Hospital-Acquired Pneumonia

Key points Hospital-acquired pneumonia has a major impact in terms of mortality and morbidity. Empirical treatment approach is still the best course of action. Prevention is of critical importance. Educational aims To improve knowledge of HAP management. To better understand the epidemiological basis for the correct empirical therapy of HAP Summary HAP still has a major impact in terms of mortality and morbidity among hospitalised patients. Early appropriate antibiotic therapy is associated with a reduction in mortality and improved outcome. Although, in most cases, an empirical approach is still the rule, taking into account the risk factors, the severity of illness and length of stay before the pneumonia onset can better target antibiotic therapy. The patient9s follow-up course, in terms of microbiological, clinical and radiological monitoring, is important. Prevention strategies are of critical importance and are based on the understanding of the epidemiology and pathogenesis of HAP. Routine efforts for the prevention of HAP should be directed towards obtaining effective surveillance and infection-control programmes, including staff education, use of proper isolation techniques and infection-control practices. This review aims to increase understanding of these points to allow improved knowledge and treatment of HAP

Risk factors for infections caused by carbapenem-resistant Enterobacterales: an international matched case-control-control study (EURECA)

Cases were patients with complicated urinary tract infection (cUTI), complicated intraabdominal (cIAI), pneumonia or bacteraemia from other sources (BSI-OS) due to CRE; control groups were patients with infection caused by carbapenem-susceptible Enterobacterales (CSE), and by non-infected patients, respectively. Matching criteria included type of infection for CSE group, ward and duration of hospital admission. Conditional logistic regression was used to identify risk factors. Findings Overall, 235 CRE case patients, 235 CSE controls and 705 non-infected controls were included. The CRE infections were cUTI (133, 56.7%), pneumonia (44, 18.7%), cIAI and BSI-OS (29, 12.3% each). Carbapenemase genes were found in 228 isolates: OXA-48/like, 112 (47.6%), KPC, 84 (35.7%), and metallo-beta-lactamases, 44 (18.7%); 13 produced two. The risk factors for CRE infection in both type of controls were (adjusted OR for CSE controls; 95% CI; p value) previous colonisation/infection by CRE (6.94; 2.74-15.53; <0.001), urinary catheter (1.78; 1.03-3.07; 0.038) and exposure to broad spectrum antibiotics, as categorical (2.20; 1.25-3.88; 0.006) and time-dependent (1.04 per day; 1.00-1.07; 0.014); chronic renal failure (2.81; 1.40-5.64; 0.004) and admission from home (0.44; 0.23-0.85; 0.014) were significant only for CSE controls. Subgroup analyses provided similar results. Interpretation The main risk factors for CRE infections in hospitals with high incidence included previous coloni-zation, urinary catheter and exposure to broad spectrum antibiotics

Guideline adherence and survival of patients with candidaemia in Europe: results from the ECMM Candida III multinational European observational cohort study

© 2022 Elsevier Ltd. All rights reserved.[Background] The European Confederation of Medical Mycology (ECMM) collected data on epidemiology, risk factors, treatment, and outcomes of patients with culture-proven candidaemia across Europe to assess how adherence to guideline recommendations is associated with outcomes.[Methods] In this observational cohort study, 64 participating hospitals located in 20 European countries, with the number of eligible hospitals per country determined by population size, included the first ten consecutive adults with culture-proven candidaemia after July 1, 2018, and entered data into the ECMM Candida Registry (FungiScope CandiReg). We assessed ECMM Quality of Clinical Candidaemia Management (EQUAL Candida) scores reflecting adherence to recommendations of the European Society of Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of America guidelines.[Findings] 632 patients with candidaemia were included from 64 institutions. Overall 90-day mortality was 43% (265/617), and increasing age, intensive care unit admission, point increases in the Charlson comorbidity index score, and Candida tropicalis as causative pathogen were independent baseline predictors of mortality in Cox regression analysis. EQUAL Candida score remained an independent predictor of mortality in the multivariable Cox regression analyses after adjusting for the baseline predictors, even after restricting the analysis to patients who survived for more than 7 days after diagnosis (adjusted hazard ratio 1·08 [95% CI 1·04–1·11; p<0·0001] in patients with a central venous catheter and 1·09 [1·05–1·13; p<0·0001] in those without one, per one score point decrease). Median duration of hospital stay was 15 days (IQR 4–30) after diagnosis of candidaemia and was extended specifically for completion of parenteral therapy in 100 (16%) of 621 patients. Initial echinocandin treatment was associated with lower overall mortality and longer duration of hospital stay among survivors than treatment with other antifungals.[Interpretation] Although overall mortality in patients with candidaemia was high, our study indicates that adherence to clinical guideline recommendations, reflected by higher EQUAL Candida scores, might increase survival. New antifungals, with similar activity as current echinocandins but with longer half-lives or oral bioavailability, are needed to reduce duration of hospital stay.Scynexis.Peer reviewe

