Die neuen WHO-Empfehlungen für schnelle Diagnostik und Therapie resistenter Tuberkulose in Deutschland, Österreich und der Schweiz

Die erfreulicherweise zunehmende Evidenz hat in den letzten Jahren mehrfache Änderungen der internationalen Empfehlungen für die Diagnostik und Therapie der resistenten Tuberkulose notwendig gemacht. In diesem Jahr hat die WHO umfassende Empfehlungen veröffentlicht, die die Entwicklungen der letzten Jahre berücksichtigen. Die aktuelle deutsche Tuberkuloseleitlinie erschien im Jahr 2017 und weicht in einigen Bereichen von diesen Empfehlungen ab. Hier werden die Neuerungen der WHO-Empfehlungen von 2020 für schnelle Diagnostik und die Therapie resistenter Tuberkulose zusammengefasst und relevante Abweichungen für Deutschland, Österreich und die Schweiz kommentiert. Eine Neubewertung der Literatur findet derzeit im Rahmen der Aktualisierung der deutschsprachigen AWMF-2k-Leitlinie statt.

Case series of carbapenemase-producing Enterobacteriaceae osteomyelitis: Feel it in your bones

OBJECTIVES

Limited data have been reported regarding osteomyelitis due to carbapenemase-producing Enterobacteriaceae (CPE), including co-infections with extended-spectrum β-lactamase (ESBL)-producing micro-organisms.

METHODS

We conducted a retrospective study in a reference centre for bone and joint infections from 2011 to 2019 among patients infected with CPE.

RESULTS

Nine patients (mean age 46.8 ± 16.6 years), including three with infected implants, were identified. Infections were mostly polymicrobial (n = 8/9), including Staphylococcus aureus (n = 6/9). CPE were mainly OXA-48-type, associated with ESBL-producing Enterobacteriaceae (n = 8/9), of which 5/9 isolates were Klebsiella pneumoniae. Control of the infection was achieved in seven cases.

CONCLUSIONS

CPE osteomyelitides are essentially polymicrobial and fluoroquinolone-resistant infections, highlighting the need for efficient surgery with implant removal.

[Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 - German Respiratory Society]

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.

Poynting singularities in the transverse flow-field of random vector waves

In order to utilize the full potential of tailored flows of electromagnetic energy at the nanoscale, we need to understand its general behavior given by its generic representation of interfering random waves. For applications in on-chip photonics as well as particle trapping, it is important to discern between the topological features in the flow-field of the commonly investigated cases of fully vectorial light fields and their 2D equivalents. We demonstrate the distinct difference between these cases in both the allowed topology of the flow-field and the spatial distribution of its singularities, given by their pair correlation function g(r). Specifically, we show that a random field confined to a 2D plane has a divergence-free flow-field and exhibits a liquid-like correlation, whereas its freely propagating counterpart has no clear correlation and features a transverse flow-field with the full range of possible 2D topologies around its singularities.

Transcatheter aortic valve implantation in nonagenarians: insights from the German Aortic Valve Registry (GARY)

OBJECTIVE

The aim of this study was to compare the outcome of nonagenarians (≥ 90 years) with that of younger (< 90 years) patients undergoing transcatheter aortic valve implantation (TAVI) in current practice.

METHODS

Data are collected from the German Aortic Valve Registry (GARY), which was designed to evaluate current practice in the invasive treatment of patients with aortic valve diseases in Germany. Data were analyzed regarding procedural outcome, 30-day, and 1-year outcomes of nonagenarians in comparison to that of younger patients.

RESULTS

Between 2011 and 2015, 2436/33,051 (7.3%) nonagenarians underwent TAVI and were included in GARY. Nonagenarians were significantly more often male (45.2% vs. 40.0%, p < 0.001), frail (38.7% vs. 34.7%, p < 0.001), and had higher EuroSCORE scores than younger patient group (23.2% vs. 17.0%). Nonagenarians were significantly less often treated via transapical access (16.3% vs. 22.3%, p < 0.001). Procedure was performed significantly less often in general anesthesia (58.2% vs. 60.7%, p = 0.02) in nonagenarians, while necessity of pacemaker implantation was significantly higher in nonagenarians (27.2% vs. 24.8%, p > 0.001). The incidence of other typical postprocedural complications such as severe bleeding events and vascular complications were comparable between groups. However, 30-day (5.2% vs. 3.9%) and 1-year (22.7% vs. 17.7%) mortality rates were significantly higher among nonagenarians and age ≥ 90 years could be identified as an isolated risk factor for mortality.

CONCLUSION

TAVI is a highly standardized procedure that can be performed safely with high procedural success even in very old patients. Although mortality is significantly higher in these patients-most probably due to the intrinsic higher risk profile of the very old patients-the results are still acceptable. To optimize outcome, especially elderly patients seem to profit from a procedure under local anesthesia or conscious sedation, to minimize the rate of postoperative delirium and the length of stay and to facilitate early mobilization.

