Clinical outcomes in vaccinated and unvaccinated patients with COVID-19: a population-based analysis.

OBJECTIVE: Real-life data for vaccination against COVID-19 are sorely needed. This was a population-based analysis aiming at investigating the hospitalization risk for COVID-19 of 98,982 subjects and compare features of vaccinated and unvaccinated patients. PATIENTS AND METHODS: Hospitalized patients with COVID-19 between 01/07/2021 and 11/02/2022 were included in the study. RESULTS: 582 patients were included in the analysis [males: 58.6% (n=341), vaccinated patients: 28.5% (n=166), unvaccinated patients: 71.5% (n=416)]. Median age of vaccinated patients was significantly higher compared to median age of unvaccinated [74.0 (95% CI: 72.0-77.0) vs. 59.0 (95% CI: 57.0-62.0), p=0.0001]. Mean latency time (±SD) from the second dose to hospitalization was 5.7±2.6 months. Between 01/07/2021 and 01/12/2021, unvaccinated subjects had higher risk for hospitalization compared to vaccinated [HR: 2.82, 95% CI: 2.30-3.45, p<0.0001]. Between 02/12/2021 and 11/02/2022, unvaccinated subjects presented with higher risk for hospitalization than subjects that had received booster dose [HR: 2.07, 95% CI: 1.44-2.98, p=0.005], but not than subjects that got two doses. Median value of hospitalization days was higher in unvaccinated patients compared to vaccinated [7.0 (95% CI: 7.0-8.0) vs. 6.0 (95% CI: 5.0-7.0), p=0.02]. Finally, age-adjusted analysis showed that hospitalized unvaccinated patients presented with significantly higher mortality risk compared to hospitalized vaccinated patients [HR: 2.59, 95% CI: 1.69-3.98, p<0.0001]. CONCLUSIONS: Vaccination against COVID-19 remains the best way to contain the pandemic. There is an amenable need for booster dose during the omicron era.

The role of pancreatic stone protein as a prognostic factor for COVID-19 patients.

OBJECTIVE: The outbreak of Severe Acute Respiratory Syndrome-CoronaVirus 2 (SARS-CoV-2) has rapidly spread throughout the world straining health care systems. Several biomarkers indicate the presence of hyper-inflammation and evaluate the severity of the disease. Our aim was to investigate the prognostic value of pancreatic stone protein plasma concentration in patients with SARS-CoV-2 pneumonia. PATIENTS AND METHODS: We prospectively studied 55 patients with acute SARS-CoV-2 pneumonia admitted to our tertiary hospital. Sepsis biomarkers, including pancreatic stone protein (PSP), were measured on admission. The role of these biomarkers in the prediction of in-hospital mortality (28 day) and length of hospital stay was investigated. RESULTS: Although Pancreatic stone protein did not have significant prognostic value for in-hospital mortality, there was a moderate accuracy for prolonged length of stay. The optimal cut-off value for prolonged hospital stay was 51 ng/dL (Sensitivity: 0.65, Specificity: 0.913). CONCLUSIONS: Pancreatic Stone Protein on admission could accurately identify patients requiring prolonged hospitalization. The results of this study can serve as a strong early basis for future validation studies of such an innovative approach.

CTPA imaging findings, beyond pulmonary embolism, in patients with Severe Acute Respiratory Syndrome Corona Virus-2 infection and their relation to clinical outcome - a single center experience.