Blood Cultures and Clinical Significance

The detection of a microorganism in the blood of a patient is not only important for diagnosis but also important in terms of therapy and prognosis. Bacteria can persist in three manners in blood; transiently, intermitantly or continuously. To provide a benefit from blood cultures several points have to be considered including skin antisepsis, timing and frequency of culture, amount of blood taken, contents of culture media and culture method used. In addition, patient with immunodeficiency or intravascular catheter needs to be carefully evaluated. Every positive blood culture may not be clinically significant. Especially, in interpretation of skin flora elements, evaluation only made by taking into account the number of cultures taken may not be significant always. Good communication between the clinician and microbiology laboratory increases the usefulness of blood cultures

Antibiotic Associated Diarrhea: Retrospective Evaluation of 30 Cases

Antibiotic associated diarrhea may develop due to several causes. Here, we report the cases with diarrhea syndrome developed during the use of oral antibiotics for the treatment of community-acquired infections. Thirty hospitalized patients (15 male, 15 female) with bloody diarrhea were included in this study. The mean age was 40.8 years (range 16-85). Twenty-six of the cases had history of ampicillin/sulbactam usage before the onset of diarrhea, whereas remaning four cases mentioned use of amoxycilline/clavunate (2), azitromycine (1) or ampicillin/sulbactam + ornidazole (1). The time from onset of antibiotic use before the appearance of symptoms varied from 1 day to 8 days (median ± SEM, 3.73 ± 0.34 days). The frequencies of defecation were 3-9 times/day in six cases, 10-20 times/day in 15 cases and ≥ 20 times in nine cases. The presence of Clostridium difficile toxin in feces was assessed in 10 patients, and was weak positive in one patient. No enteric pathogen was isolated from feces culture. The diarrhea was regressed within two to six days (median ± SEM, 3.96 ± 0.18 days) after starting metronidazole (4 x 250 mg/day, oral, 10 days) treatment. In conclusion, cephalosporins and clindamycine, which are the most common causes of antibioticassociated colitis worldwide, were not responsible for the diarrheas observed in our cases. This may be due to the fact that ampicillin/sulbactam is commonly used for the treatment of community-acquired infections in our country

The in vitro activity of danofloxacin plus ceftiofur combination: implications for antimicrobial efficacy and resistance prevention

Due to the high prevalence of multi-drug resistant bacteria, combination therapy is an efficient choice for treatment of infections caused by highly resistant strains. In this study, the efficacy of ceftiofur plus danofloxacin combination was investigated against resistant Escherichia coli. The interaction between the two drugs was determined by checkerboard tests and time-kill assays. The combination was defined as bactericidal or bacteriostatic based on the minimum bactericidal concentration test results. Mutant prevention concentration test was used to evaluate the resistance tendency suppression potential of the combination. The combination had a synergistic effect against 83.00% of the isolates as verified by the checkerboard and time-kill assays. The combination was defined as bactericidal against all E. coli strains, since minimum bactericidal concentration: minimum inhibitory concentration ratios were below four thresholds and also markedly reduced mutant prevention concentration values of ceftiofur up to 4000-fold compared to its single use. Ceftiofur plus danofloxacin combination inhibited growth of E. coli strains which were resistant to ceftiofur or newer generation of fluoroquinolones. Our results suggest that ceftiofur plus danofloxacin combination has a bactericidal characteristic and can be an important alternative for the treatment of infections caused by resistant E. coli

