Does tourism affect the long term course of COVID-19 pandemic in a country of destination? Evidence from a popular Greek island in 2020 where control measures were implemented

Greece opened its points of entry on July 1, 2020, with specific guidelines for travellers arriving by sea, air or land. The aim of this article is to examine the effect of tourism on the long term course of the Coronavirus Disease 2019 (COVID-19) pandemic during the pre-vaccination era (June to December 2020) on the popular Greek island of Crete. To achieve this, a cross-sectional serosurvey, repeated at monthly intervals, was conducted to compare the seroprevalence in Crete with seroprevalence in the mainland of Greece. Crete welcomed nearly 2,000,000 travellers during the 2020 summer season. Left-over serum samples were collected and obtained from public and private laboratories located in Greece, including the island of Crete. These samples were tested for the presence of anti-SARS-CoV-2 IgG antibodies. A total of 55,938 samples were collected, 3,785 of which originated from Crete. In Crete, the seroprevalence ranged between 0% (June 2020) and 2.58% (December 2020), while the corresponding seroprevalence in Greece was 0.19% and 10.75%, respectively. We identified 4.16 times lower seropositivity in Crete (2.58%) in comparison with the mainland of Greece (10.75%) during December 2020. Moreover, the monthly infection fatality rate (IFR) in Crete was calculated at 0.09%, compared with 0.21% in mainland Greece for December 2020. The island of Crete presented more than four times lower seroprevalence than the mainland of Greece, despite being a highly attractive tourist destination. This evidence supports the idea that tourism may not have affected the long term course of the COVID-19 pandemic in Greece. However, due to contradicting results from previous studies, further investigation is needed.

Impact of SARS-CoV-2 Preventive Measures against Healthcare-Associated Infections from Antibiotic-Resistant ESKAPEE Pathogens: A Two-Center, Natural Quasi-Experimental Study in Greece

The COVID-19 pandemic led to unprecedented stress on healthcare systems worldwide, forming settings of concern for increasing antimicrobial resistance. We investigated the impact of SARS-CoV-2 preventive measures against healthcare-associated infections (HAIs) from antibiotic-resistant bacteria in two tertiary-care hospitals. We compared infection rates between March 2019 and February 2020 (pre-intervention period) and March 2020 and February 2021 (COVID-19 intervention period) from drug-resistant ESKAPEE bacteria (methicillin-resistant Staphylococcus aureus; vancomycin-resistant Enterococci; carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species and Escherichia coli). Over 24 months, 586 drug-resistant ESKAPEE HAIs occurred in 439 patients (0.3% of 179,629 inpatients) with a mean age of 63 years, with 43% being treated in intensive care units (ICUs), and having a 45% inpatient mortality rate. Interrupted time series analysis revealed increasing infection rates before the intervention that were sharply interrupted by abrupt drops for most pathogens and henceforth remained stable in the ICUs but progressively increased in ordinary wards. In the ICUs, the pooled infection rate was 44% lower over the intervention period compared to the pre-intervention period (incidence rate ratio (IRR) 0.56, 95%CI 0.41-0.75, p < 0.001). Pooled infection rates in the wards were slightly higher over the COVID-19 period (IRR 1.12, 95%CI 0.87-1.45, p = 0.368). The findings confirmed the ancillary beneficial impact of the enhanced bundle of transmission-based precautions adopted against SARS-CoV-2 in rapidly constraining antimicrobial-resistant HAIs in two Greek hospitals.

630. Emergence of Colistin Resistance in the OVERCOME Trial: Impact of Combination Therapy with Meropenem

Background

Colistin (COL) remains an important therapeutic option for carbapenem-resistant (CR) Gram-negative bacilli (GNB). COL is often utilized in combination with meropenem (MEM), in part due to concerns regarding the development of COL resistance with monotherapy. We recently completed a randomized controlled trial comparing outcomes in patients receiving COL + placebo to those receiving COL + MEM; herein we present data on the emergence of COL resistance in this trial.

Methods

OVERCOME was an international, multicenter, randomized, double-blind, placebo-controlled study comparing COL and COL + MEM for the treatment of bloodstream infection and/or pneumonia due to CR GNB. Subjects were included in the modified intent to treat population (mITT) if their enrollment pathogen had a COL MIC ≤2 mg/L, as determined by broth microdilution (BMD). Daily blood and/or respiratory samples were obtained in patients per protocol until two consecutive negatives were obtained or the end of study treatment. All subsequent isolates were evaluated for COL resistance via BMD, defined as MIC ≥ 4 mg/L.

Results

Of the 425 patients in the mITT population, 380 (191 COL; 189 COL + MEM) were evaluable for the endpoint of COL resistance development. The median age of the cohort was 70, 38% were female, 47% were white, and 45% were Asian. 70% had an index infection of pneumonia, 68% were in the intensive care unit at the onset of their infection, and A. baumannii was the most common pathogen (78% of patients). Baseline characteristics, infection type, severity of illness, and index pathogen were similar amongst treatment arms. No significant difference in resistance development was seen between the COL and COL + MEM groups overall (12% vs. 8%; p = 0.31), or in any subgroup (Table). In patients with A. baumannii, there was a trend towards decreased resistance development with COL + MEM (13.3% vs 7.5%; p = 0.13).

Conclusion

We were unable to identify a significant difference in resistance emergence between treatment arms, but given the low incidence of this outcome, were underpowered to do so. The impact of COL + MEM on preventing emergence of COL resistance in A. baumannii warrants further clinical study.

Disclosures

Jason M Pogue, PharmD, BCPS, BCIDP, Merck (Consultant)QPex (Consultant)Shionogi (Consultant)Utility Therapeutics (Consultant)VenatoRX (Consultant) Michael J. Rybak, PharmD, MPH, PhD, Paratek Pharmaceuticals (Research Grant or Support) Emmanuel Roilides, MD, PhD, FIDSA, FAAM, FESCMID, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Matthew Sims, MD, PhD, Astra Zeneca (Independent Contractor)Diasorin Molecular (Independent Contractor)Epigenomics Inc (Independent Contractor)Finch (Independent Contractor)Genentech (Independent Contractor)Janssen Pharmaceuticals NV (Independent Contractor)Kinevant Sciences gmBH (Independent Contractor)Leonard-Meron Biosciences (Independent Contractor)Merck and Co (Independent Contractor)OpGen (Independent Contractor)Prenosis (Independent Contractor)Regeneron Pharmaceuticals Inc (Independent Contractor)Seres Therapeutics Inc (Independent Contractor)Shire (Independent Contractor)Summit Therapeutics (Independent Contractor)

638. The Impact of in vitro Synergy Between Colistin and Meropenem on Clinical Outcomes in Invasive Carbapenem-resistant Gram-negative Infections: A Report from the OVERCOME Trial

Background

Consensus guidelines caution against colistin (COL) monotherapy due to efficacy and resistance development concerns. The COL + meropenem (MEM) combination often displays in vitro synergy against carbapenem-resistant (CR) Gram-negative bacilli (GNB). We recently completed a clinical trial comparing outcomes in patients receiving COL vs. COL + MEM. Herein we assess if, amongst patients receiving COL + MEM, outcomes differed as a function of the presence (or absence) of in vitro synergy against the index pathogen.