OBJECTIVE: The aim of our study was to investigate a potential association between the severity of COVID-19 disease and related 28-day mortality, with the presence of mediastinal lymphadenopathy, the extension of lung parenchymal infiltrates, the presence of pulmonary embolism, the density and distribution of mediastinal and subcutaneous fat, the inflammatory markers and the direct and indirect radiological signs of right heart overload and strain. PATIENTS AND METHODS: We retrospectively included patients diagnosed with SARS-CoV-2 infection, who were admitted to the Departments of Internal and Respiratory Medicine of Patras University Hospital during the second pandemic wave (February 2021 up to July 2021) and underwent CTPA for routine diagnostic workup. Demographic characteristics, routine laboratory, radiological parameters and 28-day mortality were also recorded. RESULTS: Fifty-three consecutive patients were included. The mean age was 64.47±17.1 years and 64,1% (n=34) were males. Pulmonary embolism (PE) (p=0.019), Right Ventricle-to-Left Ventricle Diameter (RV/LV)  Ratio>1 (p<0.01), Reverse Flow in Hepatic Veins (RFHV) (p=0.019), higher density in subcutaneous fat (-99 HU vs. -104HU, p=0.016), increased Lactic Dehydrogenase (LDH), Polymorphonuclear cells (PMN), ferritin, and d-dimer levels (534 vs. 367 U/L, p=0.001, 9220 vs. 5660 Κ/µL, p=001, 956 vs. 360 ng/ml, p=0.005 and 2300 vs. 1040 µg/ml, p=0.003, respectively) were statistically significant related with worse 28-day mortality. Binomial multivariate regression analysis revealed that only RV/LV diameter>1, higher subcutaneous fat density and higher LDH values were independently associated with increased 28-day mortality (OR: 82.9, 95%CI: 1.334-5158, p=0.036, OR: 1.2, 95%CI: 1.016-1.426, p=0.032 and OR:1.016, 95% CI:1.004-1.029, p=0.011, respectively). Subgroup analysis revealed that mediastinal lymph node enlargement (EML) and PE were associated to increased Pulmonary Disease Severity Index (PDSI) score (p=0.042 and p=0.007, respectively), but not to mortality. CONCLUSIONS: Our study showed that right heart strain as depicted by a RV/LV diameter>1, higher subcutaneous fat density and higher LDH values are independently associated with an increased 28-day mortality in our SARS-COV2 patient group.

Burnout in the intensive care units in Western Greece.

OBJECTIVE: Prevention of burnout is a national imperative, and blame-free investigations of clinical events are advocated. Reflective inquiry techniques are helpful in processing adverse events while minimizing blame. The purpose of the present study was to investigate the factors inducing occupational exhaustion, staff perceptions through their interdisciplinary collaboration and communication, as well as the possibility of any conflicts in the Intensive Care Units of Western Greece. Moreover, we also aimed at developing an inter-professional peer-review program to process emotions and improve teamwork, which will also lead to the improvement of the care provided to patients. PATIENTS AND METHODS: Healthcare workers of four Intensive Care Units from three (3) Hospitals in Western Greece participated in the present study. Our manuscript included all items according to STROBE statement. RESULTS: We found a moderate to high choice in the collaboration scale and showed that one of the major reasons for conflict was the lack of mutual understanding between coworkers. It was also shown that all participants were characterized by moderate to high levels of occupational exhaustion. CONCLUSIONS: Effective relationships to establish constructive communication, require the development of skills aiming at building mutual understanding. Possible proposals for future directions in this area of research are discussed. Aiming at improving clinical practice it would be helpful the design of staff support services for better management of exhaustion.

Prediction of complicated appendicitis risk in children.

OBJECTIVE: We aimed to predict the risk of complicated appendicitis in children, constructing a risk-based prediction tool with the optimal combination of sensitivity and specificity outcomes. PATIENTS AND METHODS: This is a prospective study on a random sample of children with acute appendicitis who underwent appendectomy. Clinical examination, history, routine laboratory tests, Alvarado and pediatric appendicitis scores, operative and histopathological findings were taken into consideration. The predictive ability of the outcome variables was assessed by the Receiver Operating Characteristics (ROC) analysis. The overall predictive ability and determination of the best cut-off value (the higher sum of sensitivity plus specificity) were calculated. A Classification and Regression Tree (CRT) was used to create a multi-level classification algorithm. The model was set to predict the outcome of complicated appendicitis, considering as potential predictors the demographic characteristics, the clinical findings, and the outcome parameters. RESULTS: The various combinations of clinical and laboratory parameters did not improve their overall diagnostic ability. However, the CRT analysis resulted in a short classification algorithm based on the Pediatric appendicitis score, neutrophils percentage and the CRP. This model yielded a significantly better predictive ability than all the other combinations of the outcome parameters. The application of the model would predict complicated appendicitis with 90% sensitivity and 78.6% specificity. CONCLUSIONS: The constructed predictive model may be a useful tool for daily practical use by the clinician, especially in areas where modern diagnostic imaging facilities are absent or not always available. Clinical evaluation and close follow-up remain the more accurate preoperative method to decide the performance and timing of appendectomy.