P962Follow-up of protected high-risk percutaneous coronary intervention with microaxial Impella pump. Results from the retrospective German Impella Registry

Background

Percutaneous coronary intervention (PCI) presents a relevant alternative to coronary bypass surgery for the treatment of patients with complex coronary artery disease and high perioperative risk. By temporary implantation of a percutaneous ventricular assist devices (pVAD) interventionalists attempt to anticipate the hemodynamic risk of those high-risk patients in a so-called protected PCI. The Impella® system presents the currently most common device for protected PCI and could show hemodynamic stability in earlier trials.

Methods

This study is a retrospective, observational multi-center registry of ten hospitals in Germany. We included patients undergoing protected high-risk PCI with Impella® support. The primary endpoint was defined as major adverse cardiac events (MACE) during a 180-day follow-up and consisted of all-cause mortality, myocardial infarction (MI) and stroke.

Results

Six of the participating hospitals performed a follow-up. In total, 157 patients (80.3% male; mean age 71.8±10.8 years) were included in the present study. Prior to PCI, median left ventricular ejection fraction was 39.0% (25.0%-50.0%) and median SYNTAX-Score I was 33.0 (24.0–40.5). The 180-day follow-up was available for 149 patients (94.9%). Eight patients (5.1%) were lost to follow-up. During the follow-up period, 34 patients (22.8%) suffered from a MACE. A total of 27 patients (18.1%) died. Nine patients (6.0%) sustained a MI, while 4 patients (2.7%) had a stroke.

Kaplan-Meier curves for primary endpoint

Conclusions

Patients undergoing protected high-risk PCI with Impella® support show a good 180-day clinical outcome regarding rates of MACE and mortality. However, a head-to-head comparison of Impella supported patients to protected PCI with other pVADs is pending.

Acknowledgement/Funding

S.B., N.W., F.A.-R., J.-M.S., A.S., R.S., I.A. receive consulting fees/honoraria from Abiomed (Danvers, MA, USA).

Everolimus- vs. novolimus-eluting bioresorbable scaffolds in patients with acute coronary syndrome

BACKGROUND

Limited data exist on bioresorbable scaffolds (BRS) in patients with acute coronary syndrome (ACS). The aim of the present study was to evaluate novolimus-eluting BRS (DESolve) as interventional treatment for patients with ACS, and to compare its 12-month outcomes with the everolimus-eluting bioresorbable scaffolds (Absorb).

METHODS

In this retrospective study, patients with ACS (including unstable angina pectoris, ST-segment elevation myocardial infarction, or non-ST-segment elevation myocardial infarction) treated with either the Absorb or the DESolve BRS were evaluated in a 1:1 matched-pair analysis. Major adverse cardiac events (MACE), including death, myocardial infarction, and target lesion revascularization, were evaluated as a major endpoint. The occurrence of scaffold thrombosis was also assessed.

RESULTS

A total of 102 patients were eligible for this analysis. The rate of MACE at 12 months was comparable between the Absorb and the DESolve group (8.3% vs. 6.8%, p = 0.738). The occurrence of target lesion revascularization (6.2% vs. 4.7%; p = 0.700) and scaffold thrombosis (4.1% vs. 2.1%; p = 0.580) was comparable as well. All instances of scaffold thrombosis occurred within 30 days of the index procedure.

CONCLUSION

In this study, similar 12-month event rates were observed for both BRS types after implantation for the treatment of ACS.

Can the number of surgery delays and postponements due to unavailable instrumentation be reduced? Evaluating the benefits of enhanced collaboration between the sterilization and orthopedic surgery units

INTRODUCTION

The development of outpatient surgery, cost-reduction pressures and instrumentation storage limitations have led to their use "just-in-time". A recent study showed that stoppage of surgical procedures immediately before the incision (No-Go) was often due to the management of supplies and implantable medical devices. To our knowledge, since the development of outpatient surgery and the shortening of hospital stays, managing the flow of instrumentation has not been optimized. At our hospital, we used a two-prong approach consisting of a tool to manage instrumentation and working group from the sterilization and orthopedic surgery units. The aims of this study were to: 1) evaluate whether this approach led to better notification of the risk of supply shortage for instrumentation and 2) determine whether it could reduce by at least half operating room disruptions such as delays or cancellation of surgical procedures.

HYPOTHESIS

This approach results in better notification of the risk of supply shortage for instrumentation and reduces by at least half operating room disruptions such as delays or cancellation of surgical procedures.