Methods

OVERCOME was an international, multicenter, randomized, double-blind, placebo-controlled study comparing COL + placebo and COL + MEM for the treatment of pneumonia and/or bloodstream infection (BSI) due to CR GNB. Baseline isolates were COL susceptible (MIC ≤ 2 mg/L) and underwent synergy testing to COL + MEM in 24-hour time kill experiments (TKE). Synergy was defined as a &gt;2-log CFU/ml reduction with combination therapy compared to the most active single agent. Outcomes assessed included 28-day mortality, clinical failure, and the development of COL resistance (MIC ≥ 4 mg/L) for both the overall cohort and the subgroup with A. baumannii.

Results

Of the 211 patients who received COL + MEM in OVERCOME, 186 had baseline synergy testing performed and were eligible for this analysis. The median age of the cohort was 70 years, 35% were female, 48% were white, and 44% Asian. Sixty-eight percent were in the intensive care unit (ICU) at infection onset. A. baumannii was the most common pathogen (78%) and pneumonia was the most common infection (68%). Synergy was demonstrated in most isolates (76%). Baseline characteristics, clinical, and microbiological outcomes were similar amongst patients infected with isolates against which COL + MEM demonstrated synergy and those where no synergy was demonstrated (Table 1). In patients with A. baumannii infections, the presence of in vitro synergy was associated with a decrease in clinical failure (53% vs. 79%; p = 0.04). No significant impact of synergy on 28-day mortality or development of COL resistance was demonstrated (Table 2).

Conclusion

The presence of in vitro synergy via TKE was associated with a decrease in clinical failure in patients treated with COL + MEM for invasive infections due to CR A. baumannii.

Disclosures

Jason M Pogue, PharmD, BCPS, BCIDP, Merck (Consultant)QPex (Consultant)Shionogi (Consultant)Utility Therapeutics (Consultant)VenatoRX (Consultant) Michael J. Rybak, PharmD, MPH, PhD, Paratek Pharmaceuticals (Research Grant or Support) Emmanuel Roilides, MD, PhD, FIDSA, FAAM, FESCMID, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Matthew Sims, MD, PhD, Astra Zeneca (Independent Contractor)Diasorin Molecular (Independent Contractor)Epigenomics Inc (Independent Contractor)Finch (Independent Contractor)Genentech (Independent Contractor)Janssen Pharmaceuticals NV (Independent Contractor)Kinevant Sciences gmBH (Independent Contractor)Leonard-Meron Biosciences (Independent Contractor)Merck and Co (Independent Contractor)OpGen (Independent Contractor)Prenosis (Independent Contractor)Regeneron Pharmaceuticals Inc (Independent Contractor)Seres Therapeutics Inc (Independent Contractor)Shire (Independent Contractor)Summit Therapeutics (Independent Contractor)

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

BACKGROUND

We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific.

METHODS

Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied.

RESULTS

We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases.

CONCLUSIONS

DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Pandrug-resistant Gram-negative bacteria: a systematic review of current epidemiology, prognosis and treatment options

BACKGROUND

The literature on the epidemiology, mortality and treatment of pandrug-resistant (PDR) Gram-negative bacteria (GNB) is scarce, scattered and controversial.

OBJECTIVES

To consolidate the relevant literature and identify treatment options for PDR GNB infections.

METHODS

A systematic search in MEDLINE, Scopus and clinical trial registries was conducted. Studies reporting PDR clinical isolates were eligible for review if susceptibility testing for all major antimicrobials had been performed. Characteristics and findings of retrieved studies were qualitatively synthesized.

RESULTS

Of 81 studies reviewed, 47 (58%) were published in the last 5 years. The reports reflected a worldwide dissemination of PDR GNB in 25 countries in 5 continents. Of 526 PDR isolates reported, Pseudomonas aeruginosa (n=175), Acinetobacter baumannii (n=172) and Klebsiella pneumoniae (n=125) were most common. PDR GNB were typically isolated in ICUs, but several studies demonstrated wider outbreak potential, including dissemination to long-term care facilities and international spread. All-cause mortality was high (range 20%-71%), but appeared to be substantially reduced in studies reporting treatment regimens active in vitro. No controlled trial has been performed to date, but several case reports and series noted successful use of various regimens, predominantly synergistic combinations, and in selected patients increased exposure regimens and newer antibiotics.

CONCLUSIONS

PDR GNB are increasingly being reported worldwide and are associated with high mortality. Several treatment regimens have been successfully used, of which synergistic combinations appear to be most promising and often the only available option. More pharmacokinetic/pharmacodynamic and outcome studies are needed to guide the use of synergistic combinations.

Repeated Leftover Serosurvey of SARS-CoV-2 IgG Antibodies in Greece, May to August 2020

A serosurvey of IgG antibodies against SARS-CoV-2 was conducted in Greece between May and August 2020. It was designed as a cross-sectional survey and was repeated at monthly intervals. The leftover sampling methodology was used and a geographically stratified sampling plan was applied. Of 20,110 serum samples collected, 89 (0.44%) were found to be positive for anti-SARS-CoV-2 antibodies, with higher seroprevalence (0.35%) observed in May 2020. The highest seroprevalence was primarily observed in the "30-49" year age group. Females presented higher seroprevalence compared to males in May 2020 (females: 0.58% VS males: 0.10%). This difference reversed during the study period and males presented a higher proportion in August 2020 (females: 0.12% VS males: 0.58%). Differences in the rate of seropositivity between urban areas and the rest of the country were also observed during the study period. The four-month infection fatality rate (IFR) was estimated to be 0.47%, while the respective case fatality rate (CFR) was at 1.89%. Our findings confirm low seroprevalence of COVID-19 in Greece during the study period. The young adults are presented as the most affected age group. The loss of the cumulative effect of seropositivity in a proportion of previous SARS-CoV-2 infections was indicated.

Active Surveillance of Healthcare-associated Infections in Pediatric Intensive Care Units: Multicenter ECDC HAI-net ICU Protocol (v2.2) Implementation, Antimicrobial Resistance and Challenges

BACKGROUND

Surveillance is essential to all aspects of management of healthcare-associated infections (HAIs) in critically ill children, where data are limited. We conducted an active surveillance study to elucidate epidemiology, resistance, antimicrobial treatment practices and outcomes of pediatric intensive care unit-acquired HAIs in a southern European country.

METHODS

Four Greek pediatric intensive care unit encounters (153 patients, 2183 patient-days) during a 6-month period participated using the European Centre for Disease Prevention and Control HAI-net ICU (v2.2) protocol. Bloodstream infections and device-associated HAIs were recorded. Clinical severity, isolated pathogens, antimicrobial resistance and antibiotic prescriptions were collected on a daily basis. Mortality and excess length of stay due to HAI were also assessed.

