International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Development of case vignettes for assessment of the inter-rater variability of national validation teams for the point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals

BACKGROUND

In 2016-17 the European Centre for Disease Prevention and Control (ECDC) organized the second point prevalence survey (PPS) of healthcare-associated infections (HCAIs) and antimicrobial use in European acute care hospitals. This survey included a validation study to maximize the accuracy of case identification and classification.

AIM

ECDC developed case vignettes to assess the performance of the national validation teams.

METHODS

Case vignettes were developed by two medical doctors with experience in the management of HCAIs and antimicrobial stewardship. The case vignettes were based on actual clinical cases. The distribution of HCAIs among the case vignettes reflected the distribution of HCAIs in the previous PPS. All case vignettes were pilot-tested by three expert raters. Agreement among the expert raters was measured using kappa statistics.

FINDINGS

Sixty case vignettes were developed. Twenty-nine of them were HCAI cases and 31 were cases without an HCAI. The inter-rater reliability using kappa statistics was 0.78 for the presence of HCAI and 0.89 for the antimicrobial use, respectively.

CONCLUSION

The agreement between the expert raters was very good for antimicrobial use and good for the presence of HCAI. Case vignettes can be a tool to support standardization of surveillance, improving the validity and comparability of the data.

First secondary case of Ebola outside Africa: epidemiological characteristics and contact monitoring, Spain, September to November 2014

On 6 October 2014, a case of Ebola virus disease (EVD) acquired outside Africa was detected in Madrid in a healthcare worker who had attended to a repatriated Spanish missionary and used proper personal protective equipment. The patient presented with fever <38.6 °C without other EVD-compatible symptoms in the days before diagnosis. No case of EVD was identified in the 232 contacts investigated. The experience has led to the modification of national protocols.

Outbreak with a novel avian influenza A(H7N9) virus in China - scenarios and triggers for assessing risks and planning responses in the European Union, May 2013

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Outbreak with a novel avian influenza A(H7N9) virus in China--scenarios and triggers for assessing risks and planning responses in the European Union, May 2013

As part of the risk assessment and strategic planning related to the emergence of avian influenza A(H7N9) in China the European Centre for Disease Prevention and Control (ECDC) has considered two major scenarios. The current situation is the one of a zoonotic epidemic (Scenario A) in which the virus might be transmitted sporadically to humans in close contact with an animal reservoir. The second scenario is the movement towards efficient human to human transmission (a pandemic Scenario B). We identified epidemiological events within the different scenarios that would trigger a new risk assessment and a review of the response activities to implement in the European Union (EU). Further, we identified the surveillance activities needed to detect these events. The EU should prepare for importation of isolated human cases infected in the affected area, though this event would not change the level of public health risk. Awareness among clinicians and local public health authorities, combined with nationally available testing, will be crucial. A ’one health’ surveillance strategy is needed to detect extension of the infection towards Europe. The emergence of a novel reassortant influenza A(H7N9) underlines that pandemic preparedness remains important for Europe.

Colonization and infection by colistin-resistant Gram-negative bacteria in a cohort of critically ill patients

In recent years there has been renewed interest in colistin for the treatment of infections by multidrug-resistant Gram-negative bacteria, causing concern that increasing use may be accompanied by the emergence of resistance. This is a retrospective cohort study of colonization and infection by colistin-resistant (CR) gram-negative bacteria in critically ill patients. Colonization data were based on surveillance culture results. Among 150 patients, 78 (52%) were colonized by CR Gram-negative bacteria. Among them, 30 (20%) were colonized by Klebsiella pneumoniae isolates and 51 (34%) were colonized by intrinsically resistant to colistin (CIR) enterobacteriaceae. Seven cases of infection were caused by CR K. pneumoniae and 12 cases by CIR strains. The main risk factor for colonization by CR pathogens was colistin treatment.

Dispensing of antibiotics without prescription in Greece, 2008: another link in the antibiotic resistance chain

Antibiotic resistance has been associated with the use of antibiotics. The dispensing of antimicrobials without prescription is a potential source of inappropriate antibiotic use. In our study, antibiotics were requested without prescription from pharmacies in the metropolitan area of Athens in Greece in 2008. Twenty-one collaborators visited 174 pharmacies and asked for either amoxicillin/clavulanate acid or ciprofloxacin without providing a prescription or any other justification for the request. In Greece additional restrictions for fluoroquinolone prescriptions were implemented in 2003 after which a separate specific prescription form needs to be filled in by the prescriber, justifying the choice of any fluoroquinolone. Amoxicillin/clavulanate acid was dispensed in all cases. Furthermore, despite the regulation restricting the prescription of ciprofloxacin, this drug was dispensed by 53% of the pharmacies. It appears that the implementation of measures to restrict the use of certain antibiotics (e.g. ciprofloxacin that was studied in our case) was effective in reducing, although not eliminating, inappropriate dispensing. Overall, dispensing of antimicrobials without prescription is a widespread practice in the studied area and is contributing to the overuse of antibiotics.

