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Cancer and sepsis comorbidity is a major public health problem in most parts of the world including Zimbabwe. The microbial aetiologies of sepsis and their antibiograms vary with time and locations. Knowledge on local microbial aetiologies of sepsis and their susceptibility patterns is critical in guiding empirical antimicrobial treatment choices.
This was a descriptive cross-sectional study which determined the microbial aetiologies of sepsis from blood cultures of paediatric and adult cancer patients obtained between July 2016 and June 2017. The TDR-X120 blood culture system and TDR 300B auto identification machine were used for incubation of blood culture bottles and identification plus antimicrobial susceptibility testing, respectively.
A total of 142 participants were enrolled; 50 (35.2%) had positive blood cultures, with 56.0% Gram positive, 42.0% Gram-negative bacteria and 2.0% yeast isolated. Common species isolated included coagulase negative Staphylococcus spp. (CoNS) (22.0%), E. coli (16.0%), K. pneumoniae (14.0%), E. faecalis (14.0%) and S. aureus (8.0%). Gram-negative isolates exhibited high resistance to gentamicin (61.9%) and ceftriaxone (71.4%) which are the empiric antimicrobial agents used in our setting. Amikacin and meropenem showed 85.7 and 95.2% activity respectively against all Gram-negative isolates, whilst vancomycin and linezolid were effective against 96.2 and 100.0% of all Gram-positive isolates respectively. We isolated 10 (66.7%) extended spectrum β-lactamase (ESBL) amongst the E. coli and K. pneumoniae isolates. Ten (66.7%) of the Staphylococcus spp. were methicillin resistant.
CoNS, E. coli, K. pneumoniae, E. faecalis and S. aureus were the major microbial drivers of sepsis amongst cancer patients in Zimbabwe. Most isolates were found to be resistant to commonly used empirical antibiotics, with isolates exhibiting high levels of ESBL and methicillin resistance carriage. A nationwide survey on microbial aetiologies of sepsis and their susceptibility patterns would assist in the guidance of effective sepsis empiric antimicrobial treatment among patients with cancer.
Fever is a cause for concern for both parents and the treating pediatrician and a common reason for antibiotic overuse. However, the proportion of children hospitalized for fever with serious bacterial infection (SBI) is uncertain. We aimed to evaluate the epidemiological, clinical, hematological, and biochemical risks for SBI among the children admitted with fever.
This prospective study was conducted in a rural teaching hospital in India on consecutive children, aged 3 months–12 years, presenting with fever 100 °F (37.7 °C) or higher. The presence of SBI was confirmed with one of the following criteria: (a) a positive blood culture; (b) roentgenographically confirmed pneumonia with high titres of C-reactive protein; (c) a culture-confirmed urinary tract infection; (d) enteric fever diagnosed clinically in addition to either a positive blood culture or high Widal titers; and (e) meningitis diagnosed clinically in addition to either a positive blood culture or cerebrospinal fluid culture. A predefined questionnaire was filled.
A total of 302 children were included in the study, out of which 47% (95% CI 41.4–52.7%) presented with SBI. The factors associated with confirmed SBI in bivariate analysis were history of previous hospitalization, history of chronic illness, history of medication in the previous 1 week, a partially immunized child, history of common cold, moderate-grade fever, toxic look, significant lymphadenopathy, absence of BCG scar, delayed development, irritability, breathlessness, respiratory distress, poor feeding, significant weight loss, suspected urinary tract infection, hyponatremia, hypokalemia, and abnormal leucocyte count. The final generalized logistic regression model revealed partially immunized child (RR 4.26), breathlessness (RR 1.80), weight loss (RR 2.28), and suspected urinary tract infection (RR 1.95) as risk factors for the increased risk of SBI.
The study identified multiple risk factors for SBI. Pediatricians can be made aware of these risk factors. Further studies are warranted to identify age-specific risk factors for SBI because most clinicians depend on clinical signs and symptoms to identify SBI.
Sabrina, Araujo de Franca; Tavares, Wagner M.; Salinet, Angela S. M.; Paiva, Wellingson S.; Teixeira, Manoel J.
To elucidate the impact of early tracheostomy on hospitalization outcomes in patients with traumatic brain injury.
Lilacs, PubMed, and Cochrane databases were searched. The close-out date was August 8, 2018.
Studies written in English, French, Spanish, or Portuguese with traumatic brain injury as the base trauma, clearly formulated question, patient’s admission assessment, minimum follow-up during hospital stay, and minimum of two in-hospital outcomes were selected. Retrospective studies, prospective analyses, and case series were included. Studies without full reports or abstract, commentaries, editorials, and reviews were excluded.
The study design, year, patient’s demographics, mean time between admission and tracheostomy, neurologic assessment at admission, confirmed ventilator-assisted pneumonia, median ICU stay, median hospital stay, mortality rates, and ICU and hospital costs were extracted.
A total of 4,219 studies were retrieved and screened. Eight studies were selected for the systematic review; of these, seven were eligible for the meta-analysis. Comparative analyses were performed between the early tracheostomy and late tracheostomy groups. Mean time for early tracheostomy and late tracheostomy procedures was 5.59 days (SD, 0.34 d) and 11.8 days (SD, 0.81 d), respectively. Meta-analysis revealed that early tracheostomy was associated with shorter mechanical ventilation duration (–4.15 [95% CI, –6.30 to –1.99]) as well as ICU (–5.87 d [95% CI, –8.74 to –3.00 d]) and hospital (–6.68 d [95% CI, –8.03 to –5.32 d]) stay durations when compared with late tracheostomy. Early tracheostomy presented less risk difference for ventilator-associated pneumonia (risk difference, 0.78; 95% CI, 0.70–0.88). No statistical difference in mortality was found between the groups.
The findings from this meta-analysis suggest that early tracheostomy in severe traumatic brain injury patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient’s early rehabilitation and discharge.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Drs. Sabrina and Tavares disclosed that this research was supported by the nonprofit organization Instituto Paulista de Saude para Alta Complexidade. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Address requests for reprints to: Araujo de Franca Sabrina, BaSN, Department of Research of IPSPAC - Instituto Paulista de Saúde para a Alta Complexidade, 199 Padre Anchieta Avenue - Room 2, Jardim, Santo Andre, SP, 09090-710, Brazil. E-mail: email@example.com
Copyright © by 2020 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Yanping Bao, Yankun Sun, Shiqiu Meng, Jie Shi, Lin Lu
A novel coronavirus (2019-nCoV) has been identified as originating in Wuhan, Hubei Province, China. It has widely and rapidly spread in China and several other countries, causing an outbreak of acute infectious pneumonia. According to the official website of the National Health Commission,1 as of Feb 4, 2020, 24 324 people have been confirmed to have a 2019-nCoV infection and 490 deaths have resulted from 2019-nCoV in 31 provinces in mainland China.1 16 678 confirmed cases were in Hubei province.