RESULTS

Overall rate of HAIs was 18.3 per 1000 patient-days. Aggregate rates for device-associated HAI were: catheter-related bloodstream infection 2.32, intubation-associated pneumonia 10.5, and catheter-associated urinary tract infection 4.6 per 1000 device-days. Children with HAI (n = 28, 18.3%) had higher severity of illness (Pediatric Risk Mortality Score 7.5 vs. 4, P < 0.001), longer hospitalization (23 vs. 6 days, P < 0.001), but not higher mortality, compared with those without. Most frequent recovered pathogens were Klebsiella pneumoniae (40%), Pseudomonas aeruginosa (22.5%), Acinetobacter baumannii (12.5%), with respective carbapenem resistance 50%, 44% and 80%, and Staphylococcus aureus (12.5%). Total antibiotic use was 2142 days of treatment per 1000 patient-days.

CONCLUSIONS

Our study, based on the updated ECDC HAI-net ICU (v2.2) protocol, effectively addresses the significant burden of HAIs in critically ill children in Greece. Using a well-standardized system facilitates inter- and intra-countries reliable recordings and comparative assessments of infection control programs.

Is pandrug-resistance in A. baumannii a transient phenotype? Epidemiological clues from a 4-year cohort study at a tertiary referral hospital in Greece

Pandrug-resistant A. baumannii (PDRAB) is increasingly being reported but remains rare. Several case studies show that A. baumannii can acquire resistance to last resort antibiotics during treatment by single-step chromosomal mutations. However, re-emergence of the ancestral susceptible strain after withdrawal of antibiotics has been described, possibly due to fitness cost associated with acquired resistance. Therefore, PDRAB may be a transient phenotype. Epidemiological data to show this process in larger cohorts are currently lacking. In this study of 91 hospitalized patients with PDRAB we showed the frequent (60%) isolation of non-PDRAB, often susceptible only to colistin, aminoglycosides and/or tigecycline, preceding and/or following PDRAB isolation. However, the isolation of PDRAB in two outpatients, 25 and 36 days after their discharge from the hospital, suggests the potential of some PDRAB strains to persist even in the absence of antimicrobial pressure.

Excess mortality due to pandrug-resistant Acinetobacter baumannii infections in hospitalized patients

BACKGROUND

Pandrug-resistant Acinetobacter baumannii (PDRAB) is increasingly being reported as a nosocomial pathogen worldwide, but determining its clinical impact is challenging.

AIM

To assess the spectrum of excess mortality attributable to PDRAB infection in acute care settings.

METHODS

This four-year cohort study was conducted in a tertiary-care referral hospital in Greece to estimate excess in-hospital mortality due to PDRAB infection by comparing patients infected to those colonized with PDRAB by means of competing risks survival analysis.

FINDINGS

The study cohort comprised 91 patients (median age: 67 years; 77% men). For most patients, PDRAB was first isolated in the intensive care unit (ICU) (N = 51; 57%) or following ICU discharge (N = 26; 29%). Overall in-hospital mortality was 68% (95% confidence interval (CI): 57.5-77.5%). PDRAB-infected patients (N = 62; 68%) and PDRAB-colonized patients (N = 29; 32%) had similar baseline characteristics, but the absolute excess risk of 30-day mortality in infected patients compared to colonized patients was 34% (95% CI: 14-54%). Multivariable competing risks regression showed that PDRAB infection significantly increased the daily hazard of 30-day in-hospital death (cause-specific hazard ratio (csHR): 3.10; 95% CI: 1.33-7.21) while simultaneously decreasing the daily rate of discharge (csHR: 0.24; 95% CI: 0.08-0.74), thereby leading to longer hospitalization. Stronger effects were observed for bloodstream infections.

CONCLUSION

New effective antimicrobials would be expected to prevent mortality in one of every three patients treated for PDRAB infection and reduce their length of hospitalization. However, available therapeutic options remain extremely limited and emphasis on preventing healthcare-associated transmission of PDRAB is ever more important.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Impact of multi-drug resistant bacteria on economic and clinical outcomes of healthcare-associated infections in adults: Systematic review and meta-analysis

Background

Infections with multidrug resistant (MDR) bacteria in hospital settings have substantial implications in terms of clinical and economic outcomes. However, due to clinical and methodological heterogeneity, estimates about the attributable economic and clinical effects of healthcare-associated infections (HAI) due to MDR microorganisms (MDR HAI) remain unclear. The objective was to review and synthesize the evidence on the impact of MDR HAI in adults on hospital costs, length of stay, and mortality at discharge.

Methods and findings

Literature searches were conducted in PubMed/MEDLINE, and Google Scholar databases to select studies that evaluated the impact of MDR HAI on economic and clinical outcomes. Eligible studies were conducted in adults, in order to ensure homogeneity of populations, used propensity score matched cohorts or included explicit confounding control, and had confirmed antibiotic susceptibility testing. Risk of bias was evaluated, and effects were measured with ratios of means (ROM) for cost and length of stay, and risk ratios (RR) for mortality. A systematic search was performed on 14^th March 2019, re-run on the 10^th of June 2019 and extended the 3^rd of September 2019. Small effect sizes were assessed by examination of funnel plots. Sixteen articles (6,122 patients with MDR HAI and 8,326 patients with non-MDR HAI) were included in the systematic review of which 12 articles assessed cost, 19 articles length of stay, and 14 mortality. Compared to susceptible infections, MDR HAI were associated with increased cost (ROM 1.33, 95%CI [1.15; 1.54]), prolonged length of stay (ROM 1.27, 95%CI [1.18; 1.37]), and excess in-hospital mortality (RR 1.61, 95%CI [1.36; 1.90]) in the random effects models. Risk of publication bias was only found to be significant for mortality, and overall study quality good.

Conclusions

MDR HAI appears to be strongly associated with increases in direct cost, prolonged length of stay and increased mortality. However, further comprehensive studies in this setting are warranted.

Trial registration

PROSPERO (CRD42019126288).

Fever of unknown origin caused by infectious diseases in the era of migrant and refugee crisis

Concern exists in Europe about the possibility of importation of infectious diseases due to the recent influx of migrants and refugees after 2011. In this retrospective 6-year study, we examined the epidemiology of fever of unknown origin (FUO) in Greece over the past years. Forty-eight patients with classical FUO were included. The proportion of infectious causes of FUO (29.2%) was similar to previous studies in Greece and all infections were endemic to the area. Disease-related mortality was 12.5% and no deaths due to infection were recorded. In conclusion, none of the diagnosed infectious causes of FUO raised concerns about the possibility of imported diseases or pathogens. These results re-inforce the perception that migrants and refugees are not carriers of communicable diseases that can cause public health problems to European countries.

