patient care, and reducing antimicrobial resistance (AMR). Herein we evaluated the impact of an ASP on antimicrobial consumption and AMR in Colombia. METHODS: We designed a retrospective observational study and measured trends in antibiotic consumption and AMR before and after the implementation of an ASP using interrupted time series analysis over a 4-year period (24 months before and 24 months after ASP implementation). RESULTS: ASPs were implemented according to the available resources in each of the institutions. Before ASP implementation, there was a trend toward an increase in the antibiotic consumption of all measured antimicrobials selected. Afterward, an overall decrease in antibiotic consumption was observed. The use of ertapenem and meropenem decreased in hospital wards, while a decrease in the use of ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, and vancomycin was observed in intensive care units. After ASP implementation, the trend toward an increase of oxacillin-resistant Staphylococcus aureus, ceftriaxone-resistant Escherichia coli, and meropenem-resistant Pseudomonas aeruginosa was reversed. CONCLUSIONS: In our study, we showed that ASPs are a key strategy in tackling the emerging threat of AMR and have a positive impact on antibiotic consumption and resistance.

Post-traumatic stress disorder, anxiety, and depression symptoms in healthcare workers during COVID-19 pandemic in Colombia.

Background: Mental health outcomes in healthcare workers (HCWs) in low- and middle-income countries (LMICs) have been poorly explored during COVID-19 pandemic. Our aim was to carry out a cross-sectional study of the prevalence of mental health symptoms in HCWs in Colombia. Methods: A cross-sectional web-survey study was performed during the COVID-19 pandemic mid-2021 including HCWs in two hospitals in Colombia. The PCL-5, GAD-7, and PHQ-9 scales were used to assess the prevalence of symptoms and severity of PTSD, anxiety, and depression in Colombia. Results: From 257 surveyed respondents, 44.36% were nurses, 36.58% physicians and 19.07% other health professionals. The prevalence of PTSD, anxiety, and depressive symptoms were 18.68%, 43.19%, and 26.85%, amongst HCWs. The regression model evidence a strong risk of PTSD, anxiety, and depressive symptoms in HCWs in Colombia during the second wave of COVID-19 in the middle of 2021. Conclusions: The prevalence for several mental health symptoms in HCWs in Colombia were higher compared with the general population. HCWs are at-risk population to develop chronic symptoms and mental disorders during and after outbreaks. These results will be helpful to tailor strategies to support the physical and mental health of the HCWs in LMICs.

Clinical outcomes and bacterial characteristics of carbapenem-resistant Klebsiella pneumoniae complex among patients from different global regions (CRACKLE-2): a prospective, multicentre, cohort study.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a global threat. We therefore analysed the bacterial characteristics of CRKP infections and the clinical outcomes of patients with CRKP infections across different countries. METHODS: In this prospective, multicentre, cohort study (CRACKLE-2), hospitalised patients with cultures positive for CRKP were recruited from 71 hospitals in Argentina, Australia, Chile, China, Colombia, Lebanon, Singapore, and the USA. The first culture positive for CRKP was included for each unique patient. Clinical data on post-hospitalisation death and readmission were collected from health records, and whole genome sequencing was done on all isolates. The primary outcome was a desirability of outcome ranking at 30 days after the index culture, and, along with bacterial characteristics and 30-day all-cause mortality (a key secondary outcome), was compared between patients from China, South America, and the USA. The desirability of outcome ranking was adjusted for location before admission, Charlson comorbidity index, age at culture, Pitt bacteremia score, and anatomical culture source through inverse probability weighting; mortality was adjusted for the same confounders, plus region where relevant, through multivariable logistic regression. This study is registered at ClinicalTrials.gov, NCT03646227, and is complete. FINDINGS: Between June 13, 2017, and Nov 30, 2018, 991 patients were enrolled, of whom 502 (51%) met the criteria for CRKP infection and 489 (49%) had positive cultures that were considered colonisation. We observed little intra-country genetic variation in CRKP. Infected patients from the USA were more acutely ill than were patients from China or South America (median Pitt bacteremia score 3 [IQR 2-6] vs 2 [0-4] vs 2 [0-4]) and had more comorbidities (median Charlson comorbidity index 3 [IQR 2-5] vs 1 [0-3] vs 1 [0-2]). Adjusted desirability of outcome ranking outcomes were similar in infected patients from China (n=246), South America (n=109), and the USA (n=130); the estimates were 53% (95% CI 42-65) for China versus South America, 50% (41-61) for the USA versus China, and 53% (41-66) for the USA versus South America. In patients with CRKP infections, unadjusted 30-day mortality was lower in China (12%, 95% CI 8-16; 29 of 246) than in the USA (23%, 16-30; 30 of 130) and South America (28%, 20-37; 31 of 109). Adjusted 30-day all-cause mortality was higher in South America than in China (adjusted odds ratio [aOR] 4·82, 95% CI 2·22-10·50) and the USA (aOR 3·34, 1·50-7·47), with the mortality difference between the USA and China no longer being significant (aOR 1·44, 0·70-2·96). INTERPRETATION: Global CRKP epidemics have important regional differences in patients' baseline characteristics and clinical outcomes, and in bacterial characteristics. Research findings from one region might not be generalisable to other regions. FUNDING: The National Institutes of Health.