Ensheng Dong, Hongru Du, Lauren Gardner
In December, 2019, a local outbreak of pneumonia of initially unknown cause was detected in Wuhan (Hubei, China), and was quickly determined to be caused by a novel coronavirus,1 namely severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak has since spread to every province of mainland China as well as 27 other countries and regions, with more than 70 000 confirmed cases as of Feb 17, 2020.2 In response to this ongoing public health emergency, we developed an online interactive dashboard, hosted by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, Baltimore, MD, USA, to visualise and track reported cases of coronavirus disease 2019 (COVID-19) in real time.
Xingfei Pan, Dexiong Chen, Yong Xia, Xinwei Wu, Tangsheng Li, Xueting Ou, Liyang Zhou, Jing Liu
Since December, 2019, an outbreak of pneumonia caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a serious epidemic in China and other countries, resulting in worldwide concern.1 Family clusters of infected individuals have been reported, and this phenomenon could present a serious threat to public health if not strictly controlled. In a previously reported family cluster, most infected individuals had clinical symptoms, decreased lymphocyte counts, and abnormal chest CT images, and were positive for the virus on quantitative RT-PCR (qRT-PCR) analysis.
Kalina W, Souza V, Wu K, et al.
AbstractBackgroundIdentifying Streptococcus pneumoniae (Sp) serotypes by urinary antigen detection assay (UAD) is the most sensitive way to evaluate the epidemiology of non-bacteremic community acquired pneumonia (CAP). We first described a UAD to detect the Sp serotypes 1,-3,-4,-5,-6A,-6B,-7F,-9V,-14,-18C,-19A,-19F,-23F covered by the licensed 13-valent Sp conjugate vaccine PCV13. To assess the substantial remaining pneumococcal disease burden after introduction of several pneumococcal vaccines, a UAD-2 assay was developed to detect 11 additional serotypes (-2,-8,-9N,-10A,-11A,-12F,-15B,-17F,-20,-22F,-33F) in individuals with radiographically-confirmed CAP.MethodsUAD-2 specificity was achieved by capturing pneumococcal polysaccharides with serotype-specific monoclonal antibodies using Luminex technology. Assay qualification assessed accuracy, precision, sample linearity. Serotype positivity was based on cutoffs determined by non-parametric statistical evaluation of urine samples from individuals without pneumococcal disease. Sensitivity and specificity of the positivity cutoffs were assessed in a clinical validation using urine samples obtained from a large study that measured the proportion of radiographically-confirmed CAP caused by Sp serotypes in hospitalized US adults.ResultsThe UAD-2 was shown to be specific and reproducible. Clinical validation demonstrated assay sensitivity and specificity of 92.2% and 95.9% against a gold standard of bacteremic pneumonia. Additionally, the UAD-2 assay identified a Sp serotype in 3.72% of non-bacteremic CAP cases obtained from hospitalized US adults. When combined with bacteremic CAP cases, the percent of pneumonias with a UAD-2 serotype was 4.33%.ConclusionsThe qualified/clinically validated UAD-2 method has applicability in understanding the epidemiology of non-bacteremic Sp CAP and utility to assess vaccine efficacy of future pneumococcal conjugate vaccines that are under development.
Stabler S, Giovannelli J, Launay D, et al.
AbstractBackgroundRituximab (RTX) is widely administered to patients with autoimmune diseases (AID). This study aimed to estimate the incidence of serious infectious events (SIE) after RTX initiation in patients with AID. We also described the characteristics and risk factors of SIE, and immunoglobulin replacement therapy (IgRT) strategies.MethodsPatients treated between 2005 and 2016 were included in this retrospective monocentric cohort study. An RTX-course was defined as the complete RTX treatment regimen received by a given patient for AID. SIE and IgRT were right-censored at 24 months after RTX initiation.ResultsTwo hundred and twenty-one patients were included (corresponding to 276 RTX-courses). Reasons for RTX initiation included connective tissue disease (38%), systemic vasculitis (36%), and autoimmune cytopenia (22%). The 1- and 2-year incidences of SIE were 17.3 (12.0-22.5) and 11.3 (8.1-14.5) per 100 person-years, respectively. Forty-seven SIE were observed, mostly comprising pneumonias (45%) and bacteremias (21%). When documented, the microorganisms were bacterial (55%) and fungal (12%). Identified risk factors of SIE were age, history of diabetes, history of cancer, concomitant steroid treatment and low CD4 lymphocyte count at RTX initiation. IgRT was started in 22 RTX-courses (8%).ConclusionIn patients with AID treated with RTX, the 1- and 2-year incidence of SIE were 17.3 and 11.3 per 100 person-years, respectively. Reports of SIE characteristics, risk factors and IgRT strategies highlights the need for an appropriate and individualized assessment prior to and following RTX to prevent SIE, particularly in patients with comorbidities.
Xuejiao Chen, Junzhang Tian, Guanming Li, Guowei Li
In December, 2019, a group of patients with pneumonia of unknown origin, most of whom had been exposed to the Huanan seafood wholesale market in Wuhan, China, was first reported.1 Using deep sequencing analysis, Chinese authorities identified a new betacoronavirus (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) as the cause of the outbreak, and found that SARS-CoV-2 belongs to a clade within the subgenus sarbecovirus, orthocoronavirinae subfamily.2 As of Feb 10, 2020, the ongoing outbreak of coronavirus disease 2019 (COVID-19) originating in Wuhan had caused 42 638 confirmed cases and 1016 deaths, with 32 provinces and regions of China affected.
Rice TW, Kripalani S, Lindsell CJ.
Among critically ill patients in the intensive care unit (ICU), complications are frequent, including stress ulcers in the upper gastrointestinal tract. To help prevent the development of ulcers, antagonism of gastric acid (with antacids historically) or inhibition of the production of acid (with histamine-2 receptor blockers more recently) were implemented as part of routine critical care. The introduction of proton pump inhibitors, with data demonstrating improved ulcer prevention and recovery compared with histamine-2 receptor blockers in non–critically ill patients, led many physicians who provide care for critically ill patients to incorporate proton pump inhibitors for routine stress ulcer prophylaxis. However, the lack of randomized clinical trials (RCTs) that directly compared histamine-2 receptor blockers with proton pump inhibitors for stress ulcer prophylaxis in critically ill patients, combined with decreasing incidence of significant gastrointestinal bleeding in these patients and emerging evidence of an association between proton pump inhibitor use and adverse events, including Clostridioides difficile (Clostridium difficile) infection, cognitive decline, and nosocomial pneumonia, made the optimal choice of routine stress ulcer prophylaxis less clear.
Journal of Medical Virology, Volume 0, Issue ja, -Not available-.
