Prevalence of Infections and Antimicrobial Resistance of ESKAPE Group Bacteria Isolated from Patients Admitted to the Intensive Care Unit of a County Emergency Hospital in Romania.

The ESKAPE group (Enterococcus faecium, Staphylococcus aureus, Klebsiella Pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp.) is a group of bacteria very difficult to treat due to their high ability to acquire resistance to antibiotics and are the main cause of nosocomial infections worldwide, posing a threat to global public health. Nosocomial infections with MDR bacteria are found mainly in Intensive Care Units, due to the multitude of maneuvers and invasive medical devices used, the prolonged antibiotic treatments, the serious general condition of these critical patients, and the prolonged duration of hospitalization. MATERIALS AND METHODS: During a period of one year, from January 2023 to December 2023, this cross-sectional study was conducted on patients diagnosed with sepsis admitted to the Intensive Care Unit of the Sibiu County Emergency Clinical Hospital. Samples taken were tracheal aspirate, catheter tip, pharyngeal exudate, wound secretion, urine culture, blood culture, and peritoneal fluid. RESULTS: The most common bacteria isolated from patients admitted to our Intensive Care Unit was Klebsiella pneumoniae, followed by Acinetobacter baumanii and Pseudomonas aeruginosa. Gram-positive cocci (Enterococcus faecium and Staphilococcus aureus) were rarely isolated. Most of the bacteria isolated were MDR bacteria. CONCLUSIONS: The rise of antibiotic and antimicrobial resistance among strains in the nosocomial environment and especially in Intensive Care Units raises serious concerns about limited treatment options.

TiO2 Nanocomposite Coatings and Inactivation of Carbapenemase-Producing Klebsiella Pneumoniae Biofilm-Opportunities and Challenges.

The worldwide increase of multidrug-resistant Gram-negative bacteria is a global threat. The emergence and global spread of Klebsiella pneumoniae carbapenemase- (KPC-) producing Klebsiella pneumoniae represent a particular concern. This pathogen has increased resistance and abilities to persist in human reservoirs, in hospital environments, on medical devices, and to generate biofilms. Mortality related to this microorganism is high among immunosuppressed oncological patients and those with multiple hospitalizations and an extended stay in intensive care. There is a severe threat posed by the ability of biofilms to grow and resist antibiotics. Various nanotechnology-based strategies have been studied and developed to prevent and combat serious health problems caused by biofilm infections. The aim of this review was to evaluate the implications of nanotechnology in eradicating biofilms with KPC-producing Klebsiella pneumoniae, one of the bacteria most frequently associated with nosocomial infections in intensive care units, including in our department, and to highlight studies presenting the potential applicability of TiO2 nanocomposite materials in hospital practice. We also described the frequency of the presence of bacterial biofilms on medical surfaces, devices, and equipment. TiO2 nanocomposite coatings are one of the best long-term options for antimicrobial efficacy due to their biocompatibility, stability, corrosion resistance, and low cost; they find their applicability in hospital practice due to their critical antimicrobial role for surfaces and orthopedic and dental implants. The International Agency for Research on Cancer has recently classified titanium dioxide nanoparticles (TiO2 NPs) as possibly carcinogenic. Currently, there is an interest in the ecological, non-toxic synthesis of TiO2 nanoparticles via biological methods. Biogenic, non-toxic nanoparticles have remarkable properties due to their biocompatibility, stability, and size. Few studies have mentioned the use of nanoparticle-coated surfaces as antibiofilm agents. A literature review was performed to identify publications related to KPC-producing Klebsiella pneumoniae biofilms and antimicrobial TiO2 photocatalytic nanocomposite coatings. There are few reviews on the antibacterial and antibiofilm applications of TiO2 photocatalytic nanocomposite coatings. TiO2 nanoparticles demonstrated marked antibiofilm activity, but being nano in size, these nanoparticles can penetrate cell membranes and may initiate cellular toxicity and genotoxicity. Biogenic TiO2 nanoparticles obtained via green, ecological technology have less applicability but are actively investigated.

A Real-World Study on the Clinical Characteristics, Outcomes, and Relationship between Antibiotic Exposure and Clostridioides difficile Infection.