Bicuspid aortic valve endocarditis caused by Gemella sanguinis: Case report and literature review

Gemella species are catalase-negative, facultative anaerobic, Gram-positive cocci, which are part of the human oral microbiome and may occasionally cause systemic infections. Infective endocarditis (IE) has been reported as the most common infection caused by Gemella species. We report the first case of IE due to Gemella sanguinis in Greece, in a patient with bicuspid aortic valve and review the available literature. The patient was successfully treated with antibiotics and aortic valve replacement.

Cytomegalovirus Pneumonitis in a Patient with Homozygous β-Thalassemia and Splenectomy

Cytomegalovirus (CMV) rarely causes disease in immunocompetent individuals but may cause severe disease in immunocompromised patients. We report the case of a young woman who had undergone multiple transfusions and splenectomy for homozygous β-thalassemia. She presented with prolonged fever and respiratory distress. Although broad-spectrum antibiotic therapy had initially been administered, the patient had clinically deteriorated. Serology and molecular blood testing established CMV infection and viremia. Computed tomography of the chest demonstrated pneumonitis and she was successfully treated with a 3-week administration of ganciclovir. In β-thalassemia patients who undergo splenectomy necessitating multiple blood transfusions, CMV infection should be considered as a differential diagnosis.

Massive pericardial effusion without cardiac tamponade due to subclinical hypothyroidism (Hashimoto's disease)

CONTEXT

Hypothyroidism is a significant cause of pericardial effusion. However, large pericardial effusions due to hypothyroidism are extremely rare. Hormone replacement therapy is the cornerstone of treatment for hypothyroidism and regular follow-up of patients after initiation of the therapy is indicated. Herein, the case of a 70-year-old woman with a massive pericardial effusion due to Hashimoto's disease is presented.

ISSUES

A 70-year-old female from a rural village on the island of Crete, Greece, was admitted to our hospital due to a urinary tract infection. She was under hormone replacement therapy with levothyroxine 100 &micro;g once a day for Hashimoto's disease. Two years previously, the patient had had an episode of pericarditis due to hypothyroidism and had undergone a computed tomography-guided pericardiocentesis. The patient did not have regular follow-up and did not take the hormone replacement therapy properly. On admission, the patient's chest X-ray incidentally showed a possible pericardial effusion. The patient was referred for echocardiography, which revealed a massive pericardial effusion. Beck's triad was absent. Thyroid hormones were consistent with subclinical hypothyroidism: thyroid-stimulating hormone (TSH) 30.25 mIU/mL (normal limits: 0.25-3.43); free thyroxin 4 0.81 ng/dL (normal limits: 0.7-1.94). The patient had a score of 5 on the scale outlined by the European Society of Cardiology (ESC) position statement on triage strategy for cardiac tamponade and, despite the absence of cardiac tamponade, a pericardiocentesis was performed after 48 hours. The patient was treated with 125 &micro;g levothyroxine orally once daily.

LESSONS LEARNED

This was a rare case of an elderly female patient from a rural village with chronic massive pericardial effusion due to subclinical hypothyroidism without cardiac tamponade. Hypothyroidism should be included in the differential diagnosis of pericardial effusion, especially in a case of unexplained pericardial fluid. Initiation of hormone replacement therapy should be personalised in elderly patients. TSH levels >10 mU/L usually require therapy with levothyroxine in order to prevent adverse events. Rural patients usually do not have regular follow-up after the initiation of hormone replacement therapy. Pericardial effusions due to hypothyroidism grow slowly and subclinical hypothyroidism rarely shows signs and symptoms and can be underdiagnosed. The ESC position statement on triage strategy for pericardial diseases is a valuable clinical tool to estimate the necessity for pericardial drainage in such cases.

Epidemiology, Microbiological and Clinical Features, Treatment, and Outcomes of Infective Endocarditis in Crete, Greece

Background

This study aimed to evaluate the epidemiology, clinical and microbiological features, treatment, and outcomes of infective endocarditis (IE) on the island of Crete, a region with high levels of antimicrobial resistance.

Materials and Methods

Medical records of all hospitalized patients diagnosed with IE at the University Hospital of Heraklion, Crete, Greece, from 1995 to 2015, were retrospectively reviewed. Patients who met the modified Duke's criteria for definite or possible IE were included.

Results

A total of 82 IE patients (median age 67 [range 21–86] years) were included. Most patients suffered from left-sided IE (94%), while most cases of infection occurred in native valves (53.6%). Systemic inflammatory response syndrome criteria were lacking in almost half of the patient population. The leading causative microorganism was Staphylococcus aureus, isolated in 24 cases (29%), followed by Streptococcus spp. in 15 (18%) and Enterococcus spp. in 12 (14.5%). A number of rare and difficult to treat microorganisms had been identified, such as Gemella morbillorum in four cases (4.5%), Streptococcus lugdunensis in two (2.5%) and Streptococcus pneumoniae in one (1%). One patient was serologically positive for Coxiella burnetii (1%). All patients received empirical antimicrobial treatment, proven appropriate in 39 blood culture-positive patients (56.5%). Thirteen (16%) patients were classified as culture negative. Seven patients (8.5%) were surgically treated. In-hospital death occurred in 9 patients (11%).

Conclusion

Changes in IE profile requires continuous epidemiological updates. Staphylococcus and Streptococcus spp. remain the most common etiologic agents. However, the presence of uncommon and/or difficult to treat pathogens raise concerns on the appropriate prophylaxis as well as empirical treatment.

Gram-negative bacteria as emerging pathogens affecting mortality in skin and soft tissue infections

INTRODUCTION

Skin and soft tissue infections (SSTIs) are commonly encountered in clinical practice and mainly caused by gram-positive cocci such as S.aureus and β-hemolytic streptococci. Complicated SSTIs involving deeper tissues often necessitate surgical intervention and occur in patients with significant comorbidities such as diabetes or immunocompromising conditions.

METHODS

In this study, we retrospectively reviewed the epidemiology, clinical characteristics, microbiology, and treatment of patients admitted with SSTI during a five-year period in the Internal Medicine Department of a tertiary hospital.

RESULTS

During the study period, 317 patients were recorded, with a mean age of 72.1 years. The most common underlying medical conditions were diabetes mellitus, chronic kidney disease, and heart failure. Cultures were positive in 23.3 % of cases, 62.2 % of which were polymicrobial. The most frequently isolated microorganisms were Enterococci, Escherichia coli, and Pseudomonas aeruginosa. Significant antimicrobial resistance rates were noted, in particular for gram-negative microorganisms. Mortality was higher than described in the literature and associated with age, comorbidities, and infection by gram-negative microorganisms.

CONCLUSION

This study denotes the role of gram-negative bacteria in SSTI epidemiology. Therapeutic protocols regarding the empiric treatment of SSTIs should necessarily take into account the local epidemiology of isolated pathogens and antimicrobial resistance. HIPPOKRATIA 2018, 22(1): 23-28.