Pfaller, M. A., Huband, M. D., Shortridge, D., Flamm, R. K.
Omadacycline is a broad-spectrum aminomethylcycline approved in October 2018 by the United States Food and Drug Administration for treating acute bacterial skin and skin structure infections and community-acquired pneumonia as both an oral and intravenous once-daily formulation. In this report, omadacycline and comparators were tested against 49,000 non-duplicate bacterial isolates collected prospectively during 2016-2018 from medical centers in Europe (24,500 isolates; 40 medical centers [19 countries]) and the United States (24,500 isolates; 33 medical centers [23 states and all 9 United States Census Divisions]). Omadacycline was tested by broth microdilution following Clinical and Laboratory Standards Institute M07 (2018) methods.Omadacycline (MIC50/90, 0.12/0.25 mg/L) inhibited 98.6% of Staphylococcus aureus isolates at ≤0.5 mg/L including 96.3% of methicillin-resistant S. aureus and 99.8% of methicillin-susceptible S. aureus. Omadacycline potency was comparable for Streptococcus pneumoniae (MIC50/90, 0.06/0.12 mg/L), viridans group streptococci (MIC50/90, 0.06/0.12 mg/L) and β-hemolytic streptococci (MIC50/90, 0.12/0.25 mg/L) regardless of species and susceptibility to penicillin, macrolides or tetracycline. Omadacycline was active against Enterobacterales (MIC50/90, 1/8 mg/L; 87.5% inhibited at ≤4 mg/L) except Proteus mirabilis (MIC50/90, 16/>32 mg/L) and Indole-positive Proteus spp. (MIC50/90, 8/32 mg/L) and was most active against Escherichia coli (MIC50/90, 0.5/2 mg/L), Klebsiella oxytoca (MIC50/90, 1/2 mg/L) and Citrobacter spp. (MIC50/90, 1/4 mg/L). Omadacycline inhibited 92.4% of Enterobacter cloacae species complex and 88.5% of Klebsiella pneumoniae isolates at ≤4 mg/L. Omadacycline was active against Haemophilus influenzae (MIC50/90, 0.5/1 mg/L) regardless of β-lactamase status and against Moraxella catarrhalis (MIC50/90, ≤0.12/0.25 mg/L). The potent activity of omadacycline against Gram-positive and -negative bacteria indicates that omadacycline merits further study in serious infections in which multidrug resistance and mixed Gram-positive and -negative infections may be a concern.
Stone, G. G., Bradford, P. A., Tawadrous, M., Taylor, D., Cadatal, M. J., Chen, Z., Chow, J. W.
Nosocomial pneumonia (NP), including ventilator-associated pneumonia (VAP), is increasingly associated with multidrug-resistant Gram-negative pathogens. This study describes the in vitro activity of ceftazidime-avibactam, ceftazidime, and relevant comparator agents against bacterial pathogens isolated from patients with NP, including VAP, enrolled in a ceftazidime-avibactam phase 3 trial (ClinicalTrials.gov identifier NCT01808092). Gram-positive pathogens were included if co-isolated with a Gram-negative pathogen. In vitro susceptibility was determined at a central laboratory using Clinical and Laboratory Standards Institute broth microdilution methods. Of 817 randomized patients, 457 (55.9%) had ≥1 Gram-negative bacterial pathogen isolated at baseline, and 149 (18.2%) had ≥1 Gram-positive pathogen co-isolated. The most common isolated pathogens were Klebsiella pneumoniae (18.8%), Pseudomonas aeruginosa (15.8%), and Staphylococcus aureus (11.5%). Ceftazidime-avibactam was highly active in vitro against 370 isolates of Enterobacteriaceae, with 98.6% susceptible (MIC90 0.5 μg/ml) compared with 73.2% susceptible for ceftazidime (MIC90 >64 μg/ml). The percent susceptibility values for ceftazidime-avibactam and ceftazidime against 129 P. aeruginosa isolates were 88.4% and 72.9% (MIC90 values of 16 μg/ml and 64 μg/ml) respectively. Among ceftazidime-nonsusceptible Gram-negative isolates, ceftazidime-avibactam percent susceptibility values were 94.9% for 99 Enterobacteriaceae and 60.0% for 35 P. aeruginosa. MIC90 values for linezolid and vancomycin (permitted per-protocol for Gram-positive coverage) were within their respective MIC susceptibility breakpoints against the Gram-positive pathogens isolated. This analysis demonstrates that ceftazidime-avibactam was active in vitro against the majority of Enterobacteriaceae and P. aeruginosa isolated from patients with NP, including VAP, in a phase 3 trial.
Yu P, Zhu J, Zhang Z, et al.
AbstractAn ongoing outbreak of pneumonia associated with 2019 novel coronavirus (2019-nCoV) was reported in China. It is unclear if the infectivity exists during the incubation period, although a person-to-person transmission has been reported in previous studies. We report the epidemiological features of a familial cluster of four patients in Shanghai, of which one was 88 years old man with moving difficulties and was only exposed to his asymptomatic family members who developed symptoms later. The epidemiological evidence has shown a potential transmission of the 2019-nCoV during the incubation period.
Montoya-Ferrer A, Sanosyan A, Fayd'herbe De Maudave A, et al.
AbstractBackgroundImmune control of Epstein-Barr virus (EBV) infection is impaired in HIV-infected individuals. We explored maternal factors associated with EBV acquisition in HIV-exposed uninfected (HEU) infants and the relationship between EBV infection and serious adverse events (SAE) during the first year of life.MethodsTwo hundred and one HEU infants from Uganda enrolled in the ANRS12174 trial were tested for anti-viral capsid antigen (VCA) antibodies at week 50 of life. The date of infection was estimated by testing of EBV DNA at weeks 1, 6, 14, 26, 38 and 50 postpartum on dried blood spot (DBS).ResultsEighty-seven (43%) infants were tested positive for anti-VCA IgG at week 50. Among the 59 infants positive for EBV DNA, 25% were infected within the first 26 weeks. Almost half of them (12%) were infected before week 14. Shedding of EBV in breast milk was associated with EBV DNA in maternal plasma (P=.009), HIV RNA detection (P=.039), lower CD4 count (P=.001) and was correlated with plasma EBV DNA levels (P=.002). EBV infant infection at week 50 was associated with shedding of EBV in breast milk (P=.009) and young maternal age (P=.029). Occurrence of a clinical SAE, including malaria and pneumonia, was associated with higher levels of EBV DNA in infants (P=.010).ConclusionsBy assessing EBV infection in HEU infants we observed that infection during the first year of life is determined by HIV and EBV maternal factors and that EBV DNA levels was higher among infants with clinical SAE.
Kaur R, Pham M, Yu K, et al.