Clostridioides difficile is a Gram-positive bacteria that causes nosocomial infections, significantly impacting public health. In the present study, we aimed to describe the clinical characteristics, outcomes, and relationship between antibiotic exposure and Clostridioides difficile infection (CDI) in patients based on reports from two databases. Thus, we conducted a retrospective study of patients diagnosed with CDI from Sibiu County Clinical Emergency Hospital (SCCEH), Romania, followed by a descriptive analysis based on spontaneous reports submitted to the EudraVigilance (EV) database. From 1 January to 31 December 2022, we included 111 hospitalized patients with CDI from SCCEH. Moreover, 249 individual case safety reports (ICSRs) from EVs were analyzed. According to the data collected from SCCEH, CDI was most frequently reported in patients aged 65-85 years (66.7%) and in females (55%). In total, 71.2% of all patients showed positive medical progress. Most cases were reported in the internal medicine (n = 30, 27%), general surgery (n = 26, 23.4%), and infectious disease (n = 22, 19.8%) departments. Patients were most frequently exposed to ceftriaxone (CFT) and meropenem (MER). Also, in the EV database, most CDI-related ADRs were reported for CFT, PIP/TAZ (piperacillin/tazobactam), MER, and CPX (ciprofloxacin). Understanding the association between previous antibiotic exposure and the risk of CDI may help update antibiotic stewardship protocols and reduce the incidence of CDI by lowering exposure to high-risk antibiotics.

A Pharmacovigilance Study Regarding the Risk of Antibiotic-Associated Clostridioides difficile Infection Based on Reports from the EudraVigilance Database: Analysis of Some of the Most Used Antibiotics in Intensive Care Units.

The Gram-positive anaerobic bacterium Clostridioides difficile (CD) can produce intense exotoxins, contributing to nosocomial infections, and it is the most common cause of health-care-associated infectious diarrhea. Based on spontaneous Individual Case Safety Reports from EudraVigilance (EV), we conducted a descriptive analysis of Clostridioides difficile infection (CDI) cases that reported a spontaneous adverse reaction related to using ceftriaxone, colistimethate, ciprofloxacin, gentamicin, linezolid, meropenem, and piperacillin/tazobactam. Most ADR reports registered in EV that were related to CDI were associated with ceftriaxone (33%), ciprofloxacin (28%), and piperacillin/tazobactam (21%). Additionally, the disproportionality analysis performed showed that all studied antibiotics had a lower reporting probability when compared to clindamycin. A causal relationship between a drug and the occurrence of an adverse reaction cannot be established from EV data alone because the phenomena of underreporting, overreporting, and reporting bias may affect the results. Based on the analysis of the collected data, this study underlines the importance of surveillance and monitoring programs for the consumption of antibiotics. Furthermore, it is essential to use standardized laboratory tests to define CDI's nature accurately. To prevent this infection, specialists should collaborate and adhere strictly to antibiotic stewardship programs, hygiene practices, and isolation protocols.

A Study on the Contributions of Sonication to the Identification of Bacteria Associated with Intubation Cannula Biofilm and the Risk of Ventilator-Associated Pneumonia.

Ventilator-associated pneumonia is one of the most severe complications of critically ill patients that need mechanical respiratory support, as it poses a significant risk of prolonging hospitalization, disability, and even death. This is why physicians worldwide target newer methods for prevention, early diagnosis, and early target treatment for this condition. There are few methods for a quick etiological diagnosis of pneumonia, especially point of care, and most are only readily available in some intensive care units. This is why a new, simple, and cheap method is needed for determining the bacteria that might be infectious in a particular patient. The manner in question is sonication. Method: In this prospective, observational, single-center study, endotracheal cannula specimens will be collected from at least 100 patients in our intensive care unit. This specimen will be submitted to a specific sonication protocol for bacteria to dislodge the biofilm inside the cannula. The resulting liquid will be seeded on growth media, and then a comparison will be made between the germs in the biofilm and the ones in the tracheal secretion of the patient. The primary purpose is to determine the bacteria before the appearance of a manifest infection.

Therapeutic Plasma Exchange in Catastrophic Antiphospholipid Syndrome (CAPS): A Rare Case Report and Literature Review.