Alterations in lymphocyte subsets and monocytes in patients diagnosed with SARS-CoV-2 pneumonia: a mini review of the literature.

OBJECTIVE: Complete blood count parameters are frequently altered in COVID-19 patients. Leucopenia and lymphopenia are the most common findings. This is not specific to COVID-19 as similar alterations are found in various other viral infections. This work is intended to summarize the evidence regarding white blood cell and lymphocyte subset alterations in COVID-19 and their clinical implications. MATERIALS AND METHODS: A PubMed search was conducted to identify relevant original studies. Articles not available in English or referring exclusively to pediatric patients were excluded. The study was designed as a narrative review from its inception. RESULTS: Complete white blood cell number and lymphocytes may be reduced in COVID-19 patients. Circulating CD4+ cells (helper T lymphocytes), CD8+ cells (cytotoxic T lymphocytes), regulatory T cells and natural killer (NK) cells may be reduced, with a greater reduction observed in critically ill patients. CD4+ and regulatory cell deficiencies may contribute to the cytokine storm and subsequent tissue damage observed in severe COVID-19 infection. NK and CD8+ cell deficiency might delay infection clearance. These aberrations of cellular immunity may contribute significantly to the pathogenesis of the disease. Alterations observed in monocyte function can also be implicated as they are effector cells responsible for tissue damage and remodeling. B cell dysfunction and maturation abnormalities have also been reported, suggesting that the virus also impairs humoral immunity. CONCLUSIONS: Lymphocyte subset abnormalities may be useful prognostic biomarkers for COVID-19, with circulating CD8+ cell count being the most promising as a predictor of severe disease requiring mechanical ventilation and mortality.

The prolonged effects of COVID-19. A new "threat"?

Coronavirus 'long-haulers" currently represent a significant public health concern. Recent reports suggest that persistent effects of COVID-19, such as fatigue, dyspnea, chest pain, anxiety, depression, arthralgia, may last for months and lead to a decline in quality of life. Risk factors for long COVID are still not very well understood. Survivors suffer from ongoing symptoms. This new entity highlights the need for a multidisciplinary approach that would enable closer monitoring of affected patients and implementation of measures that could reduce the impact of the pandemic on the overall patient wellbeing after the resolution of acute symptoms.

Prevalence and significance of mediastinal lymphadenopathy in patients with Severe Acute Respiratory Syndrome Corona Virus-2 infection.

Severe Acute Respiratory Syndrome Corona Virus-2 is the causative factor of Coronavirus Disease 2019. Early in the pandemic, mediastinal lymphadenopathy was not considered to be a significant radiologic finding of the SARS-COV-2 disease. Nevertheless, most recent studies associate mediastinal lymphadenopathy with more severe COVID-19 disease and poorer patient outcomes.

Postpartum bacteraemia outbreak due to Bacillus cereus in the delivery room.

We report an outbreak Bacillus cereus causing postpartum bacteraemia in the maternity ward and delivery room. Spores transferred by the hands and gloves of the staff in the maternity ward contaminated equipment in these two areas.

Carbapenemase-producing Klebsiella pneumoniae bloodstream infection in critically ill patients: risk factors and predictors of mortality.

