Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016

MMWR  January 13, 2017  V.66 N.1 P.33

On August 25, 2016, the Washoe County Health District in Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-resistant Enterobacteriaceae (CRE) that was resistant to all available antimicrobial drugs.

The specific CRE, Klebsiella pneumoniae, was isolated from a wound specimen collected on August 19, 2016. After CRE was identified, the patient was placed in a single room under contact precautions.

The patient had a history of recent hospitalization outside the United States. Therefore, based on CDC guidance (1), the isolate was sent to CDC for testing to determine the mechanism of antimicrobial resistance, which confirmed the presence of New Delhi metallo-beta-lactamase (NDM).

The patient was a female Washoe County resident in her 70s who arrived in the United States in early August 2016 after an extended visit to India.

She was admitted to the acute care hospital on August 18 with a primary diagnosis of systemic inflammatory response syndrome, likely resulting from an infected right hip seroma.

The patient developed septic shock and died in early September.

During the 2 years preceding this U.S. hospitalization, the patient had multiple hospitalizations in India related to a right femur fracture and subsequent osteomyelitis of the right femur and hip; the most recent hospitalization in India had been in June 2016….


January 16, 2017 at 8:46 am

Severe community-acquired pneumonia: timely management measures in the first 24 hours.

Crit Care. 2016 Aug 28;20:237. doi: 10.1186/s13054-016-1414-2.

Phua J1,2, Dean NC3,4, Guo Q5,6, Kuan WS7,8, Lim HF1,2, Lim TK9,10.

Author information

1Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.

2Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

3Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.

4Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.

5Department of Respiratory Medicine, Affiliated Futian Hospital, Guangdong Medical College, Shenzhen, Guangdong, China.

6Guangzhou Institute of Respiratory Diseases (State Key Laboratory of Respiratory Diseases), First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.

7Department of Emergency Medicine, National University Hospital, National University Health System, Singapore, Singapore.

8Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

9Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.

10Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.


Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files.

We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools.

The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required.

We propose a workflow incorporating these interventions.



January 15, 2017 at 3:51 pm

New aspects in the management of pneumonia.

Crit Care. 2016 Oct 1;20(1):267.

Prina E1, Ceccato A1,2, Torres A3,4,5.

Author information

1Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.

2Seccion Neumologia, Hospital Nacional Alejandro Posadas, Palomar, Argentina.

3Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.

4Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain.

5UVIR, Servei de Pneumologia, Hospital Clínic, Villarroel 170., 08036, Barcelona, Spain.


Despite improvements in the management of community-acquired pneumonia (CAP), morbidity and mortality are still high, especially in patients with more severe disease.

Early and appropriate antibiotics remain the cornerstone in the treatment of CAP. However, two aspects seem to contribute to a worse outcome: an uncontrolled inflammatory reaction and an inadequate immune response.

Adjuvant treatments, such as corticosteroids and intravenous immunoglobulins, have been proposed to counterbalance these effects.

The use of corticosteroids in patients with severe CAP and a strong inflammatory reaction can reduce the time to clinical stability, the risk of treatment failure, and the risk of progression to acute respiratory distress syndrome.

The administration of intravenous immunoglobulins seems to reinforce the immune response to the infection in particular in patients with inadequate levels of antibodies and when an enriched IgM preparation has been used; however, more studies are needed to determinate their impact on outcome and to define the population that will receive more benefit.


January 15, 2017 at 3:49 pm

Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis.

PLoS One. 2016 Nov 15;11(11):e0165942. doi: 10.1371/journal.pone.0165942. eCollection 2016.

Bi J1, Yang J1, Wang Y1, Yao C2, Mei J1, Liu Y2, Cao J3, Lu Y1.

Author information

1Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China.

2School of Public Health, Anhui Medical University, Hefei, China.

3The Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China.



Adjunctive corticosteroids therapy is an attractive option for community-acquired pneumonia (CAP) treatment. However, the effectiveness of adjunctive corticosteroids on mortality of CAP remains inconsistent, especially in severe CAP. We performed a meta-analysis to evaluate the efficacy and safety of adjunctive corticosteroids in severe CAP patients.


