Clinical features and outcomes of critically ill patients with elizabethkingia meningoseptica: An emerging pathogen

Background: Elizabethkingia meningoseptica, formerly known as Chryseobacterium meningosepticum, is a non-motile, non-fastidious, catalase and oxidase-positive, aerobic, glucose-non-fermentative, Gram-negative bacillus that was first defined by Elizabeth O. King in 1959. It has emerged as an opportunistic pathogen that has infected patients in extreme age groups and immunocompromised individuals, especially in intensive care settings. There has been an increased interest in this pathogen due to its increasing occurrence around the world, ubiquitous nature, and inherent capacity for antimicrobial resistance.Methods: We describe an observational study at a tertiary care center in Karachi, Pakistan, based on patients admitted between January 2013 and December 2018, with E. meningoseptica infections. All patients were confirmed to have a positive clinical culture specimen for E. meningoseptica along with symptoms and signs consistent with infection. Data were collected on a structured proforma from the Hospital Information Management Systems.Results: Sixteen patients with E. meningoseptica that met the criteria for infection were identified, 13 of whom required admission. Eight patients had bacteremia in addition to confirmed E. meningoseptica infection. Two of the isolates were multi-drug resistant and only sensitive to minocycline. Nine of the 13 patients that were readmitted required intubation and mechanical ventilation. The median length of hospital stay was 13 days, and out of the 13 patients died during the hospital stay.Conclusion: This is the largest case series reporting E. meningoseptica infections and highlights the importance of this organism as an emerging nosocomial pathogen

Mortality In Patients With Respiratory And Nonrespiratory Carbapenem Resistant-Multidrug Resistant Acinetobacter Infections

Background: Mortality from carbapenem-multi-drug resistant Acinetobacter infections may vary according to site of infection. The objective of this study was to compare mortality in respiratory vs. non-respiratory infection with Carbapenem-Multi-drug Resistant Acinetobacter (C-MRAB). Methods: We conducted a prospective cohort study to compare mortality rate in patients with respiratory vs. nonrespiratory infection (n=30 each). Results: Results showed that mortality was 40% in the respiratory group compared to 23% in non-respiratory group; the difference was not statistically significant (p=0.165, RR=1.71, CI=0.73-3.75). There was a significantly higher prior admission rate in patients with respiratory infection (p=0.028). Logistic regression did not reveal any modifier effect from other variables. Conclusions: This study showed no significant difference in mortality in patients with carbapenem-multi-drug resistant acinetobacter respiratory vs. non-respiratory infections

Multifocal venous thrombosis in behcet’s disease

Behcet\u27s disease is a multisystem inflammatory vascular disorder with a chronic course characterized by recurrent oral and genital ulcers, eye lesion, arthritis and skin lesions. It has a typically waxing and waning course. The cause and pathogenesis of the disease are unclear and specific treatment is not available. A 39 years old man presented with rash, ocular manifestation and left leg swelling. He was found to have deep venous thrombosis of left leg along with recurrent cerebral venous thrombosis. He was a known case of Behcet\u27s disease since 3 years and had been on anticoagulants since then

Ralstonia pickettii Bacteremia: An Emerging Infection in a Tertiary Care Hospital Setting