BACKGROUND/AIM: Catastrophic antiphospholipid syndrome (CAPS) may be the first manifestation ("de novo") of antiphospholipid syndrome (APS) or a complication in the clinical course of patients known to have this syndrome. Approximately 40% of patients had an associated autoimmune disease, mainly, systemic lupus erythematosus (SLE). The trigger can be one of the following: infections, surgical interventions, neoplasms, pregnancy, discontinuation of anticoagulant treatment, and others. CAPS is a medical emergency in which early identification and prompt initiation of aggressive therapy is extremely important. According to the Guidelines for the use of Therapeutic Apheresis in Clinical Practice developed by the American Society for Apheresis (ASFA), last updated in April 2023, in CAPS, the indication for therapeutic plasma exchange (TPE) is category I, grade 2C. CASE REPORT: We present a case of probable CAPS secondary to systemic lupus erythematosus (SLE) in an elderly patient in whom clinical and biological improvement was achieved through a multidisciplinary approach and prompt initiation of TPE. Because TPE is considered first-line therapy in CAPS, we initiated the procedure as soon as the attending rheumatologist raised this suspicion. Four plasmapheresis sessions were performed in the Intensive Care Unit. We used TPE by membrane filtration. Following the therapeutic intervention with TPE, corticotherapy (Solumedrol in puls-therapy), cyclophosphamide and anticoagulant treatment, the evolution was favourable, with clinical and biological improvement. CONCLUSION: The prompt initiation of TPE, because of the suspicion of CAPS, increases the chances of a favourable evolution.

Adverse Drug Reactions Relevant to Drug Resistance and Ineffectiveness Associated with Meropenem, Linezolid, and Colistin: An Analysis Based on Spontaneous Reports from the European Pharmacovigilance Database.

Antimicrobial resistance is considered one of the major threats to public health and is an important factor that influences the patient's outcome in the intensive care unit. Pharmacovigilance can help raise awareness of potential drug resistance (DR) or ineffectiveness (DI) through adverse drug reaction reports that are submitted to different spontaneous reporting systems. Based on spontaneous Individual Case Safety Reports from EudraVigilance, we conducted a descriptive analysis of adverse drug reactions associated with meropenem, colistin, and linezolid, with a focus on DR and DI. Of the total adverse drug reactions (ADRs) reported for each analyzed antibiotic by 31 December 2022, between 2.38-8.42% and 4.15-10.14% of the reports were related to DR and DI, respectively. A disproportionality analysis was conducted to evaluate the frequency of reporting adverse drug reactions relevant to the DR and DI of the analyzed antibiotics compared to other antimicrobials. Based on the analysis of the collected data, this study underlines the importance of post-marketing drug safety monitoring in raising a warning signal regarding antimicrobial resistance, thereby potentially contributing to the reduction in antibiotic treatment failure in an intensive care setting.

The Effect of Convalescent Plasma in Patients With Covid-19 in Intensive Care Unit.

BACKGROUND/AIM: Convalescent plasma collected from COVID-19 survivors contains antibodies against receptor binding domains with potent antiviral activity. The use of this therapy for COVID-19 is still under investigation, as the pathophysiological and immunological mechanisms responsible for the evolution of the disease have not been fully identified. PATIENTS AND METHODS: In this retrospective observational study, we included all patients with a confirmed SARS-Cov-2 infection based on positive RT-PCR testing, who received convalescent plasma treatment in addition to standard therapy, between 17.05.2020 and 27.11.2020, following hospitalization in the Anaesthesia and Intensive Care Unit of the Sibiu County Emergency Clinical Hospital, Romania. RESULTS: Convalescent plasma therapy of patients with SARS-Cov-2 infection and severe forms of the disease (requiring only high-flow oxygen therapy or non-invasive ventilation) significantly improved inflammatory markers (CRP, fibrinogen) and ventilatory parameters (SaO2, paO2, paO2/FiO2) reducing the need of supplemental oxygen delivery (p<0.05). Other factors that had a significant influence on the outcome were age and comorbidity. CONCLUSION: Inflammatory markers and ventilatory parameters were significantly improved and the need of supplemental oxygen delivery was reduced in COVID-19 patients treated with convalescent plasma.

Effects of repeated sprint training in hypoxia on physical performance among athletes: a systematic review / Efectos del entrenamiento de velocidad repetida en hipoxia sobre el rendimiento físico entre atletas: una revisión sistemática

SUMMARY: Repeated sprint training in hypoxia (RSH) represents an innovative method in the process of development and improvement of physical performance among athletes. However, there is less scientific data on this topic. The purpose of this systematic review was to investigate the effect of RSH method on motor abilities and performance among athletes, obtain new information, and expand the already known conclusions. The data search was performed of 4 electronic databases for the years 2000-2021 May as follows: Google Scholar, PubMed, Web of Science, and ResearchGate. This search with English language restriction was made by using the following terms, individually/combination: "repeated sprint ability", "hypoxia", "effects", "physical performance", "VO2max" 844 studies were indentified, and 14 studies were selected (11 male studies, 1 female study, 2 both sexes). Results of this systematic review, a total sample size of 347 athletes (40 females and 307 males, aged 15.3 ± 0.5 - 35 ± 7 years), showed that RSH was an effective training method in improving all monitored variables (i.e. RSAmax, VO2max). However, it should be noted that major improvements were observed mainly in repeated sprint ability (RSA) tests, and less in aerobic tests (i.e. Wingate and Yo-Yo). In conclusion, based on current scientific studies, RSH is more effective method to improve the physical performance among athletes compared to repeated sprint training in normoxia (RSN). This study suggested that the RSH has a positive effect on the monitored variables in physical performance tests especially related to RSA.