Cope's sign and complete heart block in a 78-year-old patient with biliary colic

INTRODUCTION

Acute cholecystitis and biliary colic may have signs and symptoms similar to those of Acute Coronary Syndrome(ACS) along with ischemic ECG changes. Cholecystitis and/or biliary colic have been both reported as trigger factors for bradyarrhythmia in the literature.

CASE REPORT

A 78-year-old male patient was admitted to our Emergency Department (ED) due to acute abdominal pain. The ECG on admission showed sinus bradycardia with a rate of 40 beats per minute (bpm) without signs of acute ischemia and a brief period (7 s) of complete atrioventricular (AV) block. He was initially treated with analgesics. After the remission of the pain, a subsequent ECG was performed which showed sinus bradycardia of 55 bpm. The AV block terminated one hour after the patient's admission. The patient remained hemodynamically stable during the episode. He underwent an ultrasound of the abdomen in the ED which revealed sludge and one stone in the gallbladder without signs of inflammation. Laboratory test results for D-dimer and troponin were negative, while the coronary angiography showed coronary vessels without significant lesions.

CONCLUSION

Biliary colic can cause severe reversible reflex bradycardia (Cope's Sign), even complete heart block. Pain relief is very important in the management of such cases.

Expansion of KPC-producing Klebsiella pneumoniae with various mgrB mutations giving rise to colistin resistance: the role of ISL3 on plasmids

mcr-1 has been reported as the first plasmid-encoded gene conferring colistin resistance. In KPC-producing Klebsiella pneumoniae (KPC-KP), however, colistin resistance is rapidly emerging through other mechanisms. Resistance is frequently due to disruption of the mgrB gene by insertion sequences, e.g. ISL3. The aim of this study was to investigate the expansion of mgrB-mutated KPC-KP isolates. In addition, the localisation and targets of ISL3 sequences within the core and accessory genome of common KPC-KP lineages were identified. A total of 29 clinical K. pneumoniae isolates collected from Italian patients were randomly selected. Whole genome sequences were analysed for resistance genes, plasmids and insertion sequences. In addition, 27 colistin-resistant KPC-KP isolates from a previous study from Crete (Greece) were assessed. Clonal expansion of KPC-KP isolates with various mutations in mgrB among all lineages was observed. In two Italian MLST ST512 isolates and eight Greek ST258 isolates, an identical copy of ISL3 was inserted in mgrB nucleotide position 133. ISL3, a transposable restriction-modification system of 8154 nucleotides, was located on pKpQIL-like plasmids and may transpose into the chromosome. In four isolates, chromosomal integration of ISL3 in diverse inner membrane proteins other than mgrB was identified. Colistin resistance is most often explained by clonal expansion of isolates with mutated mgrB. pKpQIL-like plasmids, which are omnipresent in KPC-KP, carry insertion sequences such as ISL3 that have mgrB as a target hotspot for transposition. Transposition of insertion sequences from plasmids and subsequent clonal expansion may contribute to the emerging colistin resistance in KPC-KP.

A case of severe unprovoked hemorrhage in an elderly male: a case report

Acquired hemophilia is a rare but potentially fatal clinical condition requiring clinical suspicion to reach to a diagnosis, especially in elder patients. This diagnosis should be suspected in patients that present with unexplained persistent bleeding from skin, soft tissues, and mucosa and have a prolonged aPTT.

Zika virus infection in a newly married Greek couple

Zika virus (ZIKV) is a member of the Flaviviridae family causing asymptomatic or mildly symptomatic infections with fever, rash, arthralgia and headache. It is transmitted by the Aedes species mosquitoes and also sexually and transplacentally, and has been recently associated with congenital neurologic birth defects in South and Central America. We report the case of a newly married couple from Greece who travelled to Cuba for their honeymoon and developed mild symptoms consistent with arboviral infection. After returning to Greece, they were found to have been infected by Zika virus during their honeymoon. These are the first two cases of Zika virus infection in Greece, the southeastern border of Europe, denoting that Zika virus infection poses a threat for public health worldwide, since returning travelers could be asymptomatic carriers of the virus, not only leading to risk of neurologic birth defects for their offspring but also the real risk of transmission of the virus in their country by local Aedes mosquitoes.

Clinical characteristics, microbiology and outcomes of external ventricular drainage-associated infections: The importance of active treatment

Data concerning clinical characteristics, microbiology, treatment and outcomes of external ventricular drainage-associated infections (EVDAI) are limited. All hospitalized patients with EVDAI in a University Hospital between January 2009 and December 2015 were retrospective recorded. Only the first episode per patient was included. An antibiotic was considered "active" when its pharmacokinetic properties were appropriate for EVDAI and the implicated microorganism was in vitro susceptible. During the 7-year study period, 36 EVDAI were identified. Median patient age was 53years and 23 (63.9%) were male. Catheter types were intraventricular (70.6%) and lumbar (29.4%). Median catheterization duration before infection was 14days. Gram-negative bacteria (GNB) predominated (57.9%), followed by gram-positives (36.8%) and fungi (5.3%). Administered antibiotics were considered "active" in 69.4% of empirical and in 86.1% of definitive treatment regimens. In 10 infections, intraventricular/intrathecal (IVT) antibiotics were administered. Eleven patients died (30.6%) during hospitalization. Patients who died had higher rates of EVDAI by GNB (p=0.011) and higher rates of treatment with intravenous colistin (p=0.019 for empirical and p=0.006 for definitive colistin). Compared to EVDAI by other pathogens, patients with EVDAI by GNB had longer catheter-days before infection (p<0.001) and higher mortality (p=0.011). In our study, GNB were a frequent cause of EVDAI, and were related with high rates of inactive treatment and mortality. Intravenous colistin alone is not effective and treatment should include IVT antibiotics and intravenous antibiotics that achieve adequate CSF levels.

Characteristics and predictors of outcome of spontaneous spinal epidural abscesses treated conservatively: A retrospective cohort study in a referral center

OBJECTIVE

Recent studies have shown that in carefully selected patients, conservative treatment alone can be an option in the management of spinal epidural abscess (SEA). The aim of this study was to identify prognostic factors of outcome in patients with spontaneous SEA treated conservatively.

PATIENTS AND METHODS

A retrospective cohort study of all patients with spontaneous SEA treated with antibiotics alone from January 2012 to December 2015 was conducted in a 1200-bed tertiary referral center. Demographic, clinical, microbiological, and radiological characteristics were analyzed. Failure of medical treatment was defined as the need for delayed surgical intervention, no neurological improvement or deterioration, death due to the infection, or relapse after hospital discharge.

RESULTS

We identified 21 patients diagnosed with spontaneous SEA treated conservatively. Median age was 72 years and 10 patients were male. Eleven patients presented with radicular weakness and/or radicular sensory deficit, or incomplete cord injury. Inflammatory markers were markedly elevated in all patients. Thirteen patients were successfully treated with conservative treatment, while among 8 patients with treatment failure, 1 died due to the infection. Presence of serious neurological deficits and infection due to methicillin-resistant S. aureus (MRSA) were associated with failure of conservative treatment. Notably, neither the extension nor the location of the abscess on magnetic resonance imaging (MRI) was associated with failed medical management.