Bloodstream Infections With Candida auris Among Children in Colombia: Clinical Characteristics and Outcomes of 34 Cases.

BACKGROUND: Candida auris is an emerging multidrug-resistant yeast that can cause invasive infections and healthcare-associated outbreaks. Here, we describe 34 cases of pediatric C. auris bloodstream infections (BSIs) identified during July 2014-October 2017 in 2 hospitals in Colombia. METHODS: We conducted a retrospective review of microbiology records for possible C. auris cases in 2 hospitals in Barranquilla and Cartagena. BSIs that occurred in patients aged <18 years confirmed as C. auris were included in this analysis. RESULTS: We identified 34 children with C. auris BSIs. Twenty-two (65%) patients were male, 21% were aged <28 days, 47% were aged 29-365 days, and 32% were aged >1 year. Underlying conditions included preterm birth (26%), being malnourished (59%), cancer (12%), solid-organ transplant (3%), and renal disease (3%). Eighty-two percent had a central venous catheter (CVC), 82% were on respiratory support, 56% received total parenteral nutrition (TPN), 15% had a surgical procedure, and 9% received hemodialysis. Preinfection inpatient stay was 22 days (interquartile range, 19-33 days), and in-hospital mortality was 41%. CONCLUSIONS: Candida auris affects children with a variety of medical conditions including prematurity and malignancy, as well as children with CVCs and those who receive TPN. Mortality was high, with nearly half of patients dying before discharge. However, unlike most other Candida species, C. auris can be transmitted in healthcare settings, as suggested by the close clustering of cases in time at each of the hospitals.Candida auris is an emerging multidrug-resistant yeast that can cause invasive infections and healthcare-associated outbreaks. This report describes 34 cases of pediatric C. auris bloodstream infections, identified in two hospitals in Colombia, South America.

Case-Case Comparison of Candida auris Versus Other Candida Species Bloodstream Infections: Results of an Outbreak Investigation in Colombia.

BACKGROUND: Candida auris is an emerging multidrug-resistant yeast that causes outbreaks in healthcare settings around the world. In 2016, clinicians and public health officials identified patients with C. auris bloodstream infections (BSI) in Colombian healthcare facilities. To evaluate potential risk factors and outcomes for these infections, we investigated epidemiologic and clinical features of patients with C. auris and other Candida species BSI. METHODS: We performed a retrospective case-case investigation in four Colombian acute care hospitals, defining a case as Candida spp. isolated from blood culture during January 2015-September 2016. C. auris BSI cases were compared to other Candida species BSI cases. Odds ratio (OR), estimated using logistic regression, was used to assess the association between risk factors and outcomes. RESULTS: We analyzed 90 patients with BSI, including 40 with C. auris and 50 with other Candida species. All had been admitted to the intensive care unit (ICU). No significant demographic differences existed between the two groups. The following variables were independently associated with C. auris BSI: ≥ 15 days of pre-infection ICU stay (OR: 5.62, CI: 2.04-15.5), evidence of severe sepsis (OR: 3.70, CI 1.19-11.48), and diabetes mellitus (OR 5.69, CI 1.01-31.9). CONCLUSION: Patients with C. auris BSI had longer lengths of ICU stay than those with other candidemias, suggesting that infections are acquired during hospitalization. This is different from other Candida infections, which are usually thought to result from autoinfection with host flora.