RESUMEN: El entrenamiento de velocidad repetida en hipoxia (RSH) representa un método innovador en el proceso de desarrollo y mejora del rendimiento físico entre los deportistas. Sin embargo, existen pocos datos científicos sobre este tema. El propósito de esta revisión sistemática fue investigar el efecto del método RSH sobre las habilidades motoras y el rendimiento de los atletas, obtener nueva información y ampliar las conclusiones ya conocidas. La búsqueda de datos se realizó en 4 bases de datos electrónicas: Google Scholar, PubMed, Web of Science e Research Gate para los años 2000- a mayo de 2021. Esta búsqueda se realizó en artículos en idioma inglés mediante el uso de los siguientes términos, individualmente / combinación: "capacidad de sprint repetido", "hipoxia", "efectos", "rendimiento físico" y "VO2max" Se identificaron 844 estudios y se seleccionaron 14 de ellos (11 estudios realizados en hombres, un estudio realizado en mujeres y dos estudios realizados en am- bos sexos). Los resultados mostraron, un tamaño muestral total de 347 atletas (40 mujeres y 307 hombres, de 15,3 ± 0,5 - 35 ± 7 años). Se observó que la RSH fue un método de entrenamiento eficaz para mejorar todas las variables monitorizadas (es decir, RSAmax y VO2max). Sin embargo, se debe tener en consideración que se observaron mejoras importantes, principalmente, en las pruebas de capacidad de sprint repetido (RSA), y menos en las pruebas aeróbicas (es decir, Wingate y Yo-Yo). En conclusión, según los estudios científicos actuales, la RSH es un método más eficaz para mejorar el rendimiento físico entre los atletas en comparación con el entrenamiento de velocidad repetida en normoxia (RSN). Este estudio sugirió que la RSH tiene un efecto positivo sobre las variables monitoreadas en las pruebas de rendimiento físico especialmente relacionadas con RSA.

Gene Expression Profile of Vascular Endothelial Growth Factors (VEGFs) and Platelet-derived Growth Factors (PDGFs) in the Normal Cornea.

BACKGROUND/AIM: Angiogenic growth factors expression is not known in the normal cornea. The aim was to study corneal gene expression profile of VEGF and PDGF pathways influencing the avascular state of cornea. MATERIALS AND METHODS: cDNA synthesis was performed from mRNA extracted from five fresh pig corneas followed by cDNA synthesis and analysis of VEGF and PDGF pathways by TaqMan Array gene expression profile. RESULTS: Normal pig cornea lacks VEGFR2 and VEGFR3 gene expression. MK2 and AKT1 genes were significantly overexpressed (p=0.000684, p=0.050995, respectively). Six PDGF pathway genes were overexpressed: TIAM1 (p=0.047), PIK3CA (p=0.00005), IKBKG (p=0.000006), PAK4 (p=0.034), RAC1 (p=0.000006 and PTGS2, p=0.00375). PDGF A was up-regulated, but not with a statistical significance (p=0.79911), while PDGFRα was down-regulated and PDGFRß was not expressed. CONCLUSION: Normal cornea avascularity is given by growth factor receptors down-regulation. Rapid corneal neovascularisation is induced by activation of the main angiogenic growth factors that induce angiogenic cascade and vessel recruitment.

THERAPEUTIC PLASMA EXCHANGE AND DOUBLE FILTRATION PLASMAPHERESIS IN SEVERE NEUROIMMUNE DISORDERS.

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique, which removes large molecular weight particles such as autoantibodies from plasma. TPE is accepted by the American Society for Apheresis as first line treatment for some severe neuroimmune disorders. Double filtration plasmapheresis (DFPP) is a newer technique in which plasma is not entirely removed, only the antibodies, using special filters. High-dose intravenous immunoglobulins are an alternative treatment for these patients but are much more expensive. We reviewed medical records of 20 patients with severe neurological diseases requiring TPE or DFPP. We analyzed the indications, complications and efficacy of these procedures. After completing the procedures, neurological improvement was recorded in 80% of the patients, 5% had no improvement, and the mortality was 15%. The rate of neurological improvement was similar to other studies. None of the patients presented catheter related complications. Systemic complications were mild, transient and completely reversible.