AbstractAbstractImportanceAntibiotic-resistant S. pneumoniae strains may cause infections that fail to respond to antimicrobial-therapy. Results reported from hospitalized patients with invasive, bacteremic infections may not be the same as those observed in a primary-care setting where young children receive care for non-invasive infections. Young children experience the highest burden of pneumococcal disease.ObjectivesTo determine the antibiotic susceptibility of S. pneumoniae strains isolated from children in a primary-care setting in the post-13-valent pneumococcal conjugate vaccine (PCV-13) era.Design, Setting, and ParticipantsProspective collection of 1201 isolates of S. pneumoniae from 2006-2016 in a primary-care setting. Antibiotic susceptibility testing to 16 different antibiotics of ten classes performed. Participants were children age 6 to 36 months old. Nasopharyngeal swabs were obtained from patients during acute otitis media (AOM) visits and routine healthy visits. Middle ear fluid obtained by tympanocentesis.ResultsAfter introduction of PCV-13, antibiotic susceptibility of pneumococci, especially to penicillin, initially improved largely due to disappearance of serotype 19A, included in PCV-13. However, beginning in 2013, antibiotic susceptibility among pneumococcal strains began decreasing due to new serotypes not included in PCV-13. In addition to reduced susceptibility to penicillin, the most recent isolates show reduced susceptibility to third generation cephalosporins, fluoroquinolones and carbapenems, antibiotics commonly used to treat life-threatening, invasive pneumococcal diseases.Conclusions and relevanceIn recent years, pneumococcal nasopharyngeal and AOM isolates from children exhibit reduced susceptibility to penicillin, third generation cephalosporin, fluoroquinolone and carbapenem antibiotics. The new strains have a different profile of resistance compared to the pre-PCV-13 era.
Bingjie Wang, Fen Pan, Chun Wang, Wantong Zhao, Yan Sun, Tiandong Zhang, Yingying Shi, Hong Zhang
Akihito Okazaki, Yoshihiro Takeda, Yasuhiko Matsuda, Kazuhiko Shibata, Kazuo Kasahara
American Journal of Respiratory and Critical Care Medicine, Volume 201, Issue 4, Page e12-e12, February 15, 2020.
Charles Langelier, Monica Fung, Saharai Caldera, Thomas Deiss, Amy Lyden, Brian C. Prince, Paula Hayakawa Serpa, Farzad Moazed, Peter Chin-Hong, Joseph L. DeRisi, Carolyn S. Calfee
American Journal of Respiratory and Critical Care Medicine, Volume 201, Issue 4, Page 491-495, February 15, 2020.
Chen Wang, Peter W Horby, Frederick G Hayden, George F Gao
In December, 2019, Wuhan, Hubei province, China, became the centre of an outbreak of pneumonia of unknown cause, which raised intense attention not only within China but internationally. Chinese health authorities did an immediate investigation to characterise and control the disease, including isolation of people suspected to have the disease, close monitoring of contacts, epidemiological and clinical data collection from patients, and development of diagnostic and treatment procedures. By Jan 7, 2020, Chinese scientists had isolated a novel coronavirus (CoV) from patients in Wuhan.
Nanshan Chen, Min Zhou, Xuan Dong, Jieming Qu, Fengyun Gong, Yang Han, Yang Qiu, Jingli Wang, Ying Liu, Yuan Wei, Jia'an Xia, Ting Yu, Xinxin Zhang, Li Zhang
The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection.
Jasper Fuk-Woo Chan, Shuofeng Yuan, Kin-Hang Kok, Kelvin Kai-Wang To, Hin Chu, Jin Yang, Fanfan Xing, Jieling Liu, Cyril Chik-Yan Yip, Rosana Wing-Shan Poon, Hoi-Wah Tsoi, Simon Kam-Fai Lo, Kwok-Hung Chan, Vincent Kwok-Man Poon, Wan-Mui Chan, Jonathan Daniel Ip, Jian-Piao Cai, Vincent Chi-Chung Cheng, Honglin Chen, Christopher Kim-Ming Hui, Kwok-Yung Yuen
Our findings are consistent with person-to-person transmission of this novel coronavirus in hospital and family settings, and the reports of infected travellers in other geographical regions.
Satlin M, Lewis J, II, Weinstein M, et al.
AbstractRecent data on polymyxin pharmacokinetics (PK), pharmacodynamics (PD), toxicity and clinical outcomes suggest these agents have limited clinical utility. PK-PD data show a steady state concentration of 2 ug/mL is required for killing bacteria with colistin minimum inhibitory concentrations (MICs) of 2 ug/mL. Less than 50% of patients with normal renal function achieve this exposure and it is associated with high risk of nephrotoxicity. This exposure does not achieve bacterial stasis in pneumonia models. Randomized and observational studies consistently demonstrate increased mortality for polymyxins compared to alternative agents. CLSI and EUCAST are two global organizations that establish interpretive criteria for in vitro susceptibility data. CLSI has recently taken the step to eliminate the “susceptible” interpretive category for the polymyxins, whereas EUCAST maintains this interpretive category. This viewpoint describes the opinions of the two organizations and the data that were used to inform their perspectives.
Ali Khalid, Alicia Fajardo Lubián, Li Ma, Ruby CY Lin, Jonathan R. Iredell
Elisa Antinori, Ilaria Unali, Anna Bertoncelli, Annarita Mazzariol
Klebsiella pneumoniae producing KPC is a great health concern and therapy with ceftazidime-avibactam represent a choice for the treatment of infections supported by these strains. We report a ceftazidime-avibactam resistant strain by a deletion of 6 nucleotides in the blaKPC gene sequence.
Community–acquired pneumonia (CAP) is one of the leading worldwide causes of childhood morbidity and mortality. Its disease burden varies by age and etiology and is time dependent. We aimed to investigate the annual and seasonal patterns in etiologies of pediatric CAP requiring hospitalization.
We conducted a retrospective study in 30,994 children (aged 0–18 years) with CAP between 2010 and 2015 at 23 nationwide hospitals in South Korea. Mycoplasma pneumoniae (MP) pneumonia was clinically classified as macrolide-sensitive MP, macrolide-less effective MP (MLEP), and macrolide-refractory MP (MRMP) based on fever duration after initiation of macrolide treatment, regardless of the results of in vitro macrolide sensitivity tests.
MP and respiratory syncytial virus (RSV) were the two most commonly identified pathogens of CAP. With the two epidemics of MP pneumonia (2011 and 2015), the rates of clinical MLEP and MRMP pneumonia showed increasing trends of 36.4% of the total MP pneumonia. In children
Pneumocystis pneumonia (PCP) is increasingly being diagnosed in patients with systemic lupus erythematosus (SLE), and hydroxychloroquine (HCQ) has been found to possess antifungal activities. We hence aimed to investigate the association between HCQ and PCP risk among patients with SLE.
