Evaluation of a model to improve collection of blood cultures in patients with sepsis in the emergency room.

Sepsis begins outside of the hospital for nearly 80% of patients and the emergency room (ER) represents the first contact with the health care system. This study evaluates a project to improve collection of blood cultures (BCs) in patients with sepsis in the ER consisting of staff education and completion of the appropriate BC pre-analytical phase. A retrospective observational study performed to analyse the data on BC collection in the ER before and after a three-phase project. The first phase (1 January to 30 June 2015) before the intervention consisted of evaluation of data on BCs routinely collected in the ER. The second phase (1 July to 31 December 2015) was the intervention phase in which educational courses on sepsis recognition and on pre-analytical phase procedures (including direct incubation) were provided to ER staff. The third phase (1 January to 30 June 2016; after the intervention) again consisted of evaluation. Before the intervention, out of 24,738 admissions to the ER, 103 patients (0.4%) were identified as septic and had BCs drawn (359 BC bottles); 19 out of 103 patients (18.4%) had positive BCs. After the intervention, out of 24,702 admissions, 313 patients (1.3%) had BCs drawn (1,242 bottles); of these, 96 (30.7%) had positive BCs. Comparing the first and third periods, an increase in the percentage of patients with BCs collected (from 0.4% to 1.3% respectively, p < 0.0001) and an increase in the percentages of patients with true-positive BCs (from 0.08% to 0.39% of all patients evaluated respectively, p < 0.0001) were observed. The isolation of bacteria by BCs increased 3.25-fold after project implementation. These results can be principally ascribed to an improved awareness of sepsis in the staff associated with improved pre-analytical phase procedures in BC collection.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae in an Italian intensive care unit: clinical and therapeutical remarks.

In this study we evaluated the prevalence of Enterobacteriaceae and the epidemiology of ESBL+ microorganisms in an ICU of our Institution over a 5-year period and analyzed the clinical features and outcomes of the infections caused by these microorganisms. The most frequent ESBL+ isolate was Proteus mirabilis (69 isolates, 58%); a high rate of positive results in the double-disk synergy test (DDS) was also recognized for Klebsiella pneumoniae (52 isolates, 51%), whereas this phenomenon was observed less frequently in other species. In 312 cases the isolated microorganism was considered to be the cause of infection; we documented 103 wound infections, 89 UTIs, 62 LRTIs, 30 primary bacteremias, 27 infections of indwelling catheters and 1 CNS infection. The overall mortality rate due to ESBL+ strains was 1%, compared with 10.6% rate caused by ESBL-negative Enterobacteriaceae. This could be explained because ESBL+ strains caused mostly localized infections (wound infections and UTIs), whereas systemic or severe infections were sustained by ESBL-negative strains, and therapy with carbapenems was started promptly after ESBL+ isolation (always within 24h after strain isolation).

Catheter-related bacteremia due to Lactobacillus rhamnosus in a single-lung transplant recipient.

There is still a major debate about the pathogenicity of Lactobacillus spp. and some reports emphasize that these microorganisms are never isolated from endovascular devices. In this report we present a case of catheter-related bacteremia due to L. rhamnosus in a patient who underwent a single-lung transplant.

A 3-D marker-free system for the analysis of movement disabilities--an application to the legs.

The aim of this paper is to describe an approach allowing the analysis of human motion in three-dimensional (3-D) space. The system that we developed is composed of three charge-coupled-device cameras that capture synchronized image sequences of a human body in motion without the use of markers. Characteristic points belonging to the boundaries of the body in motion are first extracted from the initial images. Two-dimensional superquadrics are then adjusted on these points by a fuzzy clustering process. After that, the position of a 3-D model based on a set of articulated superquadrics, each of them describing a part of the human body, is reconstructed. An optical flow process allows the prediction of the position of the model from its position at the previous time, and gives initial values for the fuzzy classification. The results that we present concern more specifically the analysis of movement disabilities of a human leg during gait. They are improved by using articulation-based constraints. The methodology can be used in human motion analysis for clinical applications.

[Methicillin-resistant Staphylococcus aureus (MRSA) in an intensive care unit: a one-year survey]. / Colonizzazioni e infezioni da Staphylococcus aureus meticillino-resistente (SAMR) in una terapia intensiva polivalente: analisi su un anno di osservazione.