VEGF mRNA assessment in human pterygium: a new 'scope' for a future hope.

PURPOSE: The lack of powerful evidence to support the efficacy of anti-vascular endothelial growth factor (VEGF) therapy in human pterygium can be attributed to incomplete VEGF expression assessment by restrictive use of immunohistochemistry only and failure to use the molecular methods able to confirm immunohistochemical findings. By adding at least one more sensitive method to assess human pterygium VEGF expression, a more accurate selection of patients for bevacizumab therapy could be done and this would improve the efficacy of anti-VEGF therapy in human pterygium. METHODS: We assessed VEGF mRNA amplification on paraffin-embedded specimens by applying the RNAscope method for the first time in human pterygium, an in situ hybridization-based technique able to detect VEGF mRNA as a single gene copy on paraffin-embedded samples. RESULTS: Heterogeneous VEGF mRNA distribution and amplification inside the epithelial compartment of human pterygium were observed. Despite previous reports concerning the immunohistochemical expression of VEGF in the human pterygium fibrovascular compartment, no stromal components were characterized by VEGF mRNA amplification assessed by in situ hybridization in our study. A higher amplification score was observed in epithelium from recurrent pterygium, especially located in the basal and suprabasal epithelial cells. CONCLUSIONS: Based on our findings we consider that in situ hybridization assessment of VEGF for human pterygium specimens can be a useful tool for reconsidering the selection of pterygium patients to be enrolled in anti-VEGF therapy.

DNA damage in human pterygium: one-shot multiple targets.

PURPOSE: Little is known about DNA damage in human pterygium, and no data about DNA damage involvement as a potential angiogenic factor are available. We studied, with immunohistochemistry, the presence and localization of thymine dimers in the epithelial and stromal components of the human primary pterygium and its recurrences with a special emphasis on the vascular network and its interactions with the p53 tumor suppressor gene protein. METHODS: Thirty-five primary human pterygium, three recurrences, and three normal bulbar conjunctiva were included in the present study. Formalin-fixed, paraffin-embedded tissues were submitted for immunohistochemical analysis with antithymine dimers and p53 antibodies. Thymine dimer and p53 nuclear staining was assessed in the epithelial and stromal components of pterygial tissues and normal counterparts. RESULTS: Thymine dimers were present in the epithelial and stromal components of human pterygium and its recurrences. The thymine dimers were detected in the epithelial component of the human pterygium with a higher density and intensity in the basal layer of the epithelium. Small blood vessels' endothelial cells showed positive reaction for antithymine dimer antibodies together with isolated positive expression found in the nuclei of perivascular cells. For the recurrent pterygium, dimer expression was found only in the subepithelial fibrovascular layer components and in scattered cells from the basal layer of the epithelium. P53 expression was positive in 38.5% of the cases in the epithelial compartment, and in two cases, scattered p53 positive endothelial, fibroblast-like, and perivascular cells were detected in the fibrovascular compartment. CONCLUSIONS: Thymine dimers in human pterygium and its recurrences suggest that DNA damage is involved not only in pterygium epithelial and fibrous proliferation but also in angiogenesis and lymphangiogenesis from this ocular lesion in a still incomplete elucidated pathogenic mechanism.

Preliminary evidence of the presence of lymphatic vessels immunoreactive for D2-40 and Prox-1 in human pterygium.

Human pterygium is a benign fibrovascular outgrowth of the corneo-conjunctival junction, characterized by tissue remodeling, cellular proliferation, angiogenesis and inflammation. No data are available concerning the presence of lymphatic vessels in this pathological condition. The aim of this study was to evaluate by immunohistochemistry, using antibodies against D2-40, Prox-1 and Ki-67, the presence and the proliferative activity of lymphatic vessels in human pterygium. An increased lymphatic microvessel density was observed in the human pterygium compared to the normal conjunctiva. Moreover, D2-40-positive lymphatic endothelial cells were also actively proliferating, as assessed by Ki-67 immunostaining, while in normal conjunctiva proliferating lymphatic endothelial cells were not detectable. Overall, these data clearly indicate the presence of active proliferating lymphatic vessels in human pterygium, suggesting that active lymphangiogenesis occurs in this pathological condition.