CONCLUSIONS

A significant proportion of patients with spontaneous SEA can respond to antibiotic treatment alone. However, in patients with infection due to MRSA or with severe neurological impairment, conservative management has an increased risk of failure.

Clinical epidemiology, treatment and prognostic factors of extensively drug-resistant Acinetobacter baumannii ventilator-associated pneumonia in critically ill patients

Limited data exist regarding prognostic factors and optimal antimicrobial treatment of infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-AB). This retrospective cohort study included 93 adult patients who developed ventilator-associated pneumonia (VAP) due to XDR-AB in the ICU of the University Hospital of Heraklion, Greece, from October 2012 to April 2015. XDR-AB isolates were mainly susceptible to colistin (93.5%) and tigecycline (25.8%), whereas 6 (6.5%) were pandrug-resistant. Prior to infection, patients had long durations of mechanical ventilation and hospital stay and multiple exposures to antibiotics. Median Charlson co-morbidity and APACHE II scores were 2 and 17, respectively. Mortality at 28 days of infection onset was high (34.4%) despite high rates of in-vitro-active empirical (81.7%) and definitive (90.3%) treatment. Active colistin-based combination therapy (n = 55) and monotherapy (n = 29) groups had similar 28-day mortality (27.6% vs. 30.9%, respectively) and Kaplan-Meier survival estimates over time. In multivariable Cox regression, advanced age (aHR = 1.05 per year increase, 95% CI 1.02-1.09), rapidly fatal underlying disease (aHR = 2.64, 95% CI 0.98-9.17) and APACHE II score (aHR = 1.06 per unit increase, 95% CI 0.99-1.14) were identified as independent predictors of 28-day mortality, but no difference in mortality hazards between the active colistin-based combination therapy and monotherapy groups was produced (aHR = 0.88, 95% CI 0.35-2.38). These results support the use of colistin as a first-line agent against VAP in settings where XDR-AB is endemic, but oppose the introduction of colistin-based combination therapy as standard treatment.

Emergence of pan-resistance in KPC-2 carbapenemase-producing Klebsiella pneumoniae in Crete, Greece: a close call

OBJECTIVES

KPC-2-producing Klebsiella pneumoniae (KPC-KP) ST258 has been rapidly expanding and is often associated with serious nosocomial infections. Last-line antibiotics such as colistin and tigecycline often remain the only treatment option. We describe here the evolving genetic background of KPC-KP isolates in Crete, Greece.

METHODS

We tested the antibiotic susceptibility of 34 clinical isolates from patients hospitalized in 2010 and 2013-14. Whole-genome sequences of these isolates were analysed for acquired resistance genes and gene mutations.

RESULTS

All KPC-KP isolates belonged to ST258 with the exception of one ST147 isolate. From 2014, 26% of isolates were non-susceptible to all antibiotics, compared with 0 of 11 isolates from 2010. Colistin resistance was associated with mutations in mgrB, which was present in 61% of isolates from 2014. Core-genome MLST analysis showed that pan-resistant isolates were closely related and appeared in two separate clusters.

CONCLUSIONS

KPC-KP is rapidly evolving to pan-resistance in Crete. We identified molecular resistance markers for pan-resistant isolates and showed that core-genome MLST is a promising tool for molecular fingerprinting of KPC-KP ST258.

Controversies in guidelines for the control of multidrug-resistant Gram-negative bacteria in EU countries

The various guidelines that are available for multidrug-resistant Gram-negative bacteria are useful, and contain broad areas of agreement. However, there are also important areas of controversy between the guidelines in terms of the details of applying contact precautions, single-room isolation and active surveillance cultures, differences in the approach to environmental cleaning and disinfection, and whether or not to perform staff and patient cohorting, healthcare worker screening or patient decolonization. The evidence-base is extremely limited and further research is urgently required to inform an evidence-based approach to multidrug-resistant Gram-negative bacteria prevention and control.

Prevalence of Nosocomial Infections After Surgery in Greek Hospitals: Results of Two Nationwide Surveys

Objective:

To determine the frequency and type of nosocomial infections (NIs) (especially surgical-site infections [SSIs]), risk factors, and the type and duration of antibiotic use among surgical patients in Greek hospitals.

Design:

Two point-prevalence studies.

Setting:

Fourteen Greek hospitals.

Patients:

Those in the hospitals during two prevalence surveys undergoing surgery during their stay.

Results:

In the 1999 survey, 129 of 1,037 surgical patients had developed 148 NIs (14.3%). A total of 1,093 operations were registered, and 49 SSIs (4.5%) were found. In the 2000 survey, 82 of 868 surgical patients had developed 88 NIs (10.1%). A total of 902 operations were registered, and 38 SSIs were detected (4.2%). The median length of stay (LOS) for surgical patients without SSI was 10.0 days (range, 1-19 days); for patients who developed SSI it was 30 days (range, 1-52 days; P < .001). The median LOS prior to surgery for patients without SSI was 1 day (range, 0-4 days); for patients who developed SSI it was 3 days (range, 0-7.5 days; P < .001). Among 30 possible risk factors studied, wound class, LOS prior to surgery, and central venous catheterization were independent predictors of SSI. Median durations of prophylactic antibiotic therapy were 4 days (range, 1-14 days) and 6 days (range, 1-16 days) in the 1999 and 2000 surveys, respectively.

Conclusion:

Surgical patients in Greek hospitals suffered higher rates of SSI than did surgical patients in other developed countries while prophylactic antibiotics were used excessively.

Case-Mix Adjustment Approach to Benchmarking Prevalence Rates of Nosocomial Infection in Hospitals in Cyprus and Greece

Objective.

To examine the effect of heterogeneous case mix for a benchmarking analysis and interhospital comparison of the prevalence rates of nosocomial infection.

Design.

Cross-sectional survey.

Setting.

Eleven hospitals located in Cyprus and in the region of Crete in Greece.

Methods.

The survey included all inpatients in the medical, surgical, pediatric, and gynecology-obstetrics wards, as well as those in intensive care units. Centers for Disease Control and Prevention criteria were used to define nosocomial infection. The information collected for all patients included demographic characteristics, primary admission diagnosis, Karnofsky functional status index, Charlson comorbidity index, McCabe- Jackson severity of illness classification, use of antibiotics, and prior exposures to medical and surgical risk factors. Outcome data were also recorded for all patients. Case mix-adjusted rates were calculated by using a multivariate logistic regression model for nosocomial infection risk and an indirect standardization method.

Results.