Ralstonia species are Gram-negative bacilli that have increasingly been recognized as emerging nosocomial pathogens, particularly in immunocompromised hosts. Ralstonia pickettii is the most clinically important pathogen from the Ralstonia genus. Nosocomial outbreaks of Ralstonia pickettii infections brought about by the use of contaminated medical solutions, including saline, sterile water, as well as disinfectants, have been reported. There have been case reports of invasive infections with variable presentations. Here, we describe three cases of Ralstonia pickettii bacteremia during a period of one year in a tertiary care hospital in Karachi, Pakistan. The first case was a 76-year-old male, known case of type 2 diabetes mellitus (DM), hypertension, and amyotrophic lateral sclerosis, who presented with complaints of burning micturition, hematuria, and fever. The patient had a history of multiple hospital admissions in the recent past. His blood culture was found to be positive for Ralstonia pickettii. A computed tomography scan of the kidneys, ureter, and bladder (CT KUB) was suggestive of pyelonephritis. The patient improved on intravenous meropenem. The second case was a 47-year-old man, who was admitted with a gunshot injury to the neck, resulting in complete cervical cord resection and mild hydrocephalus with intraventricular hemorrhage. The patient had a prolonged intensive care unit (ICU) stay, which was complicated by ventilator-associated pneumonia with Acinetobacter and central line-associated bloodstream infection (CLABSI) with Ralstonia pickettii. He was treated with meropenem and colistin but continued to deteriorate and expired. The third case was a 46-year-old lady, known case of end-stage renal disease (ESRD), who was admitted with prosthetic valve endocarditis. She had a prolonged hospital stay complicated by CLABSI with Ralstonia pickettii, improved on meropenem, but later died due to fungemia. Ralstonia pickettii is an emerging cause of nosocomial infection in patients, particularly those with a prolonged hospital stay, and can cause invasive and severe infections

Clinical characteristics and outcomes of patients with H1N1 influenza pneumonia admitted at a tertiary care hospital in Karachi, Pakistan

Introduction: Influenza viruses specifically, A and B mainly contribute to seasonal outbreaks that occur globally. However, due to limited diagnostics for influenza there is little data regarding clinical outcomes of patients with H1N1 pneumonia in our region. Our objective was to determine the clinical characteristics and outcomes of patients hospitalized with H1N1 pneumonia at a tertiary care facility in Karachi, Pakistan.Methods: A retrospective study of adult patients admitted with influenza pneumonia from November 2017 to February 2018 at a tertiary care hospital in Karachi, Pakistan. Patient characteristics were compared between influenza A H1N1 and other types of influenza using multivariable logistic regression analysis and subgroup analysis for factors associated with mortality in H1N1 Pneumonia was performed.Results: Out of 497 adult patients with community acquired pneumonia (CAP), 172 fulfilled the criteria for Influenza like illness (ILI). 88 patients had PCR confirmed Influenza pneumonia of whom n = 57 (65%) had Influenza A H1N1. The mean age of patients 53.5 years (SD: 17.3) and 60% were male. The overall mortality from Influenza in this study was 15.9% (n = 14); out of these 11 (78.5%) had Influenza A H1N1. Multivariable analysis showed that the increase in length of hospital admission was significantly associated with H1N1 Influenza A infection (OR: 1.47 CI: 1.2-1.8). Factors associated with mortality showed that presence of ARDS, Septic shock and multi-organ failure was highly significantly associated with death (p-value \u3c 0.001) along with deranged liver function tests (p-value 0.01) and presence of nosocomial infection (p-value 0.027).Conclusion: Influenza A H1N1 is associated with greater length of stay compared with infection due to other types of Influenza and mortality in H1N1 Pneumonia was found to be associated with presence of nosocomial infection among several other factors which may have implications given higher rates in a low-middle income country

Hair dye poisoning and rhabdomyolysis.

Hair dye ingestion is a rare cause of toxicity in Pakistan. We are presenting the case report of a 55 year old male who presented with accidental hair dye ingestion and developed laryngeal oedema requiring emergent tracheostomy. He had also developed aspiration pneumonitis and chemical oesophagitis. However, the most alarming manifestation was rhabdomyolysis. Hair dye toxicity can be fatal if not recognized early. There is no antidote available. Rhabdomyolysis is a complication and needs to be managed aggressively in order to prevent long term morbidity

Knowledge, attitudes and practices of health care workers regarding needle stick injuries at a tertiary care hospital in Pakistan