A significant increase in carbapenemase-producing Klebsiella pneumoniae (CP-Kp) bacteraemias has been observed worldwide. The objective of the present work was to study the risk factors and predictors of mortality of CP-Kp bacteraemias among critically ill patients. During a 4-year period (2012-3015), a matched 1:2 case-control study was conducted. Klebsiella pneumoniae was identified by Vitek 2 technology. Antibiotic susceptibility was performed by the agar disc diffusion method and Etest. The presence of the bla KPC, bla VIM and bla NDM genes was confirmed by polymerase chain reaction (PCR). Epidemiologic data were collected from the intensive care unit (ICU) computerised database. One hundred and thirty-nine patients who developed a CP-Kp bacteraemia were matched with 278 patients. The majority of isolates (128; 92.1%) carried the bla KPC gene, seven carried both bla KPC and bla VIM, three bla VIM and one carried bla NDM. Risk factors for the development of CP-Kp bacteraemia were administration of tigecycline and number of antibiotics administered prior to CP-Kp bacteraemia. Overall, the 30-day mortality was 36.0%. Multivariate analysis revealed septic shock, Simplified Acute Physiology Score II (SAPS II) upon infection onset, adjunctive corticosteroid administration and parenteral nutrition as independent predictors of mortality, while treatment with a combination of appropriate antibiotics was identified as a predictor of good prognosis. Among septic shock patients (n = 74), Sequential Organ Failure Assessment (SOFA) score upon infection onset, adjunctive corticosteroid administration and strain carrying the bla KPC gene were independently associated with mortality, while the administration of combination treatment was identified as a predictor of a good prognosis. The administration of tigecycline predisposes to the induction of bacteraemia. Appropriate antibiotic treatment is associated with better survival, while concomitant corticosteroid treatment is associated with mortality.

Low-dose alemtuzumab for GvHD prevention followed by prophylactic donor lymphocyte infusions in high-risk leukemia.

We analyzed the use of low-dose alemtuzumab in a cohort of 158 consecutive patients who underwent allogeneic PBSC transplantation. Patients with high-risk acute leukemia were prospectively screened for prophylactic donor lymphocyte infusion (pDLI). Lymphocytes were administered repeatedly at low and non-escalating doses (0.5-1 × 106/kg). Low-dose alemtuzumab was effective in prevention of acute GvHD after sibling or well-matched unrelated transplantation, whereas a more intensified approach was needed after mismatched transplantation. The cumulative incidence of chronic moderate/severe chronic-GvHD (cGvHD) was 15.6%. In total, 63 high-risk leukemia patients were eligible for pDLI. Only 1 out of the 39 pDLI recipients relapsed as compared with 7 out of the 24 recipients, who did not receive pDLI due to logistical hurdles. In multivariate analysis, the use of adjuvant lymphocyte therapy was significantly associated with reduced incidence of relapse and improved disease-free survival. In summary, low-dose alemtuzumab confers to a low cGvHD incidence and the administration of pDLIs in this context is very likely to reduce relapse risk in high risk leukemia patients. This is translated in an estimated 5-year probability of GvHD-free and relapse-free survival of 43.3% for the 136 leukemia patients.

Pitfalls in the identification of Enterococcus species and the detection of vanA and vanB genes.

UNLABELLED: The aims were to assess the performance of Vitek 2 in identifying enterococcal species and the implementation of GeneXpert(®) vanA/vanB PCR for the detection of vancomycin-resistant enterococci (VRE). Gram-positive cocci from clinical and environmental specimens (n = 431) suspicious of being enterococci by conventional methods were evaluated by Vitek 2. This system identified 296 Enterococcus faecium, 87 Enterococcus faecalis, 10 Enterococcus villorum, 9 Enterococcus gallinarum, 9 Enterococcus durans, 5 Enterococcus casseliflavus, 1 Enterococcus spp. and 14 isolates as Non-Enterococcus. All strains were submitted to pulsed field gel electrophoresis (PFGE) analysis showing 64 banding patterns. Representative strains from each banding pattern were further characterized to species level by 16S rDNA sequencing. The misidentification rate by Vitek 2 to species level among 429 molecularly identified enterococci was 6% (26 isolates). Additionally, 372 rectal swabs were obtained from critically ill patients. They were evaluated for the presence of VRE by ChromID VRE combined with in-house PCR vs GeneXpert(®) . GeneXpert(®) showed high (>92%) sensitivity, specificity, accuracy for vanA-positive Enterococcus detection, as well as, sensitivity and specificity for vanB-positive strains. Positive predictive value for detection of vanB-positive enterococci by GeneXpert(®) vanA/vanB was low (30%). GeneXpert(®) showed the same efficacy as ChromID VRE in detecting vanA-positive enterococci, but lower for vanB-gene detection. SIGNIFICANCE AND IMPACT OF THE STUDY: The study shows that even though the performance of Vitek 2 Advanced Expert System was good in identifying enterococci to species level, it is important to verify results by a molecular method when phenotypic findings are discordant with epidemiologic patterns. Furthermore, GeneXpert(®) vanA/vanB PCR and ChromID VRE combined with in-house PCR were applied in rectal samples for the detection of VRE colonization among critically ill patients. GeneXpert(®) showed an excellent performance in detecting vanA-positive enterococci, but false-positive results for vanB-gene detection render its application problematic in departments with high incidence of vanB-positive enterococci.

