Management of KPC-Producing Klebsiella pneumoniae Infections

Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas

Geographical variation in therapy for bloodstream infections due to multidrug-resistant enterobacteriaceae: a post hoc analysis of the INCREMENT study

We aimed to describe regional differences in therapy for bloodstream infection (BSI) caused by extended-spectrum ?-lactamase-producing Enterobacteriaceae (ESBL-E) or carbapenemase-producing Enterobacteriaceae (CPE). 1,482 patients in 12 countries were included from an observational study of BSI caused by ESBL-E or CPE. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for the influence of country of recruitment on empirical use of ?-lactam/?-lactamase inhibitors (BLBLI) or carbapenems, targeted use of BLBLI for ESBL-E and use of targeted combination therapy for CPE. The use of BLBLI for empirical therapy was least likely in sites from Israel (aOR 0.34, 95% CI 0.14-0.81), Greece (aOR 0.49, 95% CI 0.26-0.94) and Canada (aOR 0.31, 95% CI 0.11-0.88) but more likely in Italy (aOR 1.58, 95% CI 1.11-2.2) and Turkey (aOR 2.09, 95% CI 1.14-3.81), compared to Spain as a reference. Empirical carbapenems were more likely to be used in sites from Taiwan (aOR 1.73, 95% CI 1.03-2.92) and USA (aOR 1.89; 95% CI 1.05-3.39), and less likely in Italy (aOR 0.44, 95% CI 0.28-0.69) and Canada (aOR 0.10, 95% CI 0.01-0.74). Targeted BLBLI for ESBL-E was more likely in sites from Italy. Treatment at sites within Israel, Taiwan, Turkey and Brazil was associated with less combination therapy for CPE. Although this study does not provide precise data on the relative prevalence of ESBL-E or CPE, significant variation in therapy exists across countries even after adjustment for patient factors. A better understanding of what influences therapeutic choices for these infections will aid antimicrobial stewardship efforts.PH is supported by an Australian Postgraduate Award from the University of Queensland. The study was funded by the Ministerio de Economía y Competitividad, Instituto de Salud Carlos III - co-financed by European Development Regional Fund "A way to achieve Europe" ERDF, Spanish Network for the Research in Infectious Diseases (REIPI RD12/0015). BGG, JRB, APH and YC also received funds from the COMBACTE-CARE project (grant agreement 115620), Innovative Medicines Initiative (IMI), the European Union's Seventh Framework Programme (FP7/2007-2013) and in-kind contributions from EFPIA companies

Catheter Associated Urinary Tract Infection Prevention bundle

Catheter-associated urinary tract infections (CAUTI) are among the most common healthcare-associated infections, and potentially lead to significant morbidity and mortality. Multifaceted infection control strategies implemented as bundles can prevent nosocomial infections associated with invasive devices such as CAUTIs. The components of the CAUTI bundle proposed herein, include appropriate indications for catheterization and recommendations for the procedures of catheter insertion and catheter maintenance and care. Avoiding unnecessary urinary catheter use is the most effective measure for their prevention. To minimize the risk of CAUTI, urinary catheters should be placed only when a clinical valid indication is documented and they should be removed as soon as possible; alternatives to catheterization should also be considered. Aseptic insertion technique, maintenance of closed drainage system and strict adherence to hand hygiene are essential for preventing CAUTI. The successful implementation of the bundle requires education and training for all healthcare professionals and evaluation of surveillance data

Infections caused by KPC-producing Klebsiella pneumoniae isolates: clinical, laboratory and epidemiological investigation