Three databases of PubMed, EMBASE and Cochrane Library were searched for related studies published in English up to December, 2015. Randomized controlled trials (RCTs) of corticosteroids in hospitalized adults with severe CAP were included. Meta-analysis was performed by a random-effect model with STATA 11.0 software. We estimated the summary risk ratios (RRs) or effect size (ES) with its corresponding 95% confidence interval (95%CI) to assess the outcomes.


We included 8 RCTs enrolling 528 severe CAP patients. Adjunctive corticosteroids significantly reduced all-cause mortality (RR = 0.46, 95%CI: 0.28 to 0.77, p = 0.003), risk of adult respiratory distress syndrome (ARDS) (RR = 0.23, 95%CI: 0.07 to 0.80, p = 0.02) and need for mechanical ventilation (RR = 0.50, 95%CI: 0.27 to 0.92, p = 0.026). Adjunctive corticosteroids did not increase frequency of hyperglycemia requiring treatment (RR = 1.03, 95%CI: 0.61 to 1.72, p = 0.91) or gastrointestinal hemorrhage (RR = 0.66, 95%CI: 0.19 to 2.31, p = 0.52). In subgroup analysis by duration of corticosteroids, we found that prolonged corticosteroids therapy significantly reduced all-cause mortality (RR = 0.41, 95%CI: 0.20 to 0.83, p = 0.01) and length of hospital stay (-4.76 days, 95% CI:-8.13 to -1.40, p = 0.006).


Results from this meta-analysis suggested that adjunctive corticosteroids therapy was safe and beneficial for severe CAP. In addition, prolonged corticosteroids therapy was more effective. These results should be confirmed by adequately powered studies in the future.


January 15, 2017 at 3:47 pm

Is β-Lactam Plus Macrolide More Effective than β-Lactam Plus Fluoroquinolone among Patients with Severe Community-Acquired Pneumonia?: a Systemic Review and Meta-Analysis.

J Korean Med Sci. 2017 Jan;32(1):77-84. doi: 10.3346/jkms.2017.32.1.77.

Lee JH1, Kim HJ2, Kim YH3.

Author information

1Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea.

2Institute for Evidence-based Medicine, Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea.

3Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea.


Adding either macrolide or fluoroquinolone (FQ) to β-lactam has been recommended for patients with severe community-acquired pneumonia (CAP).

However, due to the limited evidence available, there is a question as to the superiority of the two combination therapies. The MEDLINE, EMBASE, Cochrane Central Register, Scopus, and Web of Science databases were searched for systematic review and meta-analysis.

A total of eight trials were analyzed. The total number of patients in the β-lactam plus macrolide (BL-M) and β-lactam plus fluoroquinolone (BL-F) groups was 2,273 and 1,600, respectively. Overall mortality of the BL-M group was lower than that of the BL-F group (19.4% vs. 26.8%), which showed statistical significance (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.49 to 0.94; P = 0.02). Length of hospital stay was reduced in the BL-M group compared to the BL-F group (mean difference, -3.05 days; 95% CI, -6.01 to -0.09; P = 0.04).

However, there was no significant difference in length of intensive care unit (ICU) stay between the two groups.

Among patients with severe CAP, BL-M therapy may better reduce overall mortality and length of hospital stay than BL-F therapy.

However, we could not elicit strong conclusions from the available trials due to high risk of bias and methodological limitations.


January 15, 2017 at 3:46 pm

Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta-analysis.

Sci Rep. 2016 Dec 7;6:38097.

Komiya K1,2,3, Rubin BK1, Kadota JI2, Mukae H4, Akaba T1, Moro H5, Aoki N5, Tsukada H6, Noguchi S7, Shime N8, Takahashi O9, Kohno S4.

Author information

1Department of Pediatrics, Virginia Commonwealth University School of Medicine, 1217 East Marshall Street: KMSB, Room 215 Richmond, Virginia 23298, USA.

2Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan.

3Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, 5956 Nihongi, Nakahetsugi, Oita, 879-7761, Japan.

4Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.

5Department of Respiratory Medicine and Infectious Diseases, Niigata University Graduate School of Medical and Dental Sciences, 757 Asahi-machi, Chuo-ku, Niigata, 951-8510, Japan.

6Department of Respiratory Medicine/Infectious Disease, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata, 950-1197, Japan.

7Department of Respiratory Medicine, University of Occupational and Environmental Health, 1-1 Idaigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.