Methicillin-resistant Staphylococcus aureus (MRSA) is frequently isolated in nosocomial outbreaks. In our study, we analysed the occurrence of colonisation and infection in an Intensive Care Unit of our hospital during a 12-month period. We also evaluated the possibility of using automated ribotyping as a molecular method in order to type the isolates. Twice a week a nasal swab and a rectal swab were performed on all patients; from ventilator-assisted patients, a sputum culture was also taken. All the MRSA isolated were identified by using commonly phenotypic procedures and on all isolates susceptibility tests were performed. An automated ribotyping using EcoRI was also done. Out of 292 patients enrolled in the study, 205 were never colonised (group N); among the other 87 who were colonised by MRSA (29.8%), 40 patients (group A) were MRSA carriers at the time of admission, while 47 (group B) were colonised in the ICU. Twenty-seven patients (11 from group A, 15 from group B and 1 from group N) developed 31 infections due to MRSA. Patients from group A exhibited, as a rule, worse clinical conditions than those from the other two groups. For the former group, MRSA infection was frequently systemic (sepsis), while in group B pneumonia was the predominant infection. The prevalence of colonisations in our study was 30%, which is a value comparable to those presented by other authors in similar cases. MRSA colonisation is a necessary condition for subsequent infections in almost all cases, with an average lag of 7 days. Susceptibility tests were non-discriminating among the isolates: all the strains were susceptible to glycopeptides; nearly all of them were resistant to erythromycin, clindamycin, ciprofloxacin and gentamicin. Automated ribotyping allowed us to distinguish 12 different ribogroups, the most frequent of which was composed of 146 isolates. In our study, this molecular method was able to define a possible endemic clone that should be better investigated by using methods with a higher discriminatory power, such as RAPD or PFGE. The method that we employed is highly reliable, easy to perform and not time-consuming. In our opinion, it could be the method of choice in the first screening of high numbers of isolates.

Bacillus cereus fatal bacteremia and apparent association with nosocomial transmission in an intensive care unit.

Bacillus cereus has sometimes been implicated in food poisoning and in opportunistic infections of seriously ill patients. This report describes an unusual case of persistent bacteremia and multiple organ failure associated with B. cereus in a patient admitted to our institution for lung cancer. The patient was undergoing treatment with an antimicrobial agent (imipenem) that was shown to be effective against the micro-organism in vitro. No portal of entry for the strain was detected. After treatment with vancomycin, also shown to be effective in vitro, no clinical improvement was noted and the patient died. Molecular studies showed that the same strain caused an episode of pseudobacteremia in another patient admitted to the same ICU room.

[Severe infection from invasive beta-hemolytic streptococcus group A. Three cases of toxic shock observed in resuscitation]. / Infezioni invasive gravi da streptococco beta emolitico di gruppo A. A proposito di 3 casi di shock tossiemico osservati in rianimazione.

Group A streptococci (GAS) may cause a variety of infections, some of which are severe and may be life-threatening. Patients affected by severe invasive GAS infections may develop, early in the course of the infection, a syndrome characterized by circulatory insufficiency with multiple organ failure: Streptococcal Toxic Shock-Like syndrome (Strep-TSLS). The presence of shock and organ failure differentiate it from other types of invasive GAS infections. Three cases patients presenting with the Strep-TSLS, over a period of 16 months in our multidisciplinary 10-bed ICU are described. The Strep-TSLS was of nosocomial origin in the first case, due to poststernotomy wound infection, caused from erysipela in the second patient, and associated to a puerperal sepsis in the third case, respectively. In this small series the primary sources of streptococcal infection associated with the syndrome are confirmed to be in soft tissues and skin. One patient died early after the admission to the ICU, whereas the other two patients completely recovered with appropriate antibiotic and supportive treatment although early diagnosis and radical operative debridement may have been conclusive in one case. All 3 observed cases fulfilled the consensus case definition of "certain case of Strep-TSLS", whose criteria have been recently revised.

A marker-free system for the analysis of movement disabilities.

A major step toward improving the treatments of disabled persons may be achieved by using motion analysis equipment. We are developing such a system. It allows the analysis of plane human motion (e.g. gait) without using the tracking of markers. The system is composed of one fixed camera which acquires an image sequence of a human in motion. Then the treatment is divided into two steps: first, a large number of pixels belonging to the boundaries of the human body are extracted at each acquisition time. Secondly, a two-dimensional model of the human body, based on tapered superquadrics, is successively matched with the sets of pixels previously extracted; a specific fuzzy clustering process is used for this purpose. Moreover, an optical flow procedure gives a prediction of the model location at each acquisition time from its location at the previous time. Finally we present some results of this process applied to a leg in motion.