Volume 25, Issue 4, 2017
Review
Update on the main MDR pathogens: prevalence and treatment options
Esposito Silvano,
De Simone Giuseppe
In recent years the proportion of multi-drug resistance (MDR) among the bacterial pathogens causing infections, particularly those acquired in healthcare settings, has risen worryingly worldwide. It poses a serious public health threat as the multiple patterns of resistance limit the effective treatment options for such infections. Although many bacterial species have developed reduced susceptibility to a wide array of antimicrobial molecules, a particular group of pathogens acronymically referred to as ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp.) plays a clinically relevant role in the aetiology of life-threatening nosocomial infections. In this review, we represent the rise of MDR among the ESKAPE pathogens over the decades and report studies from each continent showing the current prevalence and burden of such infections worldwide.
Original article
Efficacy of loading dose of colistin in Acinetobacter baumannii ventilator-associated pneumonia
Alp Emine,
Eren Esma,
Elay Gülseren,
Cevahir Fatma,
Esmaoğlu Aliye,
Rello Jordi
Colistin loading dose (LD) has been postulated as an advance in therapy. The clinical, microbiological effectiveness and nephrotoxicity of adding an LD to systemic colistin in ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) Acinetobacter baumannii remain unknown. In this quasi-experimental study, the efficacy, outcomes and nephrotoxicity in 30 adults who received intravenous colistin with LD for MDR A. baumannii ventilator-associated pneumonia were compared with 22 in absence of LD. Adding LD, the clinical cure rate at 14 days of therapy increased from 47.6% to 56.7% (p>0.397). No significant differences in bacteriological clearance (80 vs 81%), ICU mortality (50% vs 54.2%) or ICU length of stay (median: 32 vs 36 days) were identified. Mortality increased (76.2% vs 35.5%, p=0.004) in patients with nephrotoxicity, with age (median 67.0 vs. 50.0 years, p=0.002) being the only risk factor for nephrotoxicity. The nephrotoxicity rate increased from 27.3% in absence of LD to 35.3% with LD and SOFA <8, and 69.2% (p= 0.065) with LD and SOFA >7. Overall, nephrotoxicity was more severe in the LD group according to RIFLE criteria (p=0.015). Adding LD to systemic colistin for MDR A. baumannii VAP had no significant effect on clinical cure rates, bacteriologic clearance or pre-defined outcomes. However, the nephrotoxicity rate increased with LD, with special risk in adults with high organ failure development or advanced age. Further evidence regarding the risks and benefits of LD is required. The development of newer agents and strategies is urgently needed.
Blood-Brain Barrier and Intrathecal Immune Response in patients with neuroinfections
Valkov Trifon,
Hristova Julieta,
Tcherveniakova Tatiana,
Svinarov Dobrin
Cerebrospinal fluid/serum albumin ratio is one of the most informative parameters for blood-brain barrier (BBB) integrity in cases of central nervous system (CNS) infectious diseases. Normally, CNS albumin concentration is a function of diffusion processes along with CSF drainage and resorption. In pathological processes CSF albumin levels are dependent only on the rate of CSF drainage resulting in non-linear reciprocal changes of albumin quotient (Qalb). IgG, IgA and IgM concentrations both in CSF and serum can be compared to Qalb, thus determining the intrathecal immune response.
The aim of the study was to detect BBB permeability impairment and the intrathecal immune response in patients with CNS infections with various etiologies. CSF/serum ratios were calculated and related to IgG IgA and IgM concentrations in CSF and blood serum. The results were integrated and presented by Reibergrams. The results demonstrated typical patterns which prove albumin to be the main modulator of protein dynamics and at the same time explicates the complex pathophysiological mechanisms involved in BBB disruption and intrathecal immune response in CNS infections. The diagnostic model presented in our study seeks to explain the observations of meningitis and meningoencephalitis pathophysiology and points out the mandatory cooperation between clinicians and laboratory for accurate diagnosis and proper treatment.