Using the 1997–2013 nationwide claim data, we identified 24,343 newly-diagnosed SLE patients. We then identified 58 PCP cases and selected 348 non-PCP controls matching (1:6) by age, sex, disease duration and the year of PCP diagnosis date. The risk of PCP was assessed by determing odds ratios (ORs) with 95% confidence intervals (CIs) by using multivariable conditional logistic regression.
The risk of PCP was associated with moderate to severe renal disease (OR 6.73, 95% CI 1.98–22.92), higher doses of glucocorticoids (≤5 mg/day, reference; 5–10 mg/day, OR 25.88, 95% CI 2.97–225.33; > 10 mg/day, OR 286.58, 95% CI 28.58–> 999), higher 3-month cumulative dose of cyclophosphamide (not use, reference; ≤1.4 g, OR 0.64, 95% CI 0.14–3.01; > 1.4 g, OR 11.52, 95% CI 1.97–67.39) and use of mycophenolate mofetil/mycophenolic acid (OR 50.79, 95% CI 5.32–484.77), whereas 3-month cumulative dose of HCQ was associated with a reduced risk of PCP among patients with SLE (not use, reference; ≤14 g, OR 0.69, 95% CI 0.21–2.24; > 14 g, OR 0.20, 95% CI 0.05–0.71).
This study demonstrated incident PCP was associated with mycophenolate mofetil/mycophenolic acid use and higher doses of cyclophosphamide or glucocorticoid, whereas the use of a higher dose of HCQ was associated with a reduced risk of PCP in lupus patients.
We analyzed the results of a 3-year surveillance study on the epidemiological and clinical characteristics of healthcare associated-infections (HAIs) in elderly inpatients in a large tertiary hospital in China.
Real-time surveillance was performed from January 1, 2015 to December 31, 2017. All HAIs were identified by infection control practitioners and doctors. Inpatient data were collected with an automatic surveillance system.
A total of 134,637 inpatients including 60,332 (44.8%) elderly ≥60 years were included. The overall incidence of HAI was 2.0%. The incidence of HAI in elderly patients was significantly higher than that in non-elderly patients (2.6% vs. 1.5%, χ2 = 202.421, P
Meyer Sauteur P, Trück J, van Rossum A, et al.
AbstractBackgroundWe recently demonstrated that the measurement of Mycoplasma pneumoniae (Mp)-specific IgM antibody-secreting cells (ASCs) improved diagnosis of Mp infection. Here, we aimed to describe Mp ASC kinetics and duration in comparison to conventional measures such as pharyngeal Mp DNA and serum antibodies.MethodsProspective longitudinal study of 63 community-acquired pneumonia (CAP) patients and 21 healthy controls (HCs), 3–18 years of age, from 2016–2017. Mp ASCs measured by enzyme-linked immunospot (ELISpot) were assessed alongside Mp DNA and antibodies during 6-month follow-up.ResultsMp ASCs of the isotype IgM were found in 29 (46%), IgG in 27 (43%), and IgA in 27 (43%) CAP patients. Mp ASCs were detected from 2 days to maximum 6 weeks after symptom onset, while Mp DNA and antibodies persisted until 4 months (p=0.03) and 6 months (p
Na Zhu, Dingyu Zhang, Wenling Wang, Xingwang Li, Bo Yang, Jingdong Song, Xiang Zhao, Baoying Huang, Weifeng Shi, Roujian Lu, Peihua Niu, Faxian Zhan, Xuejun Ma, Dayan Wang, Wenbo Xu, Guizhen Wu, George F. Gao, Wenjie Tan
New England Journal of Medicine, Ahead of Print.
Qun Li, Xuhua Guan, Peng Wu, Xiaoye Wang, Lei Zhou, Yeqing Tong, Ruiqi Ren, Kathy S.M. Leung, Eric H.Y. Lau, Jessica Y. Wong, Xuesen Xing, Nijuan Xiang, Yang Wu, Chao Li, Qi Chen, Dan Li, Tian Liu, Jing Zhao, Man Liu, Wenxiao Tu, Chuding Chen, Lianmei Jin, Rui Yang, Qi Wang, Suhua Zhou, Rui Wang, Hui Liu, Yinbo Luo, Yuan Liu, Ge Shao, Huan Li, Zhongfa Tao, Yang Yang, Zhiqiang Deng, Boxi Liu, Zhitao Ma, Yanping Zhang, Guoqing Shi, Tommy T.Y. Lam, Joseph T. Wu, George F. Gao, Benjamin J. Cowling, Bo Yang, Gab
Fu-Sheng Wang, Chao Zhang
The 2019 novel coronavirus (2019-nCoV) infection can lead to acute resolved or fatal pneumonia. On the basis of knowledge of other coronaviruses, the main route of human-to-human transmission of 2019-nCoV is probably through respiratory droplets. As of Feb 4, 2020, statistical data show that the outbreak constitutes an epidemic threat in China, where the exponential increase in patients has reached 20 438 confirmed cases, with 2788 (13·64%) patients in critical condition and 425 (2·08%) deaths; 23 214 additional suspected cases have also been identified so far.
Y. Chen et al.
Justin M Oldham
When a thorough evaluation of interstitial lung disease (ILD) fails to yield a diagnosis, patients are diagnosed with unclassifiable ILD. The definitions of unclassifiable ILD used in early studies have been variable;1 however, an international working group has proposed that unclassifiable ILD characterises patients for whom an ILD diagnosis cannot be assigned with more than 50% confidence.2 This scenario commonly occurs in patients with overlapping features of idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis, and connective tissue disease-associated ILD.
Sarah B Doernberg
Over 50% of patients in critical care settings receive antibiotics on any given day.1 Because of the high incidence of resistant organisms, risk of inadequate empirical therapy in patients who are critically ill, and uncertainty of diagnosis in this setting, de-escalation of antibiotics poses a unique challenge. Therefore, clinicians tend to prescribe antibiotics expansively, even in the face of data suggesting appropriateness of narrower antibiotic courses or shorter durations.2 Ventilator-associated pneumonia, a common indication for antibiotics in the intensive care unit, poses a major diagnostic challenge, often leading to indiscriminate antibiotic use.
At the age of 41 years and having never smoked, Julie Swedberg, based in Minnesota (USA), was stunned to be diagnosed with stage 4 lung cancer in 2016. Her husband Eric and two young sons, aged 8 and 10 years at the time, were all devastated. “I'd been coughing a lot, and also had a history of allergies, so went to my doctor”, she explains. Multiple visits, antibiotics, and steroids did nothing to reduce her symptoms, so Julie requested a CT scan. “There was a spot on my lung in three different x-rays that was diagnosed as pneumonia.