Number of positive blood cultures, biofilm formation, and adhesin genes in differentiating true coagulase-negative staphylococci bacteremia from contamination.

The significance of the number of coagulase-negative staphylococci (CNS)-positive blood cultures remains obscure in regards to determining true bacteremia versus contamination. The goal of this study was to determine the predictors of real CNS bloodstream infection among intensive care unit (ICU) patients. ICU patients with at least one CNS-positive blood culture were identified from the microbiology database. Biofilm formation was tested by glass tube and microtiter plate assay. mecA gene, ica operon genes (icaA, icaB, icaD), and adhesin genes (aap, bap, atlE, fbe, fnbA) were detected by polymerase chain reaction (PCR). CNS were recovered from 120 septic episodes, 20 of which were true CNS bacteremias, whereas from the remaining 100 episodes, the isolated CNS were characterized as contaminants. The number of positive blood cultures was significantly associated with true CNS bacteremia. Nineteen true bacteremic Staphylococcus epidermidis strains were compared to 38 contaminants. Biofilm synthesis was documented in 37 isolates associated with the presence of the ica operon (p = 0.048). There were 39, 26, 38, 21, and 10 strains positive for the presence of atlE, bap, fbe, aap, and fnbA genes, respectively. Rifampicin resistance, absence of severe sepsis, number of S. epidermidis-positive blood cultures, and absence of the bap gene were independently associated with true S. epidermidis bacteremia as compared to contaminant strains. The number of positive blood cultures is associated with true CNS bacteremia. The presence of adhesin genes may play a role in differentiating true infection from contamination, whereas absence of the bap gene is associated with true S. epidermidis bacteremia.

Co-colonization by multidrug-resistant bacteria in two Greek intensive care units.

Our goal was to identify the risk factors for co-colonization by KPC-producing Klebsiella pneumoniae (KPC-Kp), vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) upon intensive care unit (ICU) admission and during stay. Rectal and nasal samples were taken from each patient upon admission at two Greek ICUs and each week afterwards, and were inoculated onto chromogenic agar. Representative colonies were characterized with standard methods and Vitek-2 technology. The presence of the bla KPC gene (K. pneumoniae isolates), vanA and vanB (Enterococcus faecium and E. faecalis isolates), and mecA (S. aureus isolates) was confirmed by polymerase chain reaction (PCR). Upon ICU admission, among 481 patients, 59 (12%), 63 (13%), and 20 (4%) were colonized by KPC-Kp, VRE, or MRSA, respectively. Simultaneous colonization by KPC-Kp and VRE upon admission (34 patients) was associated with the number of co-morbidities [adjusted odds ratio (aOR): 1.5; confidence interval (CI) 1.0-2.5], administered antibiotics (aOR: 1.7; CI 1.3-2.3), and prior KPC-Kp infection (aOR: 24.4; CI 1.5-396.0). Among patients with an ICU stay of more than 6 days, 181 (73%), 31 (13%), and 9 (4%) became KPC-Kp, VRE, or MRSA colonized during ICU stay, respectively. KPC-Kp colonization was an independent risk factor for VRE colonization upon admission (aOR: 2.7; CI 1.0-7.2) and during stay (aOR: 7.4; CI 2.0-27.4), whereas VRE colonization was a risk factor for KPC-Kp upon admission (aOR: 5.1; CI 1.9-13.9) and MRSA colonization upon admission (aOR: 3.5; CI 1.2-10.1) and during ICU stay (aOR: 14.5; CI 2.1-100.1). Colonization by a multidrug pathogen could promote colonization by another.