Dispensing of antibiotics without prescription in Greece, 2008: another link in the antibiotic resistance chain

Antibiotic resistance has been associated with the use of antibiotics. The dispensing of antimicrobials without prescription is a potential source of inappropriate antibiotic use. In our study, antibiotics were requested without prescription from pharmacies in the metropolitan area of Athens in Greece in 2008. Twenty-one collaborators visited 174 pharmacies and asked for either amoxicillin/clavulanate acid or ciprofloxacin without providing a prescription or any other justification for the request. In Greece additional restrictions for fluoroquinolone prescriptions were implemented in 2003 after which a separate specific prescription form needs to be filled in by the prescriber, justifying the choice of any fluoroquinolone. Amoxicillin/clavulanate acid was dispensed in all cases. Furthermore, despite the regulation restricting the prescription of ciprofloxacin, this drug was dispensed by 53% of the pharmacies. It appears that the implementation of measures to restrict the use of certain antibiotics (e.g. ciprofloxacin that was studied in our case) was effective in reducing, although not eliminating, inappropriate dispensing. Overall, dispensing of antimicrobials without prescription is a widespread practice in the studied area and is contributing to the overuse of antibiotics.

No Effect of Pyridoxine on the Incidence of Myelosuppression during Prolonged Linezolid Treatment

Complications of long-term linezolid administration include anemia and thrombocytopenia. A recent report has suggested that pyridoxine may prevent myelosuppression. Pyridoxine was administered to 24 patients with bone infections who were being treated with linezolid. Thrombocytopenia occurred in 11 patients (45.8%), and anemia occurred in 6 (25%). We concluded that treatment wtih pyridoxine is unlikely to benefit patients who have been receiving linezolid for >2 weeks.

Potential use of procalcitonin as a diagnostic criterion in febrile neutropenia: experience from a multicentre study

In order to assess the diagnostic value of procalcitonin, 158 patients with febrile neutropenia from centres across Europe were studied. Patients with fever were diagnosed on the basis of either: (1) clinical, radiological and microbiological criteria; or (2) the procalcitonin value. In the latter case, concentrations of 0.5-1.0 ng/mL were considered diagnostic of localised infection, concentrations of 1.0-5.0 ng/mL of bacteraemia, and concentrations of > 5.0 ng/mL of severe sepsis. Procalcitonin and C-reactive protein were estimated daily in serum by immunochemiluminescence and nephelometry, respectively. Overall, the sensitivity (specificity) of procalcitonin for bacteraemia was 44.2% (64.3%) at concentrations of 1.0-5.0 ng/mL, and 83.3% (100%) for severe sepsis at concentrations of > 5.0 ng/mL. It was concluded that procalcitonin is a marker strongly suggestive of severe sepsis at concentrations of > 5.0 ng/mL. Estimated concentrations of < 0.5 ng/mL indicate that infection is unlikely, but it was observed that bacteraemia associated with coagulase-negative staphylococci may fail to elevate serum procalcitonin levels.

Stimulation of innate immunity by susceptible and multidrug-resistant Pseudomonas aeruginosa: an in vitro and in vivo study

In attempt to investigate the stimulatory effect of Pseudomonas aeruginosa on innate immunity and to correlate it to its level of resistance to antimicrobials, 20 isolates were applied; 8 isolates were susceptible and 12 multidrug-resistant. Genetic diversity was defined by PFGE. Human monocytes of two healthy volunteers were in vitro stimulated by the isolates for the production of pro-inflammatory (TNF-alpha, IL-1beta, IL-6, IL-8 and IL-12) and anti-inflammatory cytokines (IL-10), of malondialdehyde and of procalcitonin. Cytokines were estimated by EIA, malondialdehyde by the thiobarbiturate assay and procalcitonin by an immunochemiluminometric assay. Survival of 48 Wistar rats was recorded after induction of sepsis by the intraperitoneal injection of three susceptible and three multidrug-resistant isolates. To test whether comparative effect of the latter isolates on survival correlates with any difference of monocyte-mediated release of pro-inflammatory mediators, monocytes of two rats were in vitro stimulated for the production of TNF-alpha and of malondialdehyde. In vitro stimulation of human monocytes by the susceptible isolates elicited elevated production of malondiadeheyde, of IL-1beta and of IL-6 compared to stimulation by multidrug-resistant isolates. Similar differences were found for TNF-alpha and IL-8, but they were not statistically significant. Production of IL-10 and IL-12 was not detected after stimulation with any isolate. Levels of procalcitonin were similar after induction with either susceptible or multidrug-resistant isolates. Mean survival of animals was 7.56, 21.80 and 55.20 h, respectively, after challenge by the susceptible isolates and 28.89, 61.8 and more than 120 h, respectively, after challenge by the multidrug-resistant isolates. Differences of survival were accompanied by greater rodent monocyte-release of TNF-alpha and malondialdehyde after stimulation by the susceptible isolates compared to multidrug-resistant ones. It is concluded that considerable differences are encountered on the stimulation of human monocytes by susceptible and resistant isolates of Pseudomonas aeruginosa. These results correlate with in vivo evidence and might influence decision on therapeutics.