Evaluation of a clinical pulmonary infection score in the diagnosis of ventilator-associated pneumonia

The most important dilemma in the diagnosis of ventilator-associated pneumonia (VAP) based on only clinical findings is overdiagnosis. The aim of the study is to prospectively evaluate the Clinical Pulmonary Infection Score (CPIS) in relation to VAP diagnosis. Design. Prospective, in a cohort of mechanically ventilated patients. Setting. The intensive care unit of a university hospital. Patients. Fifty patients, on mechanical ventilation therapy for more than 48 hours, suspected of having VAP were enrolled in the study and bacteriologic confirmation was done by bronchoalveolar lavage (BAL) culture. Interventions. Bronchoscopy with BAL fluid culture after establishing a clinical suspicion of VAP in patients having no prior antibiotic therapy or no change in current antibiotic therapy within last three days before BAL. CPIS scores during diagnosis were 6±2 (3-9) (median±QR, maximum-minimum) and it was 7±2 (2-9) at the 72nd hour, in 41 cases with a diagnosis of VAP. In cases with no diagnosis of VAP, the CPIS scores were found to be 6±2 (4-8) and 5±3 (2-7), respectively. There was no significant difference between the VAP group and the non-VAP group at diagnosis, but was significant at 72nd hour (respectively, p=0.551 and p=0.025). CPIS scores during diagnosis were 6±3 (4-8) (median± QR, maximum-minimum) and 7±4 (2-8) at the 72nd hour, in 14 cases with a diagnosis of early-onset VAP. In cases with a diagnosis of late-onset VAP, the CPIS scores were found to be 6±2 (3-9) and 7±2 (3-9), respectively. There was no significant difference between the early-onset VAP group and the late-onset VAP group. In conclusion, the CPIS results should be evaluated carefully in the clinical setting during the diagnosis

Hospital Acquired Pneumonia

In this study, we present hospital acquired pneumonia cases hospitalized at Uluda¤ University School of Medicine in 1997. In the clinics covered by the surveillance system 10 983 patients were followed up, and hospital acquired pneumonia was observed in 163 (1.4%) patients. Hospital acquired pneumonia was found to be the second common cause of nosocomial infections with the rate of 23.9%. Ventilator-associated pneumonia was found in 70% of all the cases involved in the study. Hospital acquired pneumonia was seen in 9.5% of cases in ICU, whilst only 0.5% of the cases was from other clinics

Identification of Beta-Lactamase Enzymes by Isoelectrical Focusing Method in Acinetobacter baumannii

There has been an important resistance problem to various beta-lactam antibiotics in Acinetobacter baumannii strains which cause nosocomial infections. In this study, isoelectric points of beta-lactamase enzymes of 60 strains of A. baumannii isolated from various clinical specimens were investigated by polyacrylamid gel electrophoresis (PAGE). Beta-lactamase enzymes of the isolates were estimated by evaluating their susceptibility to beta-lactam group antibiotics and isoelectric points (pI). The presence of beta-lactamase enzymes was detected in all of the A. baumannii species included in the study. Beta-lactamase band was observed in 50 species by IEF method, but couldn’t be shown in the other 10 isolates. However, the presence of betalactamase which shows spreading type around loading space without band formation was detected in all of the strains. Isoelectric points in 29 of the 50 isolates with band formation were 5.4, 8 were 6.3 and 13 were 6.3 and 5.4. According to antibiotic susceptibility and isoelectric points, 6 phenotypes were observed. We suggest that phenotype 1 was either ACE + TEM-1 or PER-1; phenotype 2 was ACE + CARB-5; phenotype 3 was ACE; phenotype 4 was either an over synthesis of ACE or a new beta-lactamase; phenotype 5 was ACE + TEM-1; phenotype 6 was either ACE + TEM-1 or PER-1 + CARB-5. Every phenotype was divided into subgroups according to their resistance to imipenem, except phenotype 5. As well as beta-lactamases, changes in porins and penicillin binding proteins were considered to be responsible for the resistance of A. baumannii strains to beta-lactam antibiotics