8Department of Emergency and Critical Care Medicine, Institute of Biomedical &Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8553, Japan.

9Center for Clinical Epidemiology, St. Luke’s Life Science Institute, 10-1 Akashicho, Chuo-ku, Tokyo, 104-0044, Japan.


Aspiration pneumonia is thought to be associated with a poor outcome in patients with community acquired pneumonia (CAP). However, there has been no systematic review regarding the impact of aspiration pneumonia on the outcomes in patients with CAP.

This review was conducted using the MOOSE guidelines

Patients: patients defined CAP.


aspiration pneumonia defined as pneumonia in patients who have aspiration risk. Comparison: confirmed pneumonia in patients who were not considered to be at high risk for oral aspiration.


mortality, hospital readmission or recurrent pneumonia. Three investigators independently identified published cohort studies from PubMed, CENTRAL database, and EMBASE. Nineteen studies were included for this systematic review. Aspiration pneumonia increased in-hospital mortality (relative risk, 3.62; 95% CI, 2.65-4.96; P < 0.001, seven studies) and 30-day mortality (3.57; 2.18-5.86; P < 0.001, five studies). In contrast, aspiration pneumonia was associated with decreased ICU mortality (relative risk, 0.40; 95% CI, 0.26-0.60; P < 0.00001, four studies). Although there are insufficient data to perform a meta-analysis on long-term mortality, recurrent pneumonia, and hospital readmission, the few reported studies suggest that aspiration pneumonia is also associated with these poor outcomes. In conclusion, aspiration pneumonia was associated with both higher in-hospital and 30-day mortality in patients with CAP outside ICU settings.


January 15, 2017 at 3:44 pm

IDSA GUIDELINES – Diagnosis of Tuberculosis in Adults and Children

Clinical Infectious Diseases January 15, 2017 V.64 N.2 P.111-115

David M. Lewinsohn, Michael K. Leonard, Philip A. LoBue, David L. Cohn, Charles L. Daley, Ed Desmond, Joseph Keane, Deborah A. Lewinsohn, Ann M. Loeffler, Gerald H. Mazurek, Richard J. O’Brien, Madhukar Pai, Luca Richeldi, Max Salfinger, Thomas M. Shinnick, Timothy R. Sterling, David M. Warshauer, and Gail L. Woods

1 Oregon Health & Science University, Portland, Oregon,

2 Emory University School of Medicine and

3 Centers for Disease Control and Prevention, Atlanta, Georgia,

4 Denver Public Health Department, Denver, Colorado,

5 National Jewish Health and the University of Colorado Denver, and

6 California Department of Public Health, Richmond;

7 St James’s Hospital, Dublin, Ireland;

8 Francis J. Curry International TB Center, San Francisco, California;

9 Foundation for Innovative New Diagnostics, Geneva, Switzerland;

10 McGill University and McGill International TB Centre, Montreal, Canada;

11 University of Southampton, United Kingdom;

12 National Jewish Health, Denver, Colorado,

13 Vanderbilt University School of Medicine, Vanderbilt Institute for Global Health, Nashville, Tennessee,

14 Wisconsin State Laboratory of Hygiene, Madison, and

15 University of Arkansas for Medical Sciences, Little Rock


Individuals infected with Mycobacterium tuberculosis (Mtb) may develop symptoms and signs of disease (tuberculosis disease) or may have no clinical evidence of disease (latent tuberculosis infection [LTBI]). Tuberculosis disease is a leading cause of infectious disease morbidity and mortality worldwide, yet many questions related to its diagnosis remain.


A task force supported by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America searched, selected, and synthesized relevant evidence. The evidence was then used as the basis for recommendations about the diagnosis of tuberculosis disease and LTBI in adults and children. The recommendations were formulated, written, and graded using the Grading, Recommendations, Assessment, Development and Evaluation (GRADE) approach.


Twenty-three evidence-based recommendations about diagnostic testing for latent tuberculosis infection, pulmonary tuberculosis, and extrapulmonary tuberculosis are provided. Six of the recommendations are strong, whereas the remaining 17 are conditional.


These guidelines are not intended to impose a standard of care. They provide the basis for rational decisions in the diagnosis of tuberculosis in the context of the existing evidence. No guidelines can take into account all of the often compelling unique individual clinical circumstances.


January 12, 2017 at 6:21 pm

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