Toxoplasma gondii meningoencephalitis without cerebral MRI findings in a patient with ulcerative colitis under immunosuppressive treatment.

Toxoplasmosis is the most common opportunistic infection of the central nervous system in immunosupressed patients. It is usually presented as a space-occupying lesion detected by cerebral computerized tomography or magnetic resonance imaging. The diffuse form of the disease (diffuse toxoplasmic meningoencephalitis) lacks the characteristic cerebral radiologic findings rendering pre-mortem diagnosis much more difficult. Herein, we describe a case of toxoplasmic menincoencephalitis, without evidence of cerebral space-occupying lesions, in a patient with ulcerative colitis under combined therapy with systemic glucocorticoids and azathioprine. Diagnosis was based on microscopic examination of cerebrospinal fluid (CSF) for the parasite, whereas, RT-PCR for Toxoplasma gondii was negative. Taking into consideration the limitations of molecular methods, investigation of the etiology of meningeal involvement in patients under immunosuppressive therapy presenting positive serology of previous T. gondii infection, should include microscopic examination of CSF for parasite presence.

Outcome of transplantation in renal allograft recipients from cadaveric donors with standard and expanded criteria: a single-center experience.

INTRODUCTION: The increasing number of patients requiring kidney transplantation and the lack of available organs has led to the utilization of kidneys from expanded criteria donors (ECD). AIM: The comparison of the clinical outcome of renal transplantation, performed in a single center, between allograft recipients from standard (SCD) and expanded criteria donors (ECD). PATIENTS AND METHODS: Data from 215 cadaveric renal transplantations performed during a 16 year period at the University Hospital of Patras were retrospectively studied. Donors' and recipients' characteristics (gender, age, history of hypertension and diabetes mellitus, cold ischemia time, post-transplant and long term graft function) were analyzed. RESULTS: Grafts from donors with expanded criteria (ECD, n = 53) were allocated to older recipients whereas grafts from donors with standard criteria (SCD, n = 162) were allocated to younger recipients. The mean cold ischemia time was 1,146 min and was similar between the two groups of patients. Patients' survival rates were similar between allograft recipients from SCD and ECD up to the 5(th) post-transplant year of follow-up. Graft survival was significantly better in allograft recipients from SCD during a 5-year follow-up period. A significantly lower eGFR was noted in allograft recipients from ECD in comparison to those from SCD throughout the observation period. Cold ischemia time was positively correlated to the development of DGF, while patients with DGF had significantly worse graft function throughout the observation period. CONCLUSION: Patient survival from ECD is comparable to that from SCD but graft survival is significantly lower. However, since renal function of recipients from ECD is adequate for long term period, grafts from ECD should be used in older patients.

Risk factors for enterococcal infection and colonization by vancomycin-resistant enterococci in critically ill patients.

PURPOSE: Vancomycin-Resistant Enterococci (VRE) are important causes of Intensive Care Unit (ICU) infections. Our goal was to identify the prevalence and risk factors for VRE colonization upon ICU admission and during ICU stay, as well as, their impact in enterococcal infection including vancomycin-susceptible cases (VSE). METHODS: A prospective study regarding patients admitted in ICU (n = 497) was conducted during a 24-month period. Rectal swabs were collected upon admission and during hospitalization and inoculated onto selective medium. Enterococci were phenotypically characterized. van genes were investigated by PCR and clones were identified by Pulsed-Field Gel Electrophoresis and Multilocus Sequence Typing. Epidemiologic data were collected from the ICU database. RESULTS: Risk factors for VRE carriage upon ICU admission (71/497) were: duration of previous hospitalization, glycopeptide administration, chronic heart failure, malignancy, insulin-dependent diabetes mellitus, and previous enterococcal infection (VRE and/or VSE). Risk factors for VRE colonization during ICU stay (36/250) were: quinolone administration, chronic obstructive pulmonary disease, chronic renal failure, and number of VRE-positive patients in nearby beds. Risk factors for enterococcal infection during ICU stay (15/284), including VRE and VSE cases, were: administration of third- or fourth-generation cephalosporins, cortisone use before ICU admission and VRE colonization, whereas, enteral nutrition was a protective factor. CONCLUSIONS: Previous VRE colonization and antibiotic usage are essential parameters for enterococcal infection (by VRE or VSE) during ICU stay. Previous enterococcal infection, co-morbidities and antibiotic usage are associated with VRE colonization upon ICU admission, whereas, patient to patient transmission, co-morbidities and antibiotic usage constitute risk factors for VRE colonization during ICU hospitalization.

