Archive for September, 2016

Carbapenem-resistant Enterobacteriaceae – Prevalence and Risk Factors in a Single Community-Based Hospital in Korea.

Infect Chemother. Sep 8. 2016

Lee HJ1,2, Choi JK1,2, Cho SY1,2, Kim SH1,2, Park SH1,2, Choi SM1,2, Lee DG1,2, Choi JH1,2, Yoo JH1,3.

Author information

1Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.

2Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.

3Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea. jhyoo@catholic.ac.kr

Abstract

BACKGROUND:

Carbapenemase-producing Enterobacteriaceae (CPE) are Gram-negative bacteria with increasing prevalence of infection worldwide. In Korea, 25 cases of CPE isolates were reported by the Korea Centers for Disease Control and Prevention in 2011. Most CPE cases were detected mainly at tertiary referral hospitals. We analyzed the prevalence and risk factors for carbapenem-resistant Enterobacteriaceae (CRE) in a mid-sized community-based hospital in Korea.

MATERIALS AND METHODS:

We retrospectively analyzed all consecutive episodes of Enterobacteriaceae in a mid-sized community-based hospital from January 2013 to February 2014. CRE was defined as organisms of Enterobacteriaceae showing decreased susceptibility to carbapenems. Risk factors for CRE were evaluated by a case-double control design. Carbapenemase was confirmed for CRE using a combined disc test.

RESULTS:

During 229,710 patient-days, 2,510 Enterobacteriaceae isolates were obtained. A total of 41 (1.6%) CRE isolates were enrolled in the study period. Thirteen species (31.7%) were Enterobacter aerogenes, 8 (19.5%) Klebsiella pneumoniae, 5 (12.2%) Enterobacter cloacae, and 15 other species of Enterobacteriaceae, respectively. Among the 41 isolates, only one (2.4%) E. aerogenes isolate belonged to CPE. For evaluation of risk factors, a total of 111 patients were enrolled and this included 37 patients in the CRE group, 37 in control group I (identical species), and 37 in control group II (different species). Based on multivariate analysis, regularly visiting the outpatient clinic was a risk factor for CRE acquisition in the control group I (P = 0.003), while vascular catheter and Charlson comorbidity index score ≥ 3 were risk factors in control group II (P = 0.010 and 0.011, each). Patients with CRE were more likely to experience a reduced level of consciousness, use a vasopressor, be under intensive care, and suffer from acute kidney injury. However, CRE was not an independent predictor of mortality compared with both control groups.

CONCLUSION:

In conclusion, the prevalence of CRE was higher than expected in a mid-sized community-based hospital in Korea. CRE should be considered when patients have a vascular catheter, high comorbidity score, and regular visits to the outpatient clinic. This study suggests the need for appropriate prevention efforts and constant attention to CRE infection control in a mid-sized community-based hospital.

PDF

http://www.icjournal.org/Synapse/Data/PDFData/0086IC/ic-48-166.pdf

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September 30, 2016 at 4:04 pm

A Pilot Study on Carbapenemase Detection: Do We See the Same Level of Agreement as with the CLSI Observations.

J Clin Diagn Res. 2016 Jul;10(7):DC09-13.

Pragasam AK1, Sahni RD2, Anandan S2, Sharma A3, Gopi R1, Hadibasha N1, Gunasekaran P1, Veeraraghavan B4.

Author information

1Research Associate, Department of Clinical Microbiology, Christian Medical College , Vellore, India .

2Professor, Department of Clinical Microbiology, Christian Medical College , Vellore, India .

3Registrar, Department of Clinical Microbiology, Christian Medical College , Vellore, India .

4Professor & Head, Department of Clinical Microbiology, Christian Medical College , Vellore, India .

Abstract

INTRODUCTION:

Rapid identification of carbapenemase producing organisms is of great importance for timely detection, treatment and implementation of control measures to prevent the spread. The Modified Hodge Test (MHT) and Carba NP test is recommended by CLSI for the detection of carbapenemases in Enterobacteriaceae. However, MHT may give false positive results or fail to detect metallo β-lactamases (MBLs). In the US, MHT is the most widely used test for detection of carbapenemases and has been found to have a sensitivity and specificity of >90% for bla KPC producers. However, in India, the prevalence of bla NDM is higher than bla KPC producers.

AIM:

To evaluate the usefulness of CarbaNP in an Indian setting.

MATERIALS AND METHODS:

A total of 260 isolates of carbapenem resistant E.coli (n=57), Klebsiella spp. (n=85), Pseudomonas aeruginosa (n=60), and Acinetobacter baumannii (58) isolated from clinical specimens between 2012-2014 at the Christian Medical College, Vellore were included in the study. All the carbapenem resistant isolates were subjected to CarbaNP, MHT and multiplex PCR for detection of carbapenemase genes.