Prevalence of zoonotic and non-zoonotic genotypes of Giardia intestinalis in cats: a systematic review and meta-analysis
Ramírez-Ocampo Sebastián,
Cotte-Alzate, Juan David,
Escobedo Ángel A.,
Rodríguez-Morales Alfonso J,
There are no meta-analyses specifically describing the prevalence of zoonotic and non-zoonotic genotypes of Giardia intestinalis in cats, which would be useful in defining the importance of cats as a source of zoonotic transmission. We performed a systematic review of the literature in three databases (PubMed, Scopus and SciELO) to assess the proportion of cats that were infected with specific G. intestinalis genotypes. A meta-analysis using a random effects model was performed to calculate the pooled prevalence and 95% confidence intervals (95%CI). A 2-tailed alpha level of 5% was used for hypothesis testing. Measures of heterogeneity, including Cochran’s Q statistic, the I2 index, and the tau-squared test, were estimated and reported. Subgroup analyses were conducted by geographic area and animal origin, as well as coinfection. Publication bias was assessed using a funnel-plot.
Up to November 1, 2015, the literature search yielded 780 articles, of which 29 studies were valid for analysis. The pooled prevalence rate was higher for genotype F (19 studies, n=368 cats) with 55.8% [95%CI (42.8%-68.7%), τ2=0.0463]. For genotype A (21 n=409) it was 38.7% [95%CI (29.0%-48.4%), τ2=0.0527], for genotype D (7, n=276) 8.9% [95%CI (2.1%-15.8%), τ2=0.0024], for genotype C (2, n=212) 3.1% [95%CI (2.5%-3.5%), τ2=0.0001], for genotype E (3, n=187) 2.9% [95%CI (0.0%-8.1%), τ2=0.0009], and for genotype B (4, n=230) it was 2.8% [95%CI (0.0%-5.7%), τ2=0.0002]. Genotypes A and B of G. intestinalis are present in a wide range of hosts, including humans and cats, whilst genotype E has been reported in bovines, ovines, caprine and porcine animals, as well as in dogs and cats; and genotype F is almost exclusive to cats. Thus genotypes A and B are the most important for zoonotic transmission. In this study, after genotype F (55.5%), genotype A yielded more than 38% in cats (95%CI 29-48). This has interesting possible implications in zoonotic transmission of giardiasis between cats and humans
Hepatitis A, B, C and HIV seroprevalence among Syrian refugee children admitted to outpatient clinics
Köse Şükran,
Ödemiş İlker,
Çelik Didem,
Gireniz Tatar Bengü,
Akbulut İlkay,
Yılmaz Çiftdoğan Dilek
Viral hepatitis is the most common cause of serious health problems such as liver cirrhosis and hepatocellular carcinoma (HCC). Leading to immunodeficiency disorders through different mechanisms, Human Immunodeficiency Virus (HIV) causes the development of severe secondary infections. Hepatitis A (HAV) is thought to spread by the faecal-oral route, while Hepatitis B (HBV), Hepatitis C (HCV) and HIV are mostly transmitted vertically during childhood. In our study, we aimed to determine the seroprevalence of HAV, HBV, HCV and HIV among Syrian refugee children who were admitted to outpatient clinics. We conducted a retrospective review of data concerning 171 Syrian children aged between 0-18 years admitted between April 2014 and December 2015 to the outpatient infectious disease clinic of İzmir Tepecik Training and Research Hospital and the social welfare outpatient clinic for Syrian refugees for reasons other than jaundice. Serum samples from patients were studied for HAV antibody IgG (anti-HAV IgG), HBV surface antigen (HBsAg), antibodies against HBV surface antigen (anti-HBs), antibodies against HBV core antigen (anti-HBc total), HCV antibody (anti-HCV) (anti-HIV) with the ELISA (Enzyme-Linked Immunosorbent Assay) method. In this study 51% of patients were female, with a mean age of 6.52 years among all patients. Six of the 140 patients (4.2%) scanned for HBV among the patients enrolled in the study were HBsAg and anti-HBc total positive and anti-HBs negative. Three patients (2.1%) were HBsAg negative, and anti-HBc total and anti-HBs positive, which indicated they had previously recovered from an HBV infection. HBsAg, anti-HBs, anti-HBc total data for 140 patients (81.9%), anti-HCV data for 109 patients (63.8%), anti-HIV data for 88 patients (51.5%) and HAV IgG data for 86 patients (50.3%) were obtained. Due to migration from regions in Syria where there is no regular follow-up of HBV vaccination in children, HBsAg seroprevalence of refugee children is thought to be higher than in other children in Turkey and anti-HBs positivity is thought to be lower. We expected to see a higher seroprevalence of anti-HCV and anti-HIV in Syria due to the lack of health facilities such as non-regular anti-HCV and anti-HIV screening before blood transfusions and during pregnancy in all regions of Syria. Yet in this study, the anti-HCV, anti-HIV seroprevalence of Syrian refugee children was similar to that in Turkey. According to the results, if the children of asylum seekers are admitted to the national HAV and HBV vaccination schedule, hepatitis infections and their complications may be prevented.