The overall prevalence rate of nosocomial infection was 7.0% (95% confidence interval, 5.9%–8.3%) among 1,832 screened patients. Significant variation in nosocomial infection rates was observed across hospitals (range, 2.2%–9.6%). Logistic regression analysis indicated that the mean predicted risk of nosocomial infection across hospitals ranged from 3.7% to 10.3%, suggesting considerable variation in patient risk. Case mix-adjusted rates ranged from 2.6% to 12.4%, and the relative ranking of hospitals was affected by case-mix adjustment in 8 cases (72.8%). Nosocomial infection was significantly and independently associated with mortality (adjusted odds ratio, 3.6 [95% confidence interval, 2.1–6.1]).

Conclusion.

The first attempt to rank the risk of nosocomial infection in these regions demonstrated the importance of accounting for heterogeneous case mix before attempting interhospital comparisons.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.

Murine typhus in elderly patients: a prospective study of 49 patients

BACKGROUND

The characteristics of Rickettsia typhi infection in elderly patients have not been extensively described in the literature.

METHODS

We conducted a prospective study on murine typhus in patients > 65 years old in two endemic areas of Greece.

RESULTS

Forty-nine elderly patients were analyzed, including 30 (61.2%) males. The clinical triad of fever (100% of patients), headache (83.7%), and rash (73.5%), occurred in 63% of patients, whereas malaise (85.7%), anorexia (65.3%), and myalgia (59.2%) were also common. Frequent laboratory findings were transaminasemia (89.8%), lactate dehydrogenase elevation (65.3%), hematuria (55.1%), thrombocytopenia (53.1%), anemia (51%), leucopenia (40.8%), and mild hyponatremia (23.5%). Complications developed in 16 patients (32.7%); no deaths were recorded.

CONCLUSIONS

The main clinical and laboratory characteristics of murine typhus are similar in elderly and younger adults. However, elderly patients have a more severe clinical picture, evidenced by a higher complication rate and longer duration of fever, even with appropriate treatment. To our knowledge, this is the first study to focus on murine typhus in a geriatric population.

Attitudes and beliefs on the establishment of a national food safety authority in Cyprus. A population-based survey

Cyprus does not have a National Food Safety Authority (NFSA), but a multi-level, fragmented system with responsibilities divided among different ministries and governmental agencies, frequently impeding efforts to effectively manage food risks by duplication and overlapping of responsibilities. A population-based survey was carried out to determine the beliefs and attitudes of interested parties concerning the establishment of a NFSA in Cyprus. Information was collected using a random stratified sampling design and a structured questionnaire. A total of 868 questionnaires were collected (704 from regular consumers, 154 from food businesses' representatives, and 10 from public services' directors or acting head officers). About 11% of food businesses' representatives and 45% of consumers reported that they did not know which public authorities are responsible for food control. Moreover, 2 out of 10 (17%) of responders from public agencies, 70% from food businesses and 91% from consumers, although not aware of ongoing efforts to establish a food safety authority in Cyprus (currently under consideration), were supportive of the idea [8 out of 10 (83%) of responders from public services, 93% from food businesses, and 89% of consumers]. Finally, 7 out of 10 (67%) from the public agencies and 84% of representatives from food businesses agreed with the separation of risk assessment from risk management activities. Public opinion in Cyprus as well as public agencies and food businesses' representatives support the establishment of a single independent national food safety authority in Cyprus based on the European paradigm including the division of risk activities.

Surveillance of Monthly Antimicrobial Consumption Rates Stratified by Patient-Care Area: A Tool for Triggering and Targeting Antibiotic Policy Changes in the Hospital

The profile and temporal trends of antimicrobial use were investigated at a university hospital. Aggregate data were analyzed according to the ATC/DDD methodology. During 1998-2002, hospital-wide antimicrobial use increased by 22%, from 86.97 to 106.24 defined daily doses per 100 bed-days [DDD/100BD]. Pooled usage rates in DDD/100BD, overall percentage increases and annual average increase rates were respectively 109.97, 35.6%, 8.1 for Medical wards, 98.21, 48.7%, 9.1 for Intensive Care Units and 74.46, 34.3%, 5.7 for Hemato-oncology wards. Surgical wards had a fairly constant usage rate (98.36). A shift towards the newer broad-spectrum antibiotics, to the detriment of the older penicillins and cephalosporins, was noted in all hospital areas. Surveillance of antimicrobial consumption using the ATC/DDD system provided a clear picture of its profile. Monthly rates over a sufficient surveillance period allowed the assessment of temporal trends. Stratification of rates according to clinical service allowed areas of concern to be specified and targeted antibiotic policy changes to be initiated.

Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010

OBJECTIVE

 To report the results of a surveillance study on surgical site infections (SSIs) conducted by the International Nosocomial Infection Control Consortium (INICC).

DESIGN

 Cohort prospective multinational multicenter surveillance study.

SETTING

 Eighty-two hospitals of 66 cities in 30 countries (Argentina, Brazil, Colombia, Cuba, Dominican Republic, Egypt, Greece, India, Kosovo, Lebanon, Lithuania, Macedonia, Malaysia, Mexico, Morocco, Pakistan, Panama, Peru, Philippines, Poland, Salvador, Saudi Arabia, Serbia, Singapore, Slovakia, Sudan, Thailand, Turkey, Uruguay, and Vietnam) from 4 continents (America, Asia, Africa, and Europe).

PATIENTS

 Patients undergoing surgical procedures (SPs) from January 2005 to December 2010.

METHODS

 Data were gathered and recorded from patients hospitalized in INICC member hospitals by using the methods and definitions of the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) for SSI. SPs were classified into 31 types according to International Classification of Diseases, Ninth Revision, criteria.

RESULTS

 We gathered data from 7,523 SSIs associated with 260,973 SPs. SSI rates were significantly higher for most SPs in INICC hospitals compared with CDC-NHSN data, including the rates of SSI after hip prosthesis (2.6% vs. 1.3%; relative risk [RR], 2.06 [95% confidence interval (CI), 1.8-2.4]; P < .001), coronary bypass with chest and donor incision (4.5% vs. 2.9%; RR, 1.52 [95% CI, 1.4-1.6]; [P < .001); abdominal hysterectomy (2.7% vs. 1.6%; RR, 1.66 [95% CI, 1.4-2.0]; P < .001); exploratory abdominal surgery (4.1% vs. 2.0%; RR, 2.05 [95% CI, 1.6-2.6]; P < .001); ventricular shunt, 12.9% vs. 5.6% (RR, 2.3 [95% CI, 1.9-2.6]; P < .001, and others.

CONCLUSIONS

 SSI rates were higher for most SPs in INICC hospitals compared with CDC-NHSN data.