The aim of the study was the clinical, laboratory and epidemiological investigation of infections caused by KPC-producing Klebsiella pneumoniae (KPC-KP).A prospective observational cohort study was conducted (5/08-10/10) in a tertiary care hospital. All patients with at least one clinical sample positive for KPC-KP were identified and followed up. Patients’ clinical and epidemiological characteristics were studied. Rectal screening was performed and a simple phenotypic algorithm for surveillance cultures was evaluated. The study isolates were screened for carbapenemase production and their susceptibility profile was determined. The presence of blaKPC was detected by PCR and sequencing. Genetic relatedness of the isolates was determined by MLST. During the study period, a total of 414 KPC-KP isolates were recovered from clinical samples of 185 patients. Medical records were available for evaluation for 175 of them. Susceptibility testing showed higher in vitro activity for tigecycline (95.4%), fosfomycin (93.8%), gentamicin (86.7%) and colistin (79.5%). Comparative evaluation of tigecycline susceptibility testing methods revealed significant discrepancies between Vitek2 and reference broth microdilution, with Vitek2 producing higher MICs, resulting in false resistance. PCR detected the concomitant presence of blaVIM-1 and blaKPC-2 gene in 21 isolates. MLST classified the isolates into 5 STs with predominance of ST258 (82.3%). The culture-based phenotypic algorithm for rectal screening was proved highly sensitive and specific. This method accurately detected the type of carbapenemase for all KPC-producing isolates. The study population consisted of 175 patients either infected (95) or colonized (80) with KPC-KP isolates. The most common infection type was BSI (62 patients). Prior rectal colonization was the only independent predictor of clinical infection. Overall mortality was 36% being significantly higher for clinically infected patients. Infection mortality was 32.6%. Microbiological response was noted for 43.4% of the patients. In the cohort of 62 patients with BSI, age, APACHE II score at infection onset and inappropriate antimicrobial treatment were identified as independent predictors of infection mortality. All patients that received combination schemes had favourable infection outcome; in contrast, infection mortality was significantly higher among patients treated with appropriate monotherapy. Investigation of risk factors for CR KPC-KP acquisition showed that colistin resistance was not associated with colistin administration. The only independent predictor was prior rectal colonization with CR KPC-KP isolate. Molecular typing showed that both CR and CS isolates belonged to the same clone. This study investigated laboratory, clinical and therapeutic issues; the importance of appropriate antimicrobial therapy and the superiority of combination regimens in the treatment of KPC-infections was demonstrated. The study also revealed the shortcomings of Vitek2 for tigecycline susceptibility testing, the inaccuracies of which may falsely restrict treatment options. In addition, a new low-cost phenotypic algorithm for direct and specific detection of carbapenemase producers from surveillance cultures has been proposed.