OBJECTIVE: To assess the knowledge, attitude and practices of HCWs regarding needle stick injuries at the Aga Khan University Hospital. METHODS: A cross-sectional study was conducted on medical personnel. A structured pre-tested questionnaire was administered during June-July 2003. The data was analysed by SPSS 13.0. Percentages of the categorical variables were computed and compared by Chi square test at a 5% level of significance. Odds ratios and their 95% CIs were also computed. RESULTS: Of 80 participants, 29 were doctors and 51 were registered nurses. About 45% reported having a needle stick injury in the past. Frequency of injury was significantly higher among doctors (p \u3c 0.001). The most common reason identified was stress or being over burdened followed by careless attitude. More than 50% of the injuries occurred while injecting or drawing blood samples. The risk of getting infections was well known amongst both the groups. Two third of participants were familiar with the prevention protocols and practices of nurses were generally safer than doctors (p \u3c 0.001). CONCLUSION: Despite knowing the risks, frequency of needle stick injury was generally higher especially among doctors reflecting bad practice and careless attitude towards work. Mandatory reporting, proper follow-up and constant reinforcement are recommended to reduce the rate of nosocomial transmission to health care workers

Risk factors for mortality of patients with ceftriaxone resistant E. coli bacteremia receiving carbapenem versus beta lactam/beta lactamase inhibitor therapy

Objective: Extended spectrum β-lactamases (ESBL) producing Enterobacteriaceae predominantly E. coli and K. pneumoniae bacteremia have limited treatment options and high mortality. The objective was to determine the risk factors for in-hospital mortality particularly treatment with carbapenem versus beta lactam/beta lactamase combination (BL/BLI) in patients with ceftriaxone resistant E. coli bacteremia. A retrospective cohort study was conducted at the Aga Khan University, Karachi, Pakistan. Adult patients with sepsis and monomicrobial ceftriaxone resistant E. coli bacteremia were enrolled. Factors associated with mortality in patients were determined using logistic regression analysis. Results: Mortality rate was 37% in those empirically treated with carbapenem compared to 20% treated with BL/BLI combination therapy (p-value: 0.012) and was 21% in those treated with a carbapenem compared to 13% in patients definitively treated with BL/BLI combination therapy (p-value: 0.152). In multivariable logistic regression analysis, only Pitt bacteremia score of ≥ four was significantly associated with mortality (OR: 7.7 CI 2.6-22.8) while a urinary source of bacteremia was protective (OR: 0.26 CI 0.11-0.58). In-hospital mortality in patients with Ceftriaxone resistant E. coli bacteremia did not differ in patients treated with either a carbapenem or BL/BLI combination. However, Pitt bacteremia score of ≥ 4 was strongly associated with mortality

Invasive pulmonary infection by syncephalastrum species: Two case reports and review of literature

Background: Syncephalastrum species belong to the class Zygomycetes and order Mucorale. These are found in the environment and tropical soil, usually presenting as colonizers and rarely cause human infection. Syncephalastrum racemosum is a species of the genus Syncephalastrum and is the most commonly identified pathogen. Most cases are reported in immunocompromised individuals, such as patients on long term steroids, poorly controlled diabetes, or patients with malignancy.Case presentation: We are describing two cases of rare fungal infection by Syncephalastrum species causing invasive pulmonary manifestation. Both patients had compromised immune status and presented with worsening dyspnea to the emergency room. Both had signs and symptoms of bilateral worsening pneumonia evident by chest X-ray showing bilateral pulmonary infiltrates. Syncephalastrum species were isolated from sputum cultures. Deoxycholate amphotericin B was started and the response was monitored. One patient expired while the other improved. Syncephalastrum species belong to class Mucormycosis, rarely causing invasive infection but when they do outcome is potentially fatal. Very few cases are reported worldwide so the clinical course is still unclear. To the best of our knowledge, these are the first two cases to be reported from Pakistan.Conclusions: These two cases describe pneumonia as a result of concomitant infection by rare fungal speciesSyncephalastrum and MRSA in immunocompromised patients. Few cases are reported so limited data is available to understand complete disease implications. Mucormycosis is a therapeutic challenge because of the phylogenetic diversity, un-availability of any serological testing and invasive disease pattern