National Food Safety Systems in the European Union: A Comparative Survey

This paper is a comparative survey of the National Food Safety Systems (NFSS) of the European Union (EU) Member-States (MS) and the Central EU level. The main organizational structures of the NFSS, their legal frameworks, their responsibilities, their experiences, and challenges relating to food safety are discussed. Growing concerns about food safety have led the EU itself, its MS and non-EU countries, which are EU trade-partners, to review and modify their food safety systems. Our study suggests that the EU and 22 out of 27 Member States (MS) have reorganized their NFSS by establishing a single food safety authority or a similar organization on the national or central level. In addition, the study analyzes different approaches towards the establishment of such agencies. Areas where marked differences in approaches were seen included the division of responsibilities for risk assessment (RA), risk management (RM), and risk communication (RC). We found that in 12 Member States, all three areas of activity (RA, RM, and RC) are kept together, whereas in 10 Member States, risk management is functionally or institutionally separate from risk assessment and risk communication. No single ideal model for others to follow for the organization of a food safety authority was observed; however, revised NFSS, either in EU member states or at the EU central level, may be more effective from the previous arrangements, because they provide central supervision, give priority to food control programs, and maintain comprehensive risk analysis as part of their activities.

Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe

OBJECTIVE

To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance.

DESIGN

An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period.

SETTING

Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey.

PARTICIPANTS

Healthcare workers at 99 ICU members of the INICC.

METHODS

A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods.

RESULTS

A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others.

CONCLUSIONS

Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.

Murine typhus in central Greece: epidemiological, clinical, laboratory, and therapeutic-response features of 90 cases

OBJECTIVES

To document and evaluate the clinico-epidemiological profile of murine typhus during the re-emergence of the disease in a previously endemic focus in central Greece.

METHODS

This was a 5-year, hospital-based, observational study, in which 90 adult patients with murine typhus were prospectively identified and studied.

RESULTS

Most cases of the disease occurred in rural (52%) and semi-urban (34%) settings, with a seasonal frequency peak during the late summer. The triad of fever, headache, and rash was present in 64% of the patients within 2 days of hospital admission. Normal white blood cell counts (63%), thrombocytopenia (81%), and a high erythrocyte sedimentation rate (93%) were the main hematological findings upon presentation. Elevated aminotransferases (>84%), hypoalbuminemia (81%), and hyponatremia (36%) were prominent biochemical abnormalities. Pulmonary, neurological, and renal complications were noted in 26% of the patients and subsided after specific treatment. The duration of fever was shorter in patients treated with doxycycline (median 3 days) compared to ofloxacin (p=0.001) or doxycycline plus ofloxacin (p=0.009).

CONCLUSIONS

Murine typhus has the potential to cause significant morbidity. Awareness of the disease in endemic areas, early recognition of its clinical and laboratory features, and prompt administration of effective treatment are key factors to prevent potentially severe complications.

Serological survey of Q fever in Crete, southern Greece

Coxiella burnetii, the causative agent of Q fever, is an obligatory intracellular bacterium with worldwide distribution. The aim of this study was to determine the prevalence of C. burnetii phase II antibodies in two different groups (high and low risk) of healthy human population and investigate the epidemiological characteristics of the infection in the island of Crete (southern Greece). Collection and testing by IFA of 493 sample sera for IgG and IgM antibodies against C. bumetii phase II antigen indicated a prevalence of IgG antibodies of 48.7%. Of the seropositive individuals, 34% also revealed IgM seropositive antibody titers. Analysis of 225 sample sera by IFA from high risk population presented a prevalence for C. burnetii of 62.2%. Our findings revealed that C. burnetii is highly endemic in Crete, indicating a high exposure of the population to the pathogen regardless of occupation or place of residence.

Antibiotic use and the risk of carbapenem-resistant extended-spectrum-{beta}-lactamase-producing Klebsiella pneumoniae infection in hospitalized patients: results of a double case-control study

OBJECTIVES

To identify the roles of various antibiotics as risk factors for carbapenem-resistant extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae (KP) infection (ESBL-KP infection).

METHODS

Data were collected over 26 months in a tertiary care university hospital with established endemicity of carbapenem-resistant ESBL-KP (ESBL-CRKP). Using a case-case-control design, patients who presented an infection caused by carbapenem-susceptible ESBL-KP (ESBL-CSKP) and patients with ESBL-CRKP infection were compared with a common control group of hospitalized patients. Effects of treatment and duration of treatment with antibiotics were examined, adjusting for major non-antibiotic risk factors and controlling for confounding effects among the antibiotics via logistic regression models.

RESULTS

Ninety-six ESBL-CRKP cases, 55 ESBL-CSKP cases and 151 controls were analysed. Multivariate analysis, adjusting for major non-antibiotic risk factors, showed that the risk of ESBL-CRKP infection rose with increasing duration of prior treatment with β-lactam/β-lactamase inhibitor combinations [odds ratio (OR) 1.15 per day increase; P = 0.001] and revealed that increased duration of treatment with fluoroquinolones amplified the impact of exposure to carbapenems (and vice versa) on ESBL-CRKP infection risk (OR 1.02 for interaction term; P = 0.009). Duration of prior treatment with fluoroquinolones was also associated with increased risk of ESBL-CSKP infection (OR 1.07 per day increase; P = 0.028), while prior receipt of carbapenems presented a protective effect against ESBL-CSKP infection (OR 0.21; P = 0.003).

CONCLUSIONS

This study highlights the major role of treatment and duration of treatment with β-lactam/β-lactamase inhibitor combinations and combinations of carbapenems with fluoroquinolones. Clinicians should counterweight the potential benefits of administering these antibiotics against the increased risk of ESBL-CRKP infection.

Time-dependent analysis of length of stay and mortality due to urinary tract infections in ten developing countries: INICC findings

OBJECTIVES

To estimate the excess length of stay (LOS) and mortality in an intensive care unit (ICU) due to a Catheter associated urinary tract infections (CAUTI), using a statistical model that accounts for the timing of infection in 29 ICUs from 10 countries: Argentina, Brazil, Colombia, Greece, India, Lebanon, Mexico, Morocco, Peru, and Turkey.

METHODS

To estimate the extra LOS due to infection in a cohort of 69,248 admissions followed for 371,452 days in 29 ICUs, we used a multi-state model, including specific censoring to ensure that we estimate the independent effect of urinary tract infection, and not the combined effects of multiple infections. We estimated the extra length of stay and increased risk of death independently in each country, and then combined the results using a random effects meta-analysis.

RESULTS

A CAUTI prolonged length of ICU stay by an average of 1.59 days (95% CI: 0.58, 2.59 days), and increased the risk of death by 15% (95% CI: 3, 28%).

CONCLUSIONS

A CAUTI leads to a small increased LOS in ICU. The increased risk of death due to CAUTI may be due to confounding with patient morbidity.

Q fever: clinical manifestations and treatment

Public awareness and advances in the diagnostic approach to Q fever have provided important information on epidemiological and clinical aspects of this zoonosis. Coxiella burnetii infection exhibits various acute or chronic clinical forms, and infection during pregnancy may jeopardize the integrity of the fetus. The presentation of infection is often nonspecific and this hinders prompt diagnosis. Therapeutic regimens vary, and treating Q fever during pregnancy and childhood is often challenging. Increasing clinical experience with C. burnetii infections has helped create treatment protocols and follow-up algorithms that have considerably improved management and prognosis. Vaccines are available, although their use is still limited.