Efficacy of Colistin Therapy in Patients with Hematological Malignancies: What if There is Colistin Resistance?

Objective: The objective of this study was to evaluate the clinical efficacy and appropriateness of colistin therapy in patients with hematological malignancies. Methods: Age, gender, type of hematologic malignancy, and potential carbapenem-resistant microorganism risk factors were all noted in this retrospective study. In empirical and agent-specific treatment groups, differences in demographic features, risk factors, treatment responses, and side effects were compared. Results: Sixty-three patients were included, 54% were male, and the median age was 49. In the last three months, the hospitalization rate history was 68%, and four patients had a hospitalization history in the ICU. Carbapenem-resistant K. pneumoniae colonization was present in 22 patients (35%). Gram-negative microorganisms were isolated in 34 patients (54%). The carbapenem, quinolone, and colistin resistance rates were 82%, 76%, and 4% respectively. Clinical and microbiological response rates were 60% and 69%. 7 and 28-day mortality rates were 17% and 35%. There was no significant difference in demographic data and comorbidities in empirical (n=48) and agent-specific (n=15) treatment groups. The rate of carbapenem and glycopeptide treatments before colistin was higher in the empirical treatment group (p = 0.004; p = 0.001). The rate of starting combined antibiotics was higher in the empirical treatment group (p = 0.016). Two of the patients developed renal failure in the first week after treatment. Conclusion: The use of empirical colistin may be unavoidable given the risk considerations. Shortly, colistin-resistant strains may also be a factor affecting treatment success negatively

Tularemia: A re-emerging disease

Tularemia is a bacterial zoonotic disease. The etiologic agent is Francisella tularensis which is a gram negative coccobacillus and has an exceedingly low infectious dose. Natural infections with F. tularensis have been reported in a range of vertebrates including mammals, birds, amphibians and fish. Tularemia occurs in humans only in the northern hemisphere and most frequently in Scandinavian countries, northern America, Japan and Russia. It is also an epidemic disease in some part of Turkey. The infection is transmitted to humans by arthropod bites (ticks, flies, mosquitoes), by direct contact with infected animals, by contact with infected tissues or fluids of infectious animals, by ingestion of contaminated water or food or by inhalation of infective aerosols. Clinical forms are ulceroglandular or glandular, oculoglandular, oropharyngeal, respiratory and typhoidal forms. The diagnosis is based on the isolation of F.tularensis and/or positive serology. In the therapy, the first choice is an aminoglycosides (streptomycin or gentamicin) and alternative choice is ciprofloxacin or doxycycline. Duration of therapy is suggested as 10-14 days. A live attenuated vaccine is only in use some parts of the former Soviet Union but no licensed vaccine available

An overview: Tularemia and travel medicine

Tularemia is a bacterial zoonotic infection. The disease is endemic in most parts of the world, has been reported through the northern hemisphere between 30 and 71 degrees N latitude. Francisella tularensis causes infection in a wide range of vertebrates (rodents, lagomorphs) and invertebrates (ticks, mosquitoes and other arthropods). Humans can acquire this infection through several routes including; a bite from an infected tick, deerfly or mosquito, contact with an infected animal or its dead body. It can also be spread to human by drinking contaminated water or breathing contaminated dirt or aerosol. Clinical manifestation of this disease varies depending on the biotype, inoculum and port of entry. Infection is potentially life threatening, but can effectively be treated with antibiotics. Travelers visiting rural and agricultural areas in endemic countries may be at greater risk. Appropriate clothing and use of insect repellants is essential to prevent tick borne illness. Travelers also should be aware of food and waterborne disease; avoid consuming potentially contaminated water and uncooked meat. Physicians should be aware of any clinical presentation of tularemia in the patients returning from endemic areas. (C) 2014 Elsevier Ltd. All rights reserved

Current therapeutic strategy in osteoarticular brucellosis.