MATERIAL AND METHODS

A tool was developed to manage instrumentation flow based on a retrospective analysis of data from 2015. This tool consisted of: (1) a list of instrumentation needed for each surgical procedure from an analysis of the surgical schedule and verification of traceability labels of the instrumentation actually used, (2) a list of reasons for supply shortage identified from an analysis of non-conformities occurring in the sterilization process of instrumentation kits. These analyses resulted in the development of checklists for instrument sets for each procedure, while identifying those with a high risk of shortage. In 2017, a working group focused on instrumentation was set up with personnel from the sterilization unit and the orthopedic surgery unit. Based on the check-lists and the schedule 24hours before the surgery, the sterilization unit alerted the surgery unit by email of the risk of material shortage; the surgery ward replied with potential changes to the material or the surgery planning. This approach (instrumentation management tool and working group) was named just-in-time (JIT). The main outcome was the number of notifications of potential supply shortage with and without JIT over a 10-week period. The secondary outcomes were the number of notifications resolved in time and the occurrence of operating room disruptions (delay>30min or postponement of surgery) related to unavailable instrumentation.

RESULTS

Nine reasons for potential supply shortage were identified such as instrumentation kits used for several types of procedures, those with fast rotation and low stock, or in double pathways (on loan and on deposit). The working group reported 163 potential shortages with JIT versus 41 without (p<10^-5), of which 150 (92.5%) were resolved. Thirteen operating room disruptions occurred; only one was not detected by the JIT approach.

CONCLUSION

Our JIT approach (instrumentation management tool and working group) is effective at preventing instrumentation supply shortages.

LEVEL OF EVIDENCE

III, prospective comparative study.

Abstract P6-18-11: Long-term responders to single-agent margetuximab, an Fc-modified anti-HER2 monoclonal antibody, in metastatic HER2+ breast cancer patients with prior anti-HER2 therapy

Background

Margetuximab is an Fc-optimized anti-HER2 antibody that recognizes the same epitope as trastuzumab. Margetuximab has increased affinity for the activating CD16A Fc-receptor on NK cells and macrophages as well as decreased affinity for the inhibitory CD32B receptor compared to trastuzumab. In a Phase 1 study (NCT01148849) of 66 patients with relapsed or metastatic HER2+ cancer across multiple indications, margetuximab was well tolerated at all doses. Among 60 response-evaluable patients, confirmed partial response (PR) and stable disease (SD) were seen in 7 (12%) and 30 (50%) patients, respectively. Tumor reductions occurred in 18/23 (78%) evaluable breast cancer patients. Ex-vivo analyses of patient peripheral blood mononuclear cell samples confirmed margetuximab's ability to enhance antibody dependent cell-mediated cytotoxicity over that from trastuzumab. We report on 3 breast cancer patients with prior anti-HER2 therapy failure with durable (≥ 3.5 years) SD (1) or PR (2).

Methods

Enrolled patients had histologically/cytologically-confirmed carcinoma with documented HER2 overexpression by immunohistochemistry (2+ or 3+) and disease progression during/following last therapy. Eligibility included life expectancy ≥3 months; performance status ≤1; measurable disease by Response Criteria for Solid Tumors 1.1; adequate bone marrow, renal, hepatic function; and left ventricular ejection fraction ≥50%. Margetuximab was given by intravenous infusion at 0.1 – 6.0 mg/kg for 3 of every 4 weeks or once every 3 weeks (10 – 18 mg/kg).

Results

Three of 17 HER2 3+ metastatic breast cancer patients received long-term margetuximab. Patient 35 had 3 prior regimens (adjuvant doxorubicin+cyclophosphamide followed by docetaxol+trastuzumab; gemcitabine+vinorelbine; lapatinib+capecitabine) and received margetuximab at 10 mg/kg q3wk, 88 cycles to date, with PR achieved Cycle 1 Day 43, maintained 4.4 years. Patient 44 had 3 prior regimens for metastatic disease (docetaxel+trastuzumab+pertuzumab; doxorubicin+cyclophosphamide; lapatinib+capecitabine) and received margetuximab at 15 mg/kg q3wk, 79 cycles to date with SD for 4.3 years. Patient 50 had 4 prior regimens for recurrent/metastatic disease (tamoxifen; anastrozole; capecitabine+trastuzumab; lapatinib+capecitabine) and received margetuximab dose of 18 mg/kg q3wk with PR achieved Cycle 1 Day 43, maintained 3.5 years. Progression was noted at Cycle 57, and margetuximab continues at 63 cycles to date. No cardiac toxicities were found during long-term follow-up for these 3 patients and there were no treatment-related adverse events ≥Grade 3.

Conclusions

Margetuximab is well-tolerated without cardiac toxicities in long-term responders, with single-agent activity including durable responses in heavily pre-treated metastatic breast cancer. A Phase 3, randomized, multi-center clinical trial (SOPHIA; NCT02492711) is enrolling patients with metastatic breast cancer, comparing margetuximab plus chemotherapy to trastuzumab plus chemotherapy in patients who have received 1 to 3 lines of therapy for advanced disease.

Citation Format: Im S-A, Bang Y-J, Oh D-Y, Giaccone G, Bauer T, Nordstrom J, Li H, Moore P, Hong S, Baughman J, Rock E, Burris H. Long-term responders to single-agent margetuximab, an Fc-modified anti-HER2 monoclonal antibody, in metastatic HER2+ breast cancer patients with prior anti-HER2 therapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-11.