Thomas P Hellyer, Daniel F McAuley, Timothy S Walsh, Niall Anderson, Andrew Conway Morris, Suveer Singh, Paul Dark, Alistair I Roy, Gavin D Perkins, Ronan McMullan, Lydia M Emerson, Bronagh Blackwood, Stephen E Wright, Kallirroi Kefala, Cecilia M O'Kane, Simon V Baudouin, Ross L Paterson, Anthony J Rostron, Ashley Agus, Jonathan Bannard-Smith, Nicole M Robin, Ingeborg D Welters, Christopher Bassford, Bryan Yates, Craig Spencer, Shondipon K Laha, Jonathan Hulme, Stephen Bonner, Vanessa Linnett, Julian Sonkse
Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect.
Ofman G, Pradarelli B, Caballero M, et al.
AbstractBackgroundEfforts to better understand the risk factors associated with respiratory failure (RF) and fatal LRTI in premature children in developing countries are necessary to elaborate evidenced-based preventive interventions. We aim to characterize the burden of RSV and hMPV LRTI in premature children and determine risk factors for RF and fatal illness in a vulnerable population.MethodsA prospective, population-based, cross-sectional study. Subjects with severe LRTI were enrolled during respiratory season. Risk factors for RF and death in premature infants were investigated.Results664 premature children participated. Infant’s hospitalization rate due to LRTI was 82.6/1,000 (95% confidence interval (CI), 68.6-96.7/1,000). Infant’s RSV and hMPV rates were 40.9/1,000 (36.3–45.6 /1,000) and 6.6/1,000 (3.9-9.2 /1,000), respectively. The RF rate was 8.2/1,000 (4.9-11.5 /1,000). LRTI mortality was 2.2/1,000 (0.7-3.7 /1,000); for RSV was 0.8/1,000 (0-1.7 /1,000) with a case fatality ratio of 1.8%. Never breastfeeding, malnutrition, younger than 6 months, congenital heart disease and lower hematocrit were risk factors for RF. Experiencing pneumonia, pneumothorax, sepsis or apnea were clinical determinants of poor outcomes.ConclusionsPremature children under 2 years old in vulnerable environments experience RF and death more often than term counterparts. Modifiable risk factors associated with poor outcomes should prompt evidence-based interventions.
Cavallazzi, Rodrigo; Ramirez, Julio
Purpose of review
The aim of this study was to discuss the literature on community-acquired pneumonia (CAP) in patients with chronic obstructive pulmonary disease (COPD).
Well designed studies show that COPD is the strongest risk factor for development of CAP. Lung microbiome, abnormal lung immunity and pathogen virulence are important components of the pathogenesis of CAP in COPD. The cause of CAP in patients with COPD is similar to that of non-COPD patients. However, patients with COPD are at an increased risk of infection by Gram-negative bacilli, including Pseudomonas aeruginosa. Empiric treatment regimens for CAP in COPD should contemplate the most common pathogens, and consideration should be given for the coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus depending on the severity of CAP, severity of COPD or prior isolation of these pathogens. COPD has not been consistently shown to be an independent risk factor for worse short-term outcomes in patients with CAP. In a long-term study, COPD is associated with worse outcomes in these patients.
Research focused on lung microbiome and abnormal lug immunity in patients with COPD should be prioritized. Further clinical research should try to consolidate the role of additional treatment approaches such as immunomodulating medications in COPD patients with CAP.
Correspondence to Rodrigo Cavallazzi, MD, 550 S. Jackson St., 3rd Floor, Ste. A3R35, Louisville, KY 40202, USA. E-mail: firstname.lastname@example.org
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Jabbour, Jean-Francois; Sharara, Sima L.; Kanj, Souha S.
Purpose of review
The increase in skin and soft tissue infections (SSTI) because of multidrug-resistant (MDR) pathogens is a global concern. Although MDR Gram-negative bacteria (GNB) are often overlooked as a cause of SSTIs, their burden on the morbidity of many subgroups of patients is high. There is a paucity in the available treatment options and guidelines on how to treat these pathogens. This manuscript reviews the management of SSTIs caused by carbapenem-resistant Enterobacteriaceae (CRE), Pseudomonas aeruginosa (CRPA), Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia. We also highlight a few novel antibiotics that show promise in the future management of MDR-GNB SSTIs.
Studies on treatment options of MDR-GNB SSTIs are scarce. Most clinical trials investigating new antibiotics have addressed conditions such as complicated intraabdominal infections, complicated urinary infections, and respiratory infections. CREs are a heterogenous group of pathogens with various mechanisms of resistance dictating susceptibility to different antimicrobial agents. Ceftazidime--avibactam, and meropenem--vaborbactam have potent activity against some of the CREs, especially Klebsiella pneumoniae carbapenemase (KPC) producers. Several novel antibiotics have potent activity against CRPA SSTIs, such as ceftazidime--avibactam, ceftolozane--tazobactam, cefiderocol, delafloxacin, finafloxacin, and murepavadin. Cefiderocol may also play an important role in the management of CRAB SSTIs, along with plazomicin and eravacycline.
MDR-GNB play a major role in SSTIs in patients with underlying immunodeficiency, as well as burn or trauma-related injuries. With the alarming global rise in MDR-GNB resistance, antibiotic therapy for SSTIs is challenging and must be guided by in-vitro susceptibility results. Currently, data extrapolated from other indications and combination therapy can be used empirically pending microbiological data and susceptibilities. Novel antibiotics are currently under development. It is hoped that future clinical trials will be designed to address MDR-GNB SSTIs.
Correspondence to Souha S. Kanj, Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh 2020, 1107 Beirut, Lebanon. Tel: +961 3 835 845; e-mail: email@example.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Dominedò, Cristina; Ceccato, Adrian; Torres, Antoni
Purpose of review
Ventilator-associated pneumonia (VAP) is a serious event in critically ill patients. We aim to review the most recent evidences about VAP, including its cause, the main differences between the American and European guidelines in the definition of risk factors for multidrug-resistant pathogens, the main principles guiding empirical antibiotic treatment, and the potential role of molecular diagnostic tests.
The 2016 ATS/IDSA and the 2017 ERS/ESICM/ESCMID/ALAT guidelines provide different approaches for the management of VAP. Both guidelines highlight the need to use local epidemiological data for antibiotic choice; however, they identify different risk factors that can assist with decision making when local data are not available. Nevertheless, validation studies of the American guidelines suggest that empiric antibiotic therapy based on risk factors may lead to an overuse of broad-spectrum antibiotics. Rapid diagnostic tests may allow a faster identification of VAP cause, resulting in more adequate antimicrobial therapy and reduced exposition to broad-spectrum antibiotics.
Clinical studies should be conducted to evaluate the benefits of implementing guidelines and new approaches such as combinations of clinical data with rapid diagnostic tests; meantime adaptations of guidelines to local settings should be carried out by a local multidisciplinary expert team.