Σκοπός της μελέτης ήταν η εργαστηριακή, κλινική και επιδημιολογική διερεύνηση των λοιμώξεων από στελέχη Klebsiella pneumoniae που παράγουν KPC καρβαπενεμάση (KPC-KP). Μελετήθηκαν προοπτικά, για διάστημα 2,5 ετών (5/08-10/10), όλοι οι ασθενείς Τριτοβάθμιου Νοσοκομείου από τους οποίους απομονώθηκε στέλεχος KPC-KP. Αναλύθηκαν τα κλινικά και επιδημιολογικά τους χαρακτηριστικά και διερευνήθηκαν οι παράγοντες κινδύνου για εμφάνιση κλινικής λοίμωξης, για δυσμενή έκβαση στους ασθενείς με βακτηριαιμία και για λοίμωξη ή αποικισμό από ανθεκτικό στην κολιστίνη στέλεχος (CR). Πραγματοποιήθηκε έλεγχος ορθικής φορείας και αξιολογήθηκε και ένας νέος φαινοτυπικός αλγόριθμος για τις καλλιέργειες επιτήρησης. Ο έλεγχος των απομονωθέντων στελεχών περιελάμβανε τον καθορισμό του προφίλ ευαισθησίας, τον φαινοτυπικό και μοριακό έλεγχο και τη μοριακή τυποποίηση. Κατά το χρονικό διάστημα της μελέτης απομονώθηκαν 414 στελέχη KPC-KP από 185 ασθενείς. Ο έλεγχος της ευαισθησίας έδειξε ότι υψηλότερη δραστικότητα εμφάνισαν η τιγεκυκλίνη (95,4%), η φωσφομυκίνη (93,8%), η γενταμικίνη (86,7%) και η κολιστίνη (79,5%). Σημαντικός βαθμός ασυμφωνίας προέκυψε στον έλεγχο ευαισθησίας της τιγεκυκλίνης μεταξύ του Vitek2 και της μεθόδου αναφοράς, με τάση για ψευδή αντοχή. Ο έλεγχος παρουσίας γονιδίων άλλων καρβαπενεμασών έδειξε ότι 21 στελέχη έφεραν και το γονίδιο blaVIM-1. Η μοριακή τυποποίηση με τη μέθοδο MLST ανέδειξε 5 ST τύπους με επικρατούντα τον ST258 (82,3%). O νέος φαινοτυπικός αλγόριθμος στις καλλιέργειες επιτήρησης παρουσίασε υψηλή ευαισθησία και ειδικότητα, ενώ η ταυτοποίηση του είδους της καρβαπενεμάσης ήταν ακριβής για όλα τα KPC-θετικά στελέχη. Κλινική λοίμωξη εμφάνισαν 95 ασθενείς, με συχνότερη τη βακτηριαιμία. Μοναδικός ανεξάρτητος παράγοντας κινδύνου για την εμφάνιση λοίμωξης ήταν η προηγηθείσα ορθική φορεία. Η ολική θνητότητα ήταν 36% στο σύνολο των ασθενών και βρέθηκε σημαντικά υψηλότερη στους ασθενείς με λοίμωξη. Η θνητότητα λοίμωξης ήταν 32,6%. Στη μελέτη των παραγόντων που σχετίζονται με την έκβαση στους ασθενείς με βακτηριαιμία η ηλικία, το APACHE II score κατά την έναρξη της λοίμωξης και η μη χορήγηση κατάλληλης αντιμικροβιακής αγωγής αναδείχτηκαν ως ανεξάρτητοι προγνωστικοί παράγοντες για δυσμενή έκβαση. Η χορήγηση συνδυασμών δραστικών αντιμικροβιακών οδήγησε σε κλινική επιτυχία για το σύνολο των ασθενών, ενώ η θνητότητα της λοίμωξης στην ομάδα της μονοθεραπείας ήταν σημαντικά υψηλότερη. Η διερεύνηση των παραγόντων κινδύνου για λοίμωξη ή αποικισμό από στέλεχος CR KPC-KP δεν ανέδειξε συσχέτιση με την προηγηθείσα χορήγηση κολιστίνης. Μοναδικός ανεξάρτητος παράγοντας κινδύνου ήταν η προηγηθείσα ορθική φορεία CR KPC-KP. Από τον έλεγχο της κλωνικότητας προέκυψε ότι όλα τα στελέχη ανήκαν στον ίδιο κλώνο. Οι λοιμώξεις από στελέχη KPC-KP παρουσιάζουν υψηλή επίπτωση και συνοδεύονται από υψηλή θνητότητα. Στην παρούσα μελέτη επιχειρήθηκε να απαντηθούν ερωτήματα που τίθενται στην κλινική και εργαστηριακή πράξη. Στο πλαίσιο αυτό, αναδείχτηκε η υπεροχή της συνδυαστικής αντιμικροβιακής αγωγής αλλά και η αδυναμία του αυτοματοποιημένου συστήματος Vitek2 να ανιχνεύσει αξιόπιστα την ευαισθησία στην τιγεκυκλίνη. Επίσης αναπτύχθηκε ένας νέος φαινοτυπικός αλγόριθμος που επιτρέπει την ταχεία και ειδική για τον τύπο της καρβαπενεμάσης ανίχνευση στις καλλιέργειες ορθικών επιχρισμάτων