Outbreak of severe Hepatitis A in Eastern Piedmont, Italy
Rossati Antonella,
Bargiacchi Olivia,
Kroumova Vesselina,
Nebbiolo Claudio,
Grazia Maria,
Pratillo Sonia,
Garavelli Pietro Luigi,
Hepatitis A (HA) is caused by a hepatovirus from the family Picornaviridae (Hepatitis A Virus, HAV). Transmission occurs mainly by the orofaecal route through food or water contaminated by faeces. Sexual transmission has also been reported among men who have sex with men (MSM). From February to May 2017, 14 patients with HA were hospitalized at the University Hospital “Maggiore della Carità”, Novara (Eastern Piedmont), Italy. One patient was two years old and was therefore admitted to the Paediatric Unit, the remaining 13 to the Infectious Disease Unit. Two of the adults were female and the rest (11) were male. The male patients were MSM, and contracted the infection sexually; three of them were known to be HIV positive, while two had a new diagnosis of syphilis infection. Women contracted the infection from contaminated food.
Symptomatic congenital Cytomegalovirus deafness: the impact of a six-week course of antiviral treatment on hearing improvement
Mazzaferri Fulvia,
Cordioli Maddalena,
Conti Michela,
Storato Silvia,
Be Giorgia,
Biban Paolo,
Concia Ercole,
Merighi Mara
Congenital Cytomegalovirus infection is the leading non-genetic cause of neurosensory deafness. We compared the outcomes of a treated group of children to an untreated group. The effect of antiviral therapy on hearing improvement between baseline and 2-year follow-up was statistically significant. These results suggest that the benefit of 6-week therapy is not limited to preventing further hearing deterioration
Prevalence of class 1 integrons and plasmid-mediated qnr-genes among Enterobacter isolates obtained from hospitalized patients in Ahvaz, Iran
Amin Mansour,
Dibachi Solmaz,
Shahin Mojtaba
Quinolones are frequently used classes of antimicrobials in hospitals, crucial for the treatment of infections caused by Gram-negative bacteria. The inappropriate use of quinolones and other antimicrobial agents for the treatment of bacterial infections leads to a significant increase of resistant isolates. The acquisition of antimicrobial resistance may be related to achievement of resistance determinant genes mediated by plasmids, transposons and gene cassettes in integrons. The objective of this cross-sectional study, conducted from December 2015 to July 2016 at two teaching hospitals in Ahvaz, southern Iran, was to screen for the presence of class 1 integrons and quinolone resistance genes in clinical isolates of Enterobacter spp. In all, 152 non-duplicated Enterobacter isolates were collected from clinical specimens and identified as Enterobacter spp. using standard microbiological methods. Antimicrobial susceptibility test was determined using the disc diffusion method according to the CLSI recommendation. Determination of class 1 integrons and PMQR genes was assessed by PCR. Analysis of antibiotic susceptibility tests showed that the highest antibiotic resistance was toward ciprofloxacin (55.3%), while the lowest level was observed against meropenem (34.9%). Moreover, 47.4% (72/152) and 29% (44/152) of isolates were positive for class 1 integron and quinolone resistance genes, respectively. The relative frequencies of antibiotic resistance were significantly higher among class 1 integron-positive isolates. In summary, our results highlight the importance of PMQR genes in the emergence of quinolone-resistant Enterobacter isolates. Moreover, it seems that class 1 integrons have a widespread distribution among Enterobacter isolates and have clinical relevance to multiple-drug-resistant isolates.