Correspondence to Antoni Torres, Department of Pulmonary Medicine, Hospital Clinic of Barcelona, C/ Villarroel 170, 08036 Barcelona, Spain. Tel: +34 93 227 5779; fax: + 34 93 227 9813; e-mail: firstname.lastname@example.org
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Howard L, Edwards K, Zhu Y, et al.
AbstractBackgroundHuman metapneumovirus (HMPV) is a leading cause of respiratory tract infections. Few studies have compared the clinical characteristics and severity of HMPV-associated pneumonia with other pathogens.MethodsActive population-based surveillance was previously conducted for radiographically-confirmed community-acquired pneumonia hospitalizations among children and adults in eight United States hospitals. Clinical data and specimens for pathogen detection were systematically collected. We described clinical features of all HMPV-associated pneumonia, and after excluding co-detections with other pathogen types, we compared features of HMPV-associated pneumonia with other viral, atypical, and bacterial pneumonia and modeled severity (mild, moderate, severe) and length of stay using multivariable proportional odds regression.ResultsHMPV was detected in 298/2358 (12.6%) children and 88/2320 (3.8%) adults hospitalized with pneumonia and was commonly co-detected with other pathogens (125/298 [42%] children and 21/88 [24%] adults). Fever and cough were the most common presenting symptoms of HMPV-associated pneumonia and were also common symptoms of other pathogens. After excluding co-detections, in children (n=1778), compared to HMPV (reference), bacterial pneumonia exhibited increased severity (OR 3.66 [95% CI 1.43-9.40]), RSV (0.76 [0.59-0.99]) and atypical (0.39 [0.19-0.81]) infections exhibited decreased severity, and other viral pneumonia exhibited similar severity (0.88 [0.55-1.39]). In adults (n=2145), bacterial (3.74 [1.87-7.47]) and RSV pneumonia (1.82 [1.32-2.50]) were more severe than HMPV (reference), but all other pathogens had similar severity.ConclusionsClinical features did not reliably distinguish HMPV-associated pneumonia from other pathogens. HMPV-associated pneumonia was less severe than bacterial and adult RSV pneumonia but otherwise as or more severe than other common pathogens.
Arcari, G., Di Lella, F. M., Bibbolino, G., Mengoni, F., Beccaccioli, M., Antonelli, G., Faino, L., Carattoli, A.
In this study we investigated VIM-1-producing Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, Citrobacter freundii, and Enterobacter cloacae strains, isolated in 2019 during a period of active surveillance of carbapenem resistant Enterobacterales in a large university hospital in Italy. VIM-1-producing strains colonized the gut of patients, with up to three different VIM-1-positive bacterial species isolated from a single rectal swab, but also caused bloodstream infection to one colonized patient. In the multi-species cluster the blaVIM-1 was identified in a 5-gene cassette class 1 integron, associated with several genetic determinants, including the blaSHV-12, qnrS1 and mph(A) genes, located on a highly conjugative and broad-host range IncA plasmid. Characteristics and origin of this IncA plasmid were studied.
Petraitiene, R., Petraitis, V., Kavaliauskas, P., Maung, B. B. W., Khan, F., Naing, E., Aung, T., Zigmantaite, V., Grigaleviciute, R., Kucinskas, A., Stakauskas, R., Georgiades, B. N., Mazur, C. A., Hayden, J. A., Satlin, M. J., Walsh, T. J.
Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) is an emerging global public health threat that causes life-threatening pneumonia and bacteremia. Ceftazidime-avibactam represents a promising advance for the treatment of serious infections caused by KPC-Kp. We investigated the pharmacokinetics and efficacy of ceftazidime-avibactam in treatment of experimental KPC-Kp pneumonia in persistently neutropenic rabbits. For single-dose and multi-dose (q8h) pharmacokinetics, rabbits received ceftazidime-avibactam intravenous infusions at 60/15, 90/22.5, and 120/30 mg/kg. Ceftazidime mean AUCs ranged from 287 to 608 μg•h/mL (single-dose) and from 300 to 781 μg•h/mL (multi-dose). Avibactam AUCs ranged from 21 to 48 μg•h/mL (single-dose) and from 26 to 48 μg•h/mL (multi-dose). KPC-Kp pneumonia was established by direct endotracheal inoculation. Treatment groups consisted of ceftazidime-avibactam (CZA) 120/30-mg/kg q6h, polymyxin B (PMB) loading-dose 2.5-mg/kg followed with 1.5-mg/kg q12h, or untreated controls (UC). There were significant reductions in residual bacterial burden, lung weights, and pulmonary hemorrhage scores in CZA- and PMB-treated rabbits for 7-day or 14-day (P≤0.01) course in comparison with UC. These results corresponded with significant decreases of BAL bacterial burden after 7-day or 14-day treatment (P≤0.01). Outcome demonstrated improved response at 14 days vs 7 days. There was significantly prolonged survival in 14-day CZA-treated rabbits in comparison with PMB-treated or UC (P≤0.05). This study demonstrates that ceftazidime-avibactam displays linear dose proportional exposures simulating those of human plasma pharmacokinetics profiles, is active in treatment of experimental KPC-Kp pneumonia in persistently neutropenic rabbits, and provides an experimental foundation for treatment of severely immunocompromised patients with this life-threatening infection.
Li, J., Lovern, M., Riccobene, T., Carrothers, T. J., Newell, P., Das, S., Talley, A. K., Tawadrous, M.
An extensive clinical development program (comprising two phase 2 and five phase 3 trials) has demonstrated the efficacy and safety of ceftazidime-avibactam in the treatment of adults with complicated intra-abdominal infection (cIAI), complicated urinary tract infection (cUTI), and hospital-acquired pneumonia (HAP), including ventilator-associated pneumonia (VAP). During the phase 3 clinical program, updated population pharmacokinetic (PK) modeling and Monte Carlo simulations using clinical PK data supported modified ceftazidime-avibactam dosage adjustments for patients with moderate or severe renal impairment (comprising a 50% increase in total daily dose compared with the original dosage adjustments) to reduce the risk of subtherapeutic drug exposures in the event of rapidly improving renal function. The modified dosage adjustments were included in the ceftazidime-avibactam labeling information at the time of initial approval, and were subsequently evaluated in the final phase 3 trial (in patients with nosocomial pneumonia, including VAP), providing supportive data for the approved US and European ceftazidime-avibactam dosage regimens across renal function categories. This review describes the analyses supporting the ceftazidime-avibactam dosage adjustments for renal impairment and discusses the wider implications and benefits of using modeling and simulation to support dosage regimen optimization based on emerging clinical evidence.
Willix, J. L., Stockton, J. L., Olson, R. M., Anderson, P. E., Anderson, D. M.