A Young Diabetic Patient With Sepsis After Gardening.

We report a case of soft tissue infection, sepsis, and bacteremia due to Burkholderia pseudomallei (melioidosis) in a diabetic young patient and the genomic characterization of Burkholderia pseudomallei isolate (COL-5428).

Hospital-Associated Multicenter Outbreak of Emerging Fungus Candida auris, Colombia, 2016.

Candida auris is an emerging multidrug-resistant fungus that causes hospital-associated outbreaks of invasive infections with high death rates. During 2015-2016, health authorities in Colombia detected an outbreak of C. auris. We conducted an investigation to characterize the epidemiology, transmission mechanisms, and reservoirs of this organism. We investigated 4 hospitals with confirmed cases of C. auris candidemia in 3 cities in Colombia. We abstracted medical records and collected swabs from contemporaneously hospitalized patients to assess for skin colonization. We identified 40 cases; median patient age was 23 years (IQR 4 months-56 years). Twelve (30%) patients were <1 year of age, and 24 (60%) were male. The 30-day mortality was 43%. Cases clustered in time and location; axilla and groin were the most commonly colonized sites. Temporal and spatial clustering of cases and skin colonization suggest person-to-person transmission of C. auris. These cases highlight the importance of adherence to infection control recommendations.

Antifungal activity and killing kinetics of anidulafungin, caspofungin and amphotericin B against Candida auris.

BACKGROUND: Candida auris is an emerging MDR pathogen. It shows reduced susceptibility to azole drugs and, in some strains, high amphotericin B MICs have been described. For these reasons, echinocandins were proposed as first-line treatment for C. auris infections. However, information on how echinocandins and amphotericin B act against this species is lacking. OBJECTIVES: Our aim was to establish the killing kinetics of anidulafungin, caspofungin and amphotericin B against C. auris by time-kill methodology and to determine if these antifungals behave as fungicidal or fungistatic agents against this species. METHODS: The susceptibility of 50 C. auris strains was studied. Nine strains were selected (based on echinocandin MICs) to be further studied. Minimal fungicidal concentrations, in vitro dose-response and time-kill patterns were determined. RESULTS: Echinocandins showed lower MIC values than amphotericin B (geometric mean of 0.12 and 0.94 mg/L, respectively). Anidulafungin and caspofungin showed no fungicidal activity at any concentration (maximum log decreases in cfu/mL between 1.34 and 2.22). On the other hand, amphotericin B showed fungicidal activity, but at high concentrations (≥2.00 mg/L). In addition, the tested polyene was faster than echinocandins at killing 50% of the initial inoculum (0.92 versus >8.00 h, respectively). CONCLUSIONS: Amphotericin B was the only agent regarded as fungicidal against C. auris. Moreover, C. auris should be considered tolerant to caspofungin and anidulafungin considering that their MFC:MIC ratios were mostly ≥32 and that after 6 h of incubation the starting inoculum was not reduced in >90%.

Molecular Epidemiology of Candida auris in Colombia Reveals a Highly Related, Countrywide Colonization With Regional Patterns in Amphotericin B Resistance.