Case report
Granulated sugar for adjuvant treatment of surgical wound infection due to multi-drug-resistant pathogens in a child with sarcoma: a case report and literature review
Naselli Aldo,
Accame Laura,
Buffa Piero,
Loy Anna,
Bandettini Roberto,
Garaventa Alberto,
Della Ornella,
Castagnola Elio
The use of sugar for treating wounds which are difficult to heal and positive to resistant pathogens has already been documented. The authors describe the successful treatment by direct instillation of granular sugar in the antibiotic-resistant infected surgical site wound of a child with sarcoma. Sugar instillation in the extended spectrum beta-lactamase (ESBL)-producing Enterobacter cloacae positive wound, in addition to systemic treatment with meropenem and levofloxacin, allowed culture negativization in six days and complete wound healing in 30 days. These results make the use of sugar an attractive option for wounds which are difficult to treat, even in an immunocompromised child.
A case of invasive infection caused by a highly virulent strain of Klebsiella pneumoniae displaying hypermucoviscosity in a patient with hepatic involvement without liver abscess
Scapaticci Margherita,
Biscaro Marta,
Burelli Francesco,
Cadamuro Lucio,
Biscaro Renzo,
Bartolini Andrea
Klebsiella pneumoniae is an opportunistic nosocomial pathogen belonging to the Enterobacteriaceae family that is associated with a wide range of infections. In the 1980s a new hypervirulent (hypermucoviscous) variant of Klebsiella pneumoniae (hvKP) emerged in southeast Asia and is now increasingly spreading to Western countries due to an invasive syndrome. hvKP isolates can cause serious, life-threatening community-acquired infections in younger healthy hosts, including liver abscess, pneumonia, meningitis and endophthalmitis. We present a case of an 83-year-old man who was examined in the Medicine Department of San Camillo Hospital in Treviso for dehydration in gastroenteritis. Since he presented fever on admission, microbiological investigations were performed and empiric antibiotic therapy with cefotaxime was started. Blood analysis showed a high level of cholestasis indexes and transaminases. Blood cultures were found positive for K. pneumoniae that showed hypermucoviscosity. The hypermucoviscous phenotype of this K. pneumoniae isolate was easily identified by the "string test”. Abdominal computed tomography and ultrasonography did not show presence of liver abscesses. After a few days of antibiotic therapy the patient's clinical condition improved. Correct microbiology identification of this kind of strain was essential for appropriate clinical management.
Miliary pulmonary infection after BCG intravesical instillation: a rare, misdiagnosed and mistreated complication
Calleris Giorgio,
Marra Giancarlo,
Corcione Silvia,
Oderda Marco,
Cardellino Chiara,
Audagnotto Sabrina,
Frea Bruno,
De Rosa Francesco Giuseppe,
Gontero Paolo
Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy decreases the progression risk of non-muscle-invasive bladder cancer, but potentially yields a broad spectrum of side effects. We report the case of a 73-year-old man affected by miliary pulmonary BCG infection, whose microbiological diagnosis was probably hindered by empiric fluoroquinolones, focusing on imaging and clinical work-up.
Rothia mucilaginosa bacteraemia in an immunocompetent paediatric patient: a new pathogen to take into account. A case report
Luque-Pérez Silvia,
Cobos-Carrascosa Elena,
Guarino-Narváez Jessica,
Fernández-Puentes Verónica,
M. Eiros José,
Sánchez-Porto Antonio
Rothia mucilaginosa, previously known as Stomatococcus mucilaginosus, is a Gram-positive coccus that is part of the oropharyngeal microbiota and upper respiratory tract. It is mainly related to infections in immunosuppressed patients. Given its complex microbiological identification, its prevalence may be underestimated. We describe in this article a case of bacteraemia by Rothia in an immunocompetent paediatric patient without epidemiological or medical relevant history. In the available literature no cases of bacteraemia by Rothia mucilaginosa in immunocompetent paediatric patients have been reported. Given the characteristics of our patient, the publication of this case is of interest. Once the diagnosis of Rothia mucilaginosa has been made, the correct functioning of the immune system of the patient should be checked.