RESULTS:

CarbaNP was found to be positive in 88% (n=50/57), 81% (n=69/51), 38% (n=23/60) and 81% (n=47/58) for E.coli, Klebsiella spp., P. aeruginosa, and A. baumannii respectively. While in MHT it showed, 89% (n=51/57) and 81 % (n=69/85) for E.coli and Klebsiella spp. respectively. In P.aeruginosa, synergy testing of imipenem plus cloxacillin showed that, 65% of CarbaNP negatives were ampC producers. Overall, the sensitivity and specificity of CarbaNP was found to be 94% and 100 for bla NDM; 77% and 100 % for bla OXA-48 like producers and 81% and 100% for CarbAcinetoNP respectively.

CONCLUSION:

This observation was more than what was reported in CLSI guidelines. Therefore, it is advisable to evaluate an assay for better laboratory diagnosis at respective regions.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020186/pdf/jcdr-10-DC09.pdf

September 30, 2016 at 4:03 pm

Acute Management of Open Fractures: An Evidence-Based Review.

Orthopedics. 2015 Nov;38(11):e1025-33.

Halawi MJ, Morwood MP.

Abstract

Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.

PDF

http://www.healio.com/orthopedics/journals/ortho/2015-11-38-11/%7B45022439-2bf0-4753-b7d6-cbf74fb1a73d%7D/acute-management-of-open-fractures-an-evidence-based-review.pdf

September 30, 2016 at 11:43 am

Impact of treatment with biologic DMARDs on the risk of sepsis or mortality after serious infection in patients with rheumatoid arthritis.

Ann Rheum Dis. 2016 Sep V.75 N.9 P.1667-73.

Richter A1, Listing J1, Schneider M2, Klopsch T3, Kapelle A4, Kaufmann J5, Zink A6, Strangfeld A1.

Author information

1Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany.

2Scientific Advisory Board Düsseldorf, Duesseldorf, Germany.

3Neubrandenburg, Germany.

4Hoyerswerda, Germany.

5Ludwigsfelde, Germany.

6Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany Charité University Medicine Berlin.

Abstract

OBJECTIVE:

This observational cohort study investigated the impact of biological (b) disease-modifying antirheumatic drugs (DMARDs) on the outcomes of serious infections (SIs) in patients with rheumatoid arthritis.

METHODS:

We investigated outcomes of SIs observed in 947 patients enrolled in the German biologics register RABBIT(Rheumatoid arthritis: observation of biologic therapy). Outcomes were (1) recovery without complication, (2) sepsis following SI (≤30 days), and (3) death after SI without known sepsis (≤90 days). We applied a multinomial generalised estimating equation model for longitudinal data to evaluate the risks of sepsis and death simultaneously.

RESULTS:

Sepsis within 30 days after SI was reported in 135 out of 947 patients, 85 of these had a fatal outcome. Fifty-three patients died within 90 days after SI without known sepsis. The adjusted risk of developing sepsis increased with age and was higher in patients with chronic renal disease. Compared with conventional synthetic (cs)DMARDs, the risk was significantly lower when patients were exposed to bDMARDs at the time of SI (OR: 0.56, 95% CI 0.38 to 0.81). Risk factors of fatal SI were higher age, use of glucocorticoids at higher doses and heart failure. Patients treated with bDMARDs and those with better physical function had a significantly lower mortality risk.

CONCLUSIONS:

These results suggest a beneficial effect of bDMARDs on the risk of sepsis after SI and the risk of a fatal outcome. Successful immunosuppression may prevent an unregulated host response to SI, that is, the escalation to sepsis. Further investigation is needed to validate these results.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5013078/pdf/annrheumdis-2015-207838.pdf

September 30, 2016 at 8:27 am

Scrub Typhus – Scientific Neglect, Ever-Widening Impact.

N Engl J Med. Sep. 8, 2016 V.375 N.10 P.:913-5.

Walker DH1.

Author information

1From the Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch, Galveston.

Scrub typhus, a systemic, life-threatening disease with an enormous incidence in Asia and the islands of the Pacific and Indian Oceans, remains remarkably neglected. Discovery of this vectorborne infectious disease on Chiloé Island in Chile (see report by Weitzel et al., pages 954–61) and its detection in Africa highlight the fact that we have heretofore paid too little attention to it and developed too little relevant expertise.1 The Allied armies were caught flat-footed during World War II when 18,000 of their troops became ill with scrub typhus in the Pacific theater, and the disease remained a major cause of severe, undifferentiated febrile illness in U.S. military forces in Vietnam. Currently, there is a tremendous widespread reemergence of scrub typhus in locations such as India, Micronesia, and the Maldives, where it had been forgotten, and its incidence is growing in locations such as South Korea and China north of the Yangtze River, where it was previously unknown…..

FULL TEXT

http://www.nejm.org/doi/full/10.1056/NEJMp1608499

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMp1608499

September 30, 2016 at 8:24 am

Adjunctive azithromycin prophylaxis for cesarean delivery.

N Engl J Med 2016 Sep 29; 375:1231

Alan T.N. Tita, M.D., Ph.D., Jeff M. Szychowski, Ph.D., Kim Boggess, M.D., George Saade, M.D., Sherri Longo, M.D., Erin Clark, M.D., Sean Esplin, M.D., Kirsten Cleary, M.D., Ron Wapner, M.D., Kellett Letson, M.D., Michelle Owens, M.D., Adi Abramovici, M.D., Namasivayam Ambalavanan, M.D., Gary Cutter, Ph.D., and William Andrews, M.D., Ph.D., for the C/SOAP Trial Consortium*

BACKGROUND

The addition of azithromycin to standard regimens for antibiotic prophylaxis before cesarean delivery may further reduce the rate of postoperative infection. We evaluated the benefits and safety of azithromycin-based extended-spectrum prophylaxis in women undergoing nonelective cesarean section.

METHODS

In this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis. The primary outcome was a composite of endometritis, wound infection, or other infection occurring within 6 weeks.

RESULTS

The primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03). There was no significant between-group difference in a secondary neonatal composite outcome that included neonatal death and serious neonatal complications (14.3% vs. 13.6%, P=0.63).

CONCLUSIONS

Among women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; C/SOAP ClinicalTrials.gov number, NCT01235546.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1602044

 

 

N Engl J Med 2016 Sep 29; 375:1284

Antibiotic prophylaxis for cesarean delivery — when broader is better.

Weinstein RA and Boyer KM

Approximately 4 million babies are born each year in the United States. Of these infants, about a third are delivered by cesarean section. One of the many concerns about cesarean deliveries is the high risk of maternal infectious complications, which are 5 to 10 times more frequent than with vaginal deliveries.1 During cesarean delivery, the endometrial cavity and operative field may be seeded with pathogens, carried from the birth canal or the skin, that put mothers at risk for endometritis (incidence without prophylaxis, 4 to 18%) and of surgical-site infections (incidence without prophylaxis, 7 to 10%).2 To reduce these risks, prophylactic administration of an intravenous periprocedural antibiotic, usually cefazolin, is routinely recommended. Such an infusion reduces these rates by about half.3 Stringent adherence to infection-control protocols and broader antibiotic regimens might yield further reductions……

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMe1610010

September 29, 2016 at 8:19 am

Validated Risk Score for Predicting 6-Month Mortality in Infective Endocarditis.

J Am Heart Assoc. 2016 Apr 18;5(4):e003016.

Park LP, Chu VH, Peterson G, Skoutelis A, Lejko-Zupa T, Bouza E, Tattevin P, Habib G, Tan R, Gonzalez J, Altclas J, Edathodu J, Fortes CQ, Siciliano RF, Pachirat O, Kanj S, Wang A; International Collaboration on Endocarditis (ICE) Investigators.

Collaborators (306)