Brucellosis is a common zoonotic disease with high morbidity. In the majority of human cases, the causative agent is B. melitensis. Infection is transmitted to humans by direct/indirect contact with the contaminated animal products (e.g., consumption of unpasteurized milk), infectious aerosols and aborted fetus. Brucellosis often affects middle-aged adults and young people. Patients with brucellosis tend to have non-specific symptoms, including fever, chills, night sweats, joint pain and myalgia. Brucellosis affects various organs and tissues. The osteoarticular system is one of the most commonly described affected systems in humans. In several clinical studies, the prevalence of Osteoarticular Brucellosis (OB) is reported as 2-77%. Most important osteoarticular clinical forms osteomyelitis, spondylitis, sacroiliitis, arthritis and bursitis. Spondylitis and spondylodiscitis are the most frequent complications. Spondylodiscitis often affects the lumbar (especially at the L4- L5 levels) and low thoracic vertebrae than the cervical spine. Back pain and sciatica radiculopathy are the most common complaints about patients. Sacroiliitis is associated with severe pain, especially back pain in affected individuals. Spinal destructive brucellar lesions are also reported in adults in previous studies. Brucellosis is diagnosed with clinical inflammatory signs (eg. tenderness, pain) of the affected joints together with positive serological tests and positive blood/synovial fluids cultures. Serological test measures the total amount of IgM/IgG antibodies. Standard agglutination test (SAT) titer >= 1:160 is in favor of brucellosis diagnosis. Enzyme-Linked Immunosorbent Assay (ELISA) and Polymerase chain reaction (PCR) are other types of diagnostic tests. Radiological assessments, such as joint sonography, computed tomography, magnetic resonance imaging, are the most helpful radiological methods to diagnose spinal brucellosis

Susceptibilities of Multidrug-Resistant Pathogens Responsible for Complicated Skin and Soft Tissue Infections to Standard Bacteriophage Cocktails

Skin and soft tissue infections (SSTIs) may represent a wide clinical spectrum from cellulitis to high mortality associated necrotizing fasciitis. Limitations in therapy due to the multiple drug resistance, leads to increase in the morbidity and mortality rates, especially in complicated SSTIs such as diabetic foot, decubitus, and surgical wound infections. Therefore, alternative treatment strategies other than antibiotics are needed in appropriate clinical conditions. "Bacteriophage therapy", which is an old method and has been used as part of standard treatment in some countries such as Georgia and Russia, has again become popular worldwide. The aim of this study was to investigate the in vitro susceptibilities of multidrug-resistant (MDR) pathogens isolated from patients with complicated SSTIs, against standard bacteriophage (phage) cocktails. Six different ready-made phage preparations [Pyophage, Intestiphage, ENKO, SES, Fersisi and Staphylococcal Bacteriophage (Sb)] used in this study have been provided by G. Eliava Institute, Georgia. Because of the absence of ready-made phage preparations for Acinetobacter baumannii and Klebsiella pneumoniae, Phi 1-Phi 7 and Phi KL1-Phi KL3 phages were used provided from the same institute's phage library, respectively. Isolation and identification of the pathogens from abscess and wound samples of patients with SSTIs were performed by conventional methods and automatized VITEK (R)-2 (bioMerieux, ABD) system. Antimicrobial susceptibility testing was conducted complying CLSI standards' and the bacteria that were resistant to at least two different antibiotic groups were considered as MDR. Accordingly, a total of 33 isolates, nine of them were E.coli (8 ESBL and 1 ESBL + carbapenemase positive); nine were MDR P.aeruginosa; nine were MDR A.baumannii; three were methicillin-resistant Staphylococcus aureus (MRSA) and three were K.pneumoniae (1 ESBL, 1 carbapenemase and 1 ESBL + carbapenemase positive) were included in the study. The phage susceptibilities of the pathogens were performed by using spot test. In the study, 29 (87.9%) out of 33 MDR pathogens were found to be susceptible to at least one of the tested phage/phage preparations. All MRSA (3/3) strains were susceptible to ENKO, SES, Fersisi and Sb phage cocktails, while all A.baumannii isolates (9/9) were susceptible to Phi 5 and Phi 7 phages. However, two E.coli, one K. pneumoniae and one P.aeruginosa strains were resistant to the all phage preparations tested. Although the clinical use of phages has not been approved yet, except a few Eastern European countries, this study exhibits the potential use of the topical bacteriophage therapy in the treatment of complicated SSTIs caused by MDR pathogens with limited treatment options, such as diabetic foot, decubitus, and surgical wound infections

Economic Burden of Multidrug-Resistant Gram-Negative Infections in a Developing Country

