Archive for September 30, 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.



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.


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.


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.


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.



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 .



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.


To evaluate the usefulness of CarbaNP in an Indian setting.


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.


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.


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.


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.


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.


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.



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.


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.


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.


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.


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…..



September 30, 2016 at 8:24 am


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