Clara L, Sanchez M, Casabé J, Cortes C, Nacinovich F, Fernandez Oses P, Ronderos R, Sucari A, Thierer J, Kogan S, Spelman D, Athan E, Harris O, Kennedy K, Gordon D, Papanicolas L, Korman T, Kotsanas D, Dever R, Jones P, Konecny P, Lawrence R, Rees D, Ryan S, Feneley MP, Harkness J, Jones P, Ryan S, Jones P, Ryan S, Jones P, Post J, Reinbott P, Ryan S, Gattringer R, Wiesbauer F, Andrade AR, de Brito AC, Guimarães AC, Grinberg M, Mansur AJ, Strabelli TM, Vieira ML, de Medeiros Tranchesi RA, Paiva MG, de Oliveira Ramos A, Weksler C, Ferraiuoli G, Golebiovski W, Lamas C, Karlowsky JA, Keynan Y, Morris AM, Rubinstein E, Jones SB, Garcia P, Fica A, Mella RM, Fernandez R, Franco L, Jaramillo AN, Barsic B, Bukovski S, Krajinovic V, Pangercic A, Rudez I, Vincelj J, Freiberger T, Pol J, Zaloudikova B, Ashour Z, El Kholy A, Mishaal M, Osama D, Rizk H, Aissa N, Alauzet C, Alla F, Campagnac C, Doco-Lecompte T, Selton-Suty C, Casalta JP, Fournier PE, Raoult D, Thuny F, Delahaye F, Delahaye A, Vandenesch F, Donal E, Donnio PY, Flecher E, Michelet C, Revest M, Chevalier F, Jeu A, Rémadi JP, Rusinaru D, Tribouilloy C, Bernard Y, Chirouze C, Hoen B, Leroy J, Plesiat P, Naber C, Neuerburg C, Mazaheri B, Naber C, Neuerburg C, Athanasia S, Deliolanis I, Giamarellou H, Thomas T, Giannitsioti E, Mylona E, Paniara O, Papanicolaou K, Pyros J, Mylona E, Paniara O, Papanikolaou K, Pyros J, Sharma G, Francis J, Nair L, Thomas V, Venugopal K, Hannan MM, Hurley JP, Cahan A, Gilon D, Israel S, Korem M, Strahilevitz J, Rubinstein E, Strahilevitz J, Durante-Mangoni E, Mattucci I, Pinto D, Agrusta F, Senese A, Ragone E, Utili R, Cecchi E, De Rosa F, Forno D, Imazio M, Trinchero R, Grossi P, Lattanzio M, Toniolo A, Goglio A, Raglio A, Ravasio V, Rizzi M, Suter F, Carosi G, Magri S, Signorini L, Kanafani Z, Kanj SS, Sharif-Yakan A, Abidin I, Tamin SS, Martínez ER, Soto Nieto GI, van der Meer JT, Chambers S, Holland D, Morris A, Raymond N, Read K, Murdoch DR, Dragulescu S, Ionac A, Mornos C, Butkevich OM, Chipigina N, Kirill O, Vadim K, Vinogradova T, Halim M, Liew YY, Tan RS, Logar M, Mueller-Premru M, Commerford P, Commerford A, Deetlefs E, Hansa C, Ntsekhe M, Almela M, Armero Y, Azqueta M, Castañeda X, Cervera C, Falces C, Garcia-de-la-Maria C, Fita G, Gatell JM, Heras M, Llopis J, Marco F, Mestres CA, Miró JM, Moreno A, Ninot S, Paré C, Pericas JM, Ramirez J, Rovira I, Sitges M, Anguera I, Font B, Guma JR, Bermejo J, Garcia Fernández MA, Gonzalez-Ramallo V, Marín M, Muñoz P, Pedromingo M, Roda J, Rodríguez-Créixems M, Solis J, Almirante B, Fernandez-Hidalgo N, Tornos P, de Alarcón A, Parra R, Alestig E, Johansson M, Olaison L, Snygg-Martin U, Pachirat P, Pussadhamma B, Senthong V, Casey A, Elliott T, Lambert P, Watkin R, Eyton C, Klein JL, Bradley S, Kauffman C, Bedimo R, Corey GR, Crowley AL, Douglas P, Drew L, Fowler VG, Holland T, Lalani T, Mudrick D, Samad Z, Sexton D, Stryjewski M, Woods CW, Lerakis S, Cantey R, Steed L, Wray D, Dickerman SA, Bonilla H, DiPersio J, Salstrom SJ, Baddley J, Patel M, Stancoven A, Levine D, Riddle J, Rybak M, Cabell CH, Baloch K, Corey GR, Dixon CC, Fowler VG Jr, Harding T, Jones-Richmond M, Sanderford B, Sanderford B, Stafford J, Stafford J, Anstrom K, Athan E, Bayer AS, Cabell CH, Corey GR, Fowler VG Jr, Hoen B, Karchmer AW, Miró JM, Murdoch DR, Sexton DJ, Bayer AS, Cabell CH, Chu V, Corey GR, Durack DT, Eykyn S, Fowler VG Jr, Hoen B, Miró JM, Moreillon P, Olaison L, Raoult D, Rubinstein E, Sexton DJ.

Abstract

BACKGROUND:

Host factors and complications have been associated with higher mortality in infective endocarditis (IE). We sought to develop and validate a model of clinical characteristics to predict 6-month mortality in IE.

METHODS AND RESULTS:

Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ICE]-Prospective Cohort Study [PCS], 2000-2006, n=4049), a model to predict 6-month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry (ICE-PLUS, 2008-2012, n=1197). The 6-month mortality was 971 of 4049 (24.0%) in the ICE-PCS cohort and 342 of 1197 (28.6%) in the ICE-PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left-sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6-month mortality, and surgery was associated with a lower risk of mortality (Harrell’s C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell’s C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62-0.89). A simplified risk model was developed by weight adjustment of these variables.

CONCLUSIONS:

Six-month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE.

PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859286/pdf/JAH3-5-e003016.pdf

September 28, 2016 at 8:32 am

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