Objective: Antibiotic-resistant infections represent a significant global public health threat due to their rising prevalence. The aim of this study is to identify risk factors for acquisition of multidrug-resistant gram negatives (MDR-GNs) in the first intensive care unit (ICU) infection episode of patients and also to calculate the economic burden of infection with MDR-GNs that the ICU patient faced

In Vitro Activity of Tigecycline Against Francisella tularensis Subsp holarctica in Comparison with Doxycycline, Ciprofloxacin and Aminoglycosides

Francisella tularensis is the etiological agent of tularemia which is a zoonosis of the northern hemisphere. For decades, streptomycin was considered the drug of choice, despite possible side effects, and vestibular toxicity in particular. Alternatives are tetracylines and chloramphenicol which are bacteriostatic agents that are associated with a considerable risk of relapse. The aim of the present study was to assess the in vitro susceptibility of F.tularensis subsp. holarctica biovar II strains to tigecycline, a member of a new class of glycylcyclines. Fourteen F.tularensis strains isolated from patients in Central Anatolia region of Turkey were examined. Minimum inhibitory concentration (MIC) values of tigecycline, doxycycline, streptomycin, gentamicin, and ciprofloxacin were determined using the E-test method on glucosecysteine blood agar plates. Interpretation of results was made according to CLSI clinical breakpoints. All strains were susceptible to the antibiotics traditionally used to treat tularemia. Tigecycline showed good in vitro activity to all the isolates (MIC range: 0.094-0.38 mg/L). In this study, tigecycline was more active than doxycycline against F.tularensis subsp. holarctica strains, according to MIC50 (0.19 mg/L) and MIC90 (0.25 mg/L) values. Doxycycline (MIC90: 0.38 mg/L) showed good in vitro activity against all the isolates and MIC values interpreted according to the CLSI criteria for potential bioterrorism agents, have shown ranges below the breakpoint for sensitivity determination (S <= 4 mg/L). Ciprofloxacin had the lowest MIC50 and MIC90 values. In case the other antibiotics can not be used or intravenous therapy is required, tigecycline may be an important therapeutic alternative agent. However, confinement of tigecycline in the treatment of multi-drug resistant bacterial infections, its parenteral way of administration and overall cost were considered as the major limitations of tigecycline in tularemia treatment

Cutaneous candidiasis caused by Candida glabrata in a HIV/AIDS patient

Cutaneous Candida infections may occur in patients with HIV/AIDS, cancer, receiving chemotherapy and solid organ transplantation. A 32-year-old woman was admitted to the department suffering from pruritic and erythematous plaque on left side of her face for the past two months. The patient was HIV positive, diagnosed five years previously, and had been on antiretroviral therapy (tenofovir/emtricitabine and lopinavir/ritonavir) for a year. She was not compliant with the medication. Elevated HIV RNA load and decreased CD4+ lymphocyte count were observed. Fungal elements were detected from the skin scraping sample taken from the facial plaque. Fluconazole-sensitive Candida glabrata was isolated from this sample. Topical clotrimazole ointment and systemic fluconazole 400 mg/day were used. After systemic fluconazole therapy was continued for two months, the plaque was cured. C. glabrata rarely causes cutaneous infection without involving the mucous membranes. Presentation of cutaneous fungal infections in HIV patients with decreased CD4+ T lymphocyte counts can be atypical and require extensive antifungal treatment

Establishing molecular microbiology facilities in developing countries

Microbiology laboratories play an important role in epidemiology and infection control programs. Within microbiology laboratories, molecular microbiology techniques have revolutionized the identification and surveillance of infectious diseases. The combination of excellent sensitivity, specificity, low contamination levels and speed has made molecular techniques appealing methods for the diagnosis of many infectious diseases. In a well-equipped microbiology laboratory, the facility designated for molecular techniques remains indiscrete. However, in most developing countries, poor infrastructure and laboratory mismanagement have precipitated hazardous consequences. The establishment of a molecular microbiology facility within a microbiology laboratory remains fragmented. A high-quality laboratory should include both conventional microbiology methods and molecular microbiology techniques for exceptional performance. Furthermore, it should include appropriate laboratory administration, a well-designed facility, laboratory procedure standardization, a waste management system, a code of practice, equipment installation and laboratory personnel training. This manuscript lays out fundamental issues that need to be addressed when establishing a molecular microbiology facility in developing countries. (C) 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved