In vitro activity of ceftazidime-avibactam against clinical isolates of Enterobacterales and Pseudomonas aeruginosa collected in Malaysia: Results from the ATLAS Programme, 2013 to 2019.

INTRODUCTION: There has been a steady rise in antimicrobial resistance among common pathogens in Malaysia. This study aims to determine the in vitro antimicrobial activities of ceftazidime-avibactam and its comparators against clinical isolates of Enterobacterales and Pseudomonas aeruginosa collected in Malaysia from 2013 to 2019, and to determine the rates of resistance among these isolates. MATERIALS AND METHODS: In this retrospective study, four participating study centres located in East (N = 1) and West (N = 3) Malaysia contributed to the collection of clinical isolates of Enterobacterales and P. aeruginosa from 2013 to 2019. Antimicrobial minimum inhibitory concentrations (MICs) and percentage susceptibilities were interpreted according to Clinical Laboratory Standards Institute (CLSI) breakpoints, except for tigecycline and colistin, which utilised the United States Food and Drug Administration (US FDA) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints, respectively. RESULTS: A total of 1,073 isolates of Enterobacterales and 332 isolates of P. aeruginosa were collected in Malaysia from the four centres. Among Enterobacterales isolates, the highest percentages of susceptibility were seen with ceftazidimeavibactam (99.2%), meropenem (98.9%), and tigecycline (96.9%). Whereas P. aeruginosa isolates demonstrated the highest susceptibilities to colistin (95.6%), followed by ceftazidime-avibactam (93.1%) and cefepime (87.1%). All metallo-ß-lactamase (MBL)-negative isolates of Enterobacterales, including ceftazidime-nonsusceptible, meropenem-nonsusceptible, and colistin-resistant phenotypes, were susceptible to ceftazidime-avibactam. Furthermore, ceftazidime-avibactam demonstrated the highest percentage of susceptibility (97.1%) against multidrug-resistant (MDR) isolates of Enterobacterales. CONCLUSION: Ceftazidime-avibactam exhibited potent in vitro activity against clinical isolates of Enterobacterales and P. aeruginosa collected in Malaysia from 2013 to 2019. The results of this study show that ceftazidime-avibactam should be considered in the treatment of indicated infections caused by susceptible strains of aerobic Gramnegative pathogens and is a valuable alternative to carbapenems.

Leptospirosis in pregnancy: A lesson in subtlety.

INTRODUCTION: Leptospirosis is a zoonotic disease caused by spirochaete of the genus Leptospira. Human infection occurs after exposure to water or soil contaminated by urine from an infected animal. Most patients manifest as self-limited systemic illness. However 10% of patients manifest as severe disease associated with high fatality. The disease affects mostly men, cases involving pregnant women are uncommon. We presented a case of leptospirosis in a pregnant woman leading to mortality of both mother and foetus. CASE REPORT: A 28-year-old woman at 18 weeks of gestation, had shortness of breath and collapsed. She was brought unconscious to the emergency department and died shortly after arrival. A week prior to this, she had presented to the same hospital with pain on both thighs. Examination of the patient and ultrasound of the foetus revealed normal findings. Post mortem examination revealed hepatosplenomegaly and congested lungs; no jaundice, meningeal inflammation or cardiac abnormalities was evident. Histopathology examination of the lungs revealed pulmonary haemorrhages and oedema. Multiple infarcts were seen in the spleen and the kidneys showed foci of acute tubular necrosis. Laboratory investigations revealed Leptospira IgM antibody and PCR for leptospira were positive. This case illustrates the subtleness of clinical presentation of leptospirosis. The diagnosis was obscure even at post-mortem and was only suspected following histopathological examination, leading to further investigations. CONCLUSION: Leptospirosis may have a subtle presentation and a high index of suspicion for this infection is required for early identification of the disease.

A sudden paediatric death due to hand, foot and mouth disease: the importance of vigilance.

BACKGROUND: Hand, foot and mouth disease (HFMD) is caused by enteroviruses such as Coxsackie virus A16 (CVA16) and Enterovirus 71 (EV71). The diagnostic hallmarks are oral ulcers and maculo-papular or vesicular rash on the hands and feet. Severe form of this disease can lead to death due to neurological and cardiopulmonary complications. This case report aims to describe a fatal case of HFMD with minimal oral and skin manifestations. CASE REPORT: A four-year-old girl was brought to a hospital after suddenly becoming unresponsive at home. She had a history of fever and lethargy for three days prior to her demise. The patient, and f ive other children in her neighbourhood had been diagnosed to have HFMD at a local health clinic; the other children had recovered without complications. RESULTS: Autopsy revealed a few punctate, sub-epidermal vesicles measuring 1 to 2 mm on the palm of her right hand and sole of the right foot, visible only with a magnifying glass. Internal examination revealed prominent nodularity at the oro- and hypopharynxes. The lungs were markedly congested and oedematous. Histopathology of the lung showed marked oedema and haemorrhage with mild pneumonic changes. Oedema with increase in macroglia and astrocytic proliferation were seen in the cerebral tissue, but no lymphocytic infiltration was evident. Enterovirus EV71 was detected by polymerase chain reaction in samples from the lung, cerebrospinal fluid and serum. The cause of death was given as HFMD complicated by pneumonia. CONCLUSION: Fatal HFMD may have minimal signs. A complete history, careful physical examination and relevant investigations lead to a diagnosis at post mortem examination. Awareness of the subtle signs and rapid deterioration associated with a fatal case of HFMD is a challenge to clinicians who encounter these cases.