A case of Candida septic arthritis with rice body formation in a 2-month-old infant
d’Aleo Francesco,
Bonanno Roberta,
Midiri Angelina,
Mancuso Giuseppe,
Cordaro Stefania,
Warm Amiel,
Verduci Elisa,
Beninati Concetta,
Biondo Carmelo
We present a case of rice body formation in the left knee joint of a 2-month-old infant affected by Candida albicans septic arthritis which has never been reported before. Rice body formation has been described in association with rheumatoid or tuberculous arthritis and is very rare in Candida arthritis. After three weeks of therapy with amphotericin B administered intravenously, the infant recovered fully from infection. Septic arthritis is a serious cause of morbidity and for proper evaluation and treatment fungal septic arthritis should be included in the differential diagnosis.
Toenail onychomycosis by Trichophyton rubrum and concurrent infestation with Tyrophagus putrescentiae
Fabrizi Valentina,
Zacconi Ivana,
Principato Mario,
Pesca Cristina,
Cruciani Deborah,
Crotti Silvia,
Papini Manuela
A remarkable case of onychomycosis by Trichophyton (T.) rubrum combined with nail infestation by Tyrophagus (T.) putrescentiae in an elderly diabetic farmer is described and discussed. Large numbers of eggs and mites in all development stages were present in nail debris, reflecting active reproduction on site. Treatment with ivermectin 0.1% cream and environmental decontamination cleared the mite infestation, while onychomycosis responded well to oral terbinafine and ciclopirox 8% nail lacquer. Such a combination of onychomycosis and mite infestation of the same nail is an exceptional finding reported only twice in the literature
The Infections in the History of Medicine
Italian prisoners with tuberculosis in the early nineteenth century: the experience in the Pianosa prison hospital
Sabbatani Sergio,
Fiorino Sirio,
Manfredi Roberto
In the late nineteenth century, with industrial growth and the resulting mass urbanisation, tuberculosis represented a plague mainly among the poor social classes. The outdated and crowded Italian prisons (formerly old monasteries) during the early 1900s were insufficient to “host” the multitude of inmates condemned or waiting for judgment. Italian prisoners were beset by hunger and poor hygiene facilities. Clothes did not differ between winter and summer.
The Criminal Sanatorium of Pianosa was officially inaugurated in 1907, but from the 1860s it had been set up to host an agricultural penal colony. Here we report the excellent results obtained between 1907 and 1909 in the management of tuberculosis among prisoners in Pianosa, where surgery was also available. In those times, climate therapy with an enriched and varied nutrition was the only effective treatment for tuberculosis. Overall, of the 913 prisoners housed in Pianosa in that period and according to the acknowledged scientific criteria, the following results were achieved: complete cure in 182, improvement in 416, mild amelioration in 94, worsening in 80, no change in 20. The number of prisoners who died or were transferred to another prison is unknown. The case series of the prison hospital in Pianosa may be reconstructed thanks to data published by the Director Roberto Passini. The better outcome of the prisoners in Pianosa, in comparison with inmates of other Italian institutions, was due both to treatment standards (climate, nutritional, hygienic, and surgical) and to the proportionally longer period of stay in Pianosa for prisoners with already confirmed detention periods.
Preventing syphilis in the 16th century: the distinguished Italian anatomist Gabriele Falloppio (1523-1562) and the invention of the condom
Tsaraklis Athanasios,
Karamanou Marianna,
Androutsos George,
Skandalakis Panagiotis,
Venieratos Dionysios
By the end of the 15th century, syphilis had reached epidemic proportions in Europe. Unable to ascertain its causes, physicians resorted to superstition. At the beginning of the 16th century, the sexual transmission of the disease was established. Initially, the principal measure of infection control was sexual abstinence and mutual fidelity. However, during the same period the Italian anatomist Gabriele Falloppio (1523-1562) proposed a method of preventing syphilis transmission: the medication-soaked linen sheath. Thus was born the idea of a mechanical barrier against sexually transmitted diseases: the condom.