Intestinal barrier dysfunction in HIV infection: pathophysiology, clinical implications and potential therapies.

INTRODUCTION: Current pathogenetic aspects on HIV infection highlight the importance of a chronic immune activation ultimately leading to T lymphocyte homeostasis disruption and immune deregulation associated with disease manifestations and progression. It is widely accepted that this continuous immune activation in HIV infection is principally driven by the phenomenon of pathological microbial translocation (MT). METHODS: Review of the literature on the role of intestinal barrier dysfunction in HIV infection, with emphasis on the implicated pathophysiological mechanisms, clinical implications and potentially effective therapeutic interventions. FINDINGS: MT in HIV infection is promoted by a multifactorial disruption of all major levels comprising the intestinal barrier defense. Specifically, HIV infection disrupts the integrity of the intestinal biological (quantitative and qualitative alterations of gut microecology, overgrowth of pathogenic bacteria), immune (depletion of CD4(+) T cells, especially Th17 cells, increased CD4+ FoxP3+ Tregs, decreased mucosal macrophages phagocytic capacity, development of intestinal proinflammatory milieu) and mechanical barrier (enterocytes' apoptosis, disruption of tight junctions). Intestinal barrier dysfunction allows the passage of microbes and immunostimulatory bioproducts from the gut lumen first in the lamina propria and thereafter in the systemic circulation, thus continuously promoting a local and systemic inflammatory response. This chronic immune activation is associated with HIV disease progression, suboptimal response to HAART and development of non-AIDS comorbidities. CONCLUSIONS: We have reached a point where the effective control of HIV viremia by HAART should be combined with emerging pharmacological approaches aiming at the restoration of the intestinal barrier, targeting its diverse levels of structure and function. Elimination of the MT phenomenon would mitigate its effect on immune homeostasis, which might improve the prognosis of the HIV-infected patient in terms of morbidity and mortality.

The role of colonization pressure in the dissemination of colistin or tigecycline resistant KPC-producing Klebsiella pneumoniae in critically ill patients.

PURPOSE: To identify the risk factors for incident enteric colonization by KPC-producing Klebsiella pneumoniae (KPC-Kp) resistant to colistin or tigecycline during Intensive Care Unit (ICU) stay. METHOD: A prospective observational study of patients admitted to the ICU was conducted during a 27-month period. Rectal samples taken upon admission and weekly afterwards were inoculated on selective chromogenic agar. K. pneumoniae isolates were characterized by standard methodology. Mean inhibitory concentration (MIC) to colistin and tigecycline were determined by E-test. The presence of bla KPC gene was confirmed by PCR. RESULTS: Among 254 patients, 62 (24.4%) became colonized by colistin- resistant KPC-Kp during their stay. Multivariate analysis revealed that corticosteroid, colistin administration and number of colonized patients in nearby beds per day were significantly associated with colonization. Among 257 patients, 39 (17.9%) became colonized by tigecycline resistant KPC-Kp during their stay. Risk factors identified by multivariate analysis were: days at risk, obesity, number of colonized patients treated in nearby beds per day and administration of tigecycline. CONCLUSIONS: The high prevalence of colistin or tigecycline resistant KPC-Kp enteric carriage in ICU patients indicate that dissemination is due to their transfer from patient to patient via the personnel and indicates the importance of strict infection control protocols.

Mycobacterium kansasii cutaneous infection in a patient with sarcoidosis treated with anti-TNF agents.

We describe a Mycobacterium kansasii cutaneous infection that was diagnosed in a 52-year-old female patient with sarcoidosis receiving anti-TNF agents. The diagnosis was based on the positive culture of the foot ulcerative tissue. The isolation and identification of bacterium was based on phenotypic and molecular methods. Therapy and follow-up of the patient is discussed.