Pneumonic plague, caused by the gram-negative bacteria Yersinia pestis, is an invasive, rapidly progressing disease with poor survival rates. Following inhalation of Y. pestis, bacterial invasion of the lungs and a tissue-damaging inflammatory response allows vascular spread of the infection. Consequently, primary pneumonic plague is a multi-organ disease involving sepsis, necrosis of immune tissues and the liver, as well as bronchopneumonia and rampant bacterial growth. Given the likely role of the hyper-inflammatory response in accelerating the destruction of tissue, in this work we evaluated the therapeutic potential of the inducible cytoprotective enzyme heme oxygenase 1 (HO-1) against primary pneumonic plague. On its own, the HO-1 inducer cobalt protoporphyrin IX (CoPP) provided mice protection from lethal challenge with Y. pestis CO92 with improved pulmonary bacterial clearance and a dampened inflammatory response compared to vehicle-treated mice. Furthermore, CoPP treatment combined with doxycycline strongly enhanced protection in a rat aerosol challenge model. Compared to doxycycline alone, CoPP treatment increased survival, with a 3-log decrease in median bacterial titer recovered from the lungs and the general absence of a systemic hyper-inflammatory response. In contrast, treatment with the HO-1 inhibitor SnPP had no detectable impact on doxycycline efficacy. The combined data indicate that countering inflammatory toxicity by therapeutically inducing HO-1 is effective in reducing the rampant growth of Y. pestis and preventing pneumonic plague.
Current risk stratification in community-acquired pneumonia (CAP) does not incorporate the dynamic nature of CAP evolution. Study aim was to evaluate the predictive value of early blood pressure (BP) drop and its consideration within the CRB-65 score.
We performed a retrospective cohort study including consecutive adult hospitalized CAP patients 2013–2014 without documented treatment limitations or direct ICU admission. The CRB-65 score was calculated initially and re-calculated including any BP below the threshold (BP drop) within the first 24 h (CRB-65[BP24]). The primary endpoint was need for mechanical ventilation or vasopressors (MVVS) occurring after 24 h. Prognostic values were evaluated by uni- and multivariate and ROC curve analyses.
28/294 patients (9.5%) met the primary endpoint. Only 3 (11%) of them showed an initial BP of
The identification of the pathogens in pleural effusion has mainly relied on conventional bacterial culture or single species polymerase chain reaction (PCR), both with relatively low sensitivity. We investigated the efficacy of a commercially available multiplex bacterial PCR assay developed for pneumonia to identify the pathogens involved in pleural infection, particularly empyema.
A prospective, monocentric, observational study including 194 patients with pleural effusion. Patients were evaluated based on imaging, laboratory values, pleura ultrasound and results of thoracentesis including conventional microbiology studies during hospitalisation. Multiplex bacterial PCR (Curetis Unyvero p55) was performed in batch and had no influence on therapeutic decisions.
Overall, there were 51/197 cases with transudate and 146/197 with exudate. In 42% (n = 90/214) there was a clinical suspicion of parapneumonic effusion and the final clinical diagnosis of empyema was made in 29% (n = 61/214) of all cases. The most common microorganisms identified in the cases diagnosed with empyema were anaerobes  followed by gram-positive cocci  and gram-negative rods . The multiplex PCR assay identified more of the pathogens on the panel than the conventional methods (23.3% (7/30) vs. 6.7% (2/30), p = 0.008).
The multiplex PCR-based assay had a higher sensitivity and specificity than conventional microbiology when only the pathogens on the pneumonia panel were taken into account. A dedicated pleural empyema multiplex PCR panel including anaerobes would be needed to cover most common pathogens involved in pleural infection.
Potentially pathogenic bacteria that colonise the lower genital tract of women in labour can be passed to the baby during birth. While many babies become colonised with these bacteria after delivery, a few develop neonatal infections. The lower genital tract is a reservoir for potential pathogens and a source of infection for neonates. We determined the prevalence of vaginal colonisation of potentially pathogenic bacteria among women in labour in Central Uganda and identified potential risk factors associated with this colonisation.
We conducted a cross sectional study at three primary health care facilities and collected vaginal swabs from HIV-1 negative women in labour. Specimens were cultured on different selective microbiological media, and biochemical tests were used to classify bacterial isolates on the species level. Multivariable logistic regression analyses were used to estimate the association between relevant exposures and colonisation with potentially pathogenic bacteria.
We recruited 1472 women in labour whose mean age was 24.6 years (standard deviation [SD] 4.9). Of these, 955 (64.9%; 95% Confidence Interval [CI] 62.4, 67%) were vaginally colonised with at least one potentially pathogenic bacterial species. The most commonly isolated species were Escherichia coli (n = 508; 34.5%), Klebsiella pneumoniae (n = 144; 9.8%) and Staphylococcus aureus (n = 121; 8.2%). Results from exploratory multivariable regression analyses indicated that having had ≥5 previous pregnancies (adjusted odds ratio [aOR] 0.59; 95% CI 0.35, 0.97) or being ≥30 years old (aOR 1.52; 95% CI 1.03, 2.23) could be associated with vaginal colonisation with any potentially pathogenic bacteria, as well as with vaginal colonisation with S. aureus (aOR 0.33; 95% CI 0.12, 0.88, and aOR 2.17; 95% CI 1.17, 4.00, respectively). Possession of domestic animals in a household (aOR 0.57; 95% CI 0.35, 0.92) could be associated with vaginal colonisation with E. coli.
Two-thirds of HIV-1 negative women in labour were vaginally colonised by potentially pathogenic bacteria, mainly E. coli, K. pneumoniae, and S. aureus.
Jeremy S. Brown
American Journal of Respiratory and Critical Care Medicine, Volume 201, Issue 3, Page 268-270, February 1, 2020.
Dansk Selskab for Intern Medicin (DSIM) årsmøde og overrækkelse af Hagedorn prisen 2020
Novo Nordisk Fonden, Tuborg Havnevej 19, 2900 Hellerup
Conference on Retroviruses and Opportunistic Infections (CROI) 2020
Boston, Massachusetts, USA
8.03.2020 - 11.03.2020
Når CROI går i fisk - med transmissioner fra CROI 2020
10.03.2020 - 11.03.2020
World TB day 2020
Specialespecifikt kursus om kardiopulmonale infektioner og TB
26.03.2020 - 27.03.2020
National handlingsplan for antibiotika til mennesker (2017)
Retningslinjer til sundhedsprofessionelle vedr. håndtering af infektion med zikavirus (2019)
Antiviral behandling af hiv smittede personer (2019)
COVID-19: fighting panic with information
Childbirth settings in the US
Offline: Facts are not enough
Locust swarms in east Africa could be “a catastrophe”
Economic crisis hits Lebanese health care
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