Isolated Cerebral Mucormycosis Caused by Lichtheimia Species in a Polytrauma Patient

Isolated post-traumatic cerebral mucormycosis represents an extremely rare and severe disease. A case of isolated cerebral mucormycosis infection caused by Lichtheimia spp. in a 21-year-old multi-trauma patient is presented. The patient was hospitalized in the intensive care unit and underwent craniotomy due to brain injuries. Two weeks following the initial procedure, pus drained from the surgical wound was microscopically examined and cultured, yielding Lichtheimia spp. Imaging showed parietal, temporal and frontal abscesses at the right side. The patient was commenced on amphotericin B and underwent surgical debridement, while histopathological examination of the affected tissue demonstrated broad, aseptate hyphae, findings typical for mucormycetes. The patient passed away due to heavy traumatic injuries after 2 months. It is speculated that direct inoculation was the portal of entry for infection, and that high steroid use for 2 weeks following inoculation contributed to the severity of infection that developed. Isolated cerebral mucormycosis in immunocompetent hosts is an extremely rare, but severe disease. Diagnosis is established through direct microscopy, histopathology and/or cultures. PCR-based techniques are useful either to detect mucormycetes in tissues, especially when cultures are negative, or to accurately identify the fungi grown in cultures at the species level. A high suspicion index, especially in the necrotic lesions of traumas, is of the utmost importance for early diagnosis. Appropriate surgical debridement, as well as antifungal therapy, including amphotericin B, represents the treatment of choice. © 2022 by the authors. Licensee MDPI, Basel, Switzerland

Hand Hygiene – Focus on surgical patient care

<p>Hospital acquired infections (HAI) and antimicrobial resistance represent a serious threat to patient safety and healthcare systems globally and especially in our country. Hand hygiene (HH) promotion seems to be the cornerstone of infection control interventions as it is the most important measure to prevent transmission of pathogens by healthcare workers (HCWs). There is clear evidence that strict adherence to HH reduces the risk of cross-transmission. HH practices are well known, however, compliance is low and many factors (cultural and behavioral issues among them) have been implicated. Behavioral change seems to be crucial for improving HH compliance, though is quite difficult to be achieved and requires multifaceted techniques. World Health Organization (WHO) proposes a layered strategy to improve compliance. In 2005, WHO launched the first global HH campaign. The primary focus of 2016 WHO's campaign is the surgical patient's care, as proper implementation of HH significantly contributes to the reduction of surgical site infections (SSIs). SSIs are quite prevalent, especially in middle and low-income countries and they have important impact on patients' outcomes. Their prevention is complex, multimodal, multi-disciplinary and rather challenging. The key risk factor for SSIs is the poor adherence and incorrect HH procedures during perioperative and postoperative care. Surgical hand disinfection procedures include surgical scrub and surgical rub. According to current guidelines, both methods are considered suitable, though several factors favor the use of hand rub, including rapidity of action and thus time savings and fewer side-effects. Improving hand hygiene practices in all surgical services is the leading prevention measure to make surgery safer worldwide.</p&gt

Impact of bloodstream infections caused by carbapenem-resistant Gram-negative pathogens on ICU costs, mortality and length of stay

Background: The aim of this study was to estimate the impact of bloodstream infections (BSIs) caused by carbapenem-resistant Gram-negative (CRGN) pathogens on hospital costs, mortality and length of stay (LOS). Methods: All patients hospitalized for ≥3 days in the Intensive Care Unit (ICU) of a tertiary-care general hospital from 1/1/2015 to 31/12/2017 were included in the study. A retrospective case-control study was performed in order to examine the difference in medical, pharmaceutical and operating costs, LOS and in-hospital mortality between patients with BSI caused by CRGN/without BSI (cases/controls, respectively). The statistical analysis was performed using the SPSS software (v23.0). Results: A total of 419 patients (67.5% males, median age 60.0 years) were included in the analysis (142 cases/277 controls); 10 patients with non-CRGN BSIs were excluded. Overall mortality was 33.7% (49.3/25.6% in cases/controls). The median LOS and total cost were 30.0 vs. 12.0 days and 20 359.1 vs. 8,509.3 €, respectively, between patients with/without CRGN BSIs. After adjusting for baseline demographics, underlying disease severity and patients' specialties, CRGN BSIs remained a significant factor in mortality (odds ratio 2.9; 95% confidence interval 1.8–4.8; p <0.001). Additionally, CRGN BSIs seem to result in significantly prolonged LOS and extra cost per infected patient (p <0.001). Conclusions: ICU patients with CRGN BSI are at increased risk for mortality and prolonged hospitalization and incur higher costs, imposing a heavy burden on healthcare system. Infection control strategies, considering also the cost-efficacy of interventions, are crucial in order to control the expansion of CRGN infections. © 2019 The Author