Background: Candida auris is a multidrug-resistant yeast associated with hospital outbreaks worldwide. During 2015-2016, multiple outbreaks were reported in Colombia. We aimed to understand the extent of contamination in healthcare settings and to characterize the molecular epidemiology of C. auris in Colombia. Methods: We sampled patients, patient contacts, healthcare workers, and the environment in 4 hospitals with recent C. auris outbreaks. Using standardized protocols, people were swabbed at different body sites. Patient and procedure rooms were sectioned into 4 zones and surfaces were swabbed. We performed whole-genome sequencing (WGS) and antifungal susceptibility testing (AFST) on all isolates. Results: Seven of the 17 (41%) people swabbed were found to be colonized. Candida auris was isolated from 37 of 322 (11%) environmental samples. These were collected from a variety of items in all 4 zones. WGS and AFST revealed that although isolates were similar throughout the country, isolates from the northern region were genetically distinct and more resistant to amphotericin B (AmB) than the isolates from central Colombia. Four novel nonsynonymous mutations were found to be significantly associated with AmB resistance. Conclusions: Our results show that extensive C. auris contamination can occur and highlight the importance of adherence to appropriate infection control practices and disinfection strategies. Observed genetic diversity supports healthcare transmission and a recent expansion of C. auris within Colombia with divergent AmB susceptibility.

Actinic prurigo: a case-control study of risk factors.

BACKGROUND: Actinic prurigo (AP) is an idiopathic photodermatosis that usually onsets during childhood and predominates in women. It is characterized by the symmetrical involvement of sun-exposed areas of the skin, lips, and conjunctiva. OBJECTIVES: This study aimed to analyze the risk factors associated with AP using a case-control design. METHODS: All patients diagnosed with AP during 1990-2006 at Dr. Manuel Gea González General Hospital in Mexico City were included. Respective controls were recruited. Race, demographic, geographic, socioeconomic, environmental, clinical, and nutritional risk factors were assessed. RESULTS: A total of 132 persons were enrolled. These included 44 cases and two control groups comprising, respectively, dermatology and non-dermatology outpatients without AP or any autoimmune disease. Distribution by gender, age, place of birth, place of residence, and economic status did not differ significantly among the three groups. A total of 256 variables were analyzed. Only 19 variables were found to be statistically significant (P < 0.05). These were: use of a boiler; use of firewood; car ownership; use of earthenware; mixed material housing; socioeconomic level 1; sun exposure; use of soap; lemon consumption; use of moisturizing hair cream; living with pets in the house; living with farm animals; age; having a family member with AP; having had surgery; having had trauma; having been hospitalized; use of oral medication; and use of herbal medication. Of 40 macro- and micronutrients analyzed, 11 were found to have statistically significant effects (P < 0.05). CONCLUSIONS: Multiple epidemiologic, geographic, clinical, and immunologic factors are involved in the etiology of AP. This study proposes a clear line for research directed at specific risk factors that refer to an individual's clinical, allergic, health, and socioeconomic status. Further study should also investigate the etiologic role of diet in AP and the molecular mechanisms behind the development of AP to establish whether AP is caused by exposure to polycyclic aromatic hydrocarbons.

Frecuencia de tumores benignos durante el periodo de 2000-2006 en el Hospital General Dr. Manuel Gea González / Frequency of benign tumors at the Hospital General Dr. Manuel Gea Gonzalez: record review between 2000-2006

Antecedentes: Los tumores benignos de la piel se definen como el crecimiento autónomo de tejido sin relación con el patrón normal de crecimiento tisular, que persiste después del estímulo que le dio origen. Prácticamente todos los humanos presentan algún tumor benigno, pero la mayoría de las veces no se busca atención ya que no producen molestias. Son escasos los registros sobre la frecuencia de los tumores benignos. El objetivo de este estudio fue informar el número de tumores benignos en el Departamento de Dermatología de nuestro hospital. Material y métodos: Se realizó un estudio retrospectivo en el que se revisaron los registros de histopatología del periodo 2000 a 2006. Se registró año, número de biopsia, sexo, edad, topografía, diagnóstico clínico y diagnóstico histológico. Resultados: Se analizaron 9436 registros de biopsias, de las cuales 3765 fueron tumores benignos, de éstos se eliminaron 595 biopsias por falta de datos, para un total de 3170. Los tumores más frecuentes por grupo histopatológico en forma descendente fueron los tumores melanocíticos, quistes, tumores fibrosos, vasculares, de la epidermis, de tejido adiposo, del pelo, neurales, glandulares, sebáceos, de cartílago y hueso, y de músculo liso. Los tumores más frecuentes en general fueron nevos melanocíticos, quistes epidermoides, queratosis seborreicas, granulomas piógenos, lipomas y dermatofibromas. Conclusiones: Los tumores benignos más frecuentes fueron los melanocíticos constituidos por nevos de unión, intradérmicos y compuestos, y los quistes epidermoides. Esta serie proporciona información de los tumores benignos más comunes en un servicio dermatológico.

BACKGROUND: Benign skin neoplasms are defined as autonomous growing tissue unrelated to normal growing of the skin, that persist even after the originating stimulus dissapears. Almost all human beings have a certain number of benign cutaneous neoplasms and many never seek medical attention. There is a dearth of information regarding the frequency of these tumors. The aim of this study was to record the number of benign tumors studied at the Dermatology Department of a medical facility. MATERIAL AND METHODS: A retrospective study analyzed medical records between 2000 and 2006. We included year of admission, number of biopsies, sex, age, tumor location, histological and clinical diagnoses. RESULTS: We analyzed 9,436 biopsies of which 3,765 constituted benign neoplasms; 595 were not included and our total sample was 3,170 tumors. The most frequent tumors according to histopathological diagnoses in descending order were: melanocytic, cutaneous cysts, fibrous tumors, vascular tumors, epidermal tumors, fat tumors, tumors with hair differentiation, neural tumors, glandular tumors, tumors with sebaceous differentiation, cartilage and bone tumors, and smooth muscle tumors. The most common benign tumors were: Melanocytic nevi, epidermal cysts, seborrheic keratoses, pyogenic granulomas, lipomas and dermatofibromas. CONCLUSIONS: Melanocytes represented by melanocytic nevi (junctional, intradermic and compound) were the most frequent benign neoplasms, followed by epidermoid cysts. Our results illustrate the most common benign tumors observed in a dermatology department.

[Frequency of benign tumors at the Hospital General "Dr. Manuel Gea Gonzalez". Record review between 2000-2006]. / Frecuencia de tumores benignos durante el periodo de 2000-2006 en el Hospital General "Dr. Manuel Gea González".

BACKGROUND: Benign skin neoplasms are defined as autonomous growing tissue unrelated to normal growing of the skin, that persist even after the originating stimulus dissapears. Almost all human beings have a certain number of benign cutaneous neoplasms and many never seek medical attention. There is a dearth of information regarding the frequency of these tumors. The aim of this study was to record the number of benign tumors studied at the Dermatology Department of a medical facility. MATERIAL AND METHODS: A retrospective study analyzed medical records between 2000 and 2006. We included year of admission, number of biopsies, sex, age, tumor location, histological and clinical diagnoses. RESULTS: We analyzed 9,436 biopsies of which 3,765 constituted benign neoplasms; 595 were not included and our total sample was 3,170 tumors. The most frequent tumors according to histopathological diagnoses in descending order were: melanocytic, cutaneous cysts, fibrous tumors, vascular tumors, epidermal tumors, fat tumors, tumors with hair differentiation, neural tumors, glandular tumors, tumors with sebaceous differentiation, cartilage and bone tumors, and smooth muscle tumors. The most common benign tumors were: Melanocytic nevi, epidermal cysts, seborrheic keratoses, pyogenic granulomas, lipomas and dermatofibromas. CONCLUSIONS: Melanocytes represented by melanocytic nevi (junctional, intradermic and compound) were the most frequent benign neoplasms, followed by epidermoid cysts. Our results illustrate the most common benign tumors observed in a dermatology department.

An approach to the management of necrotising fasciitis in neonates.

Necrotising fasciitis is a severe, life-threatening soft tissue infection. It produces an extensive cellulitis with severe involvement of subcutaneous tissue, fascia, muscle or both, resulting in necrosis of the tissue. All age groups, including neonates, can be affected. Patients with necrotising fasciitis present with more severe constitutional symptoms and have a poor outcome, unless aggressive antibiotic therapy and surgical debridement are instituted promptly. The debridement of necrotic tissue is imperative to control the infection, but results in deep wounds that require further treatment. In this study, the neonate was treated with alginate dressings and negative pressure therapy after resolution of cellulitis, with excellent results and no untoward events.