Impact of the ST101 clone on fatality among patients with colistin-resistant Klebsiella pneumoniae infection

Objectives

We describe the molecular characteristics of colistin resistance and its impact on patient mortality.

Methods

A prospective cohort study was performed in seven different Turkish hospitals. The genotype of each isolate was determined by MLST and repetitive extragenic palindromic PCR (rep-PCR). Alterations in mgrB were detected by sequencing. Upregulation of pmrCAB, phoQ and pmrK was quantified by RT-PCR. mcr-1 and the genes encoding OXA-48, NDM-1 and KPC were amplified by PCR.

Results

A total of 115 patients diagnosed with colistin-resistant K. pneumoniae (ColR-Kp) infection were included. Patients were predominantly males (55%) with a median age of 63 (IQR 46-74) and the 30 day mortality rate was 61%. ST101 was the most common ST and accounted for 68 (59%) of the ColR-Kp. The 30 day mortality rate in patients with these isolates was 72%. In ST101, 94% (64/68) of the isolates had an altered mgrB gene, whereas the alteration occurred in 40% (19/47) of non-ST101 isolates. The OXA-48 and NDM-1 carbapenemases were found in 93 (81%) and 22 (19%) of the total 115 isolates, respectively. In multivariate analysis for the prediction of 30 day mortality, ST101 (OR 3.4, CI 1.46-8.15, P = 0.005) and ICU stay (OR 7.4, CI 2.23-29.61, P = 0.002) were found to be significantly associated covariates.

Conclusions

Besides ICU stay, ST101 was found to be a significant independent predictor of patient mortality among those infected with ColR-Kp. A significant association was detected between ST101 and OXA-48. ST101 may become a global threat in the dissemination of colistin resistance and the increased morbidity and mortality of K. pneumoniae infection.

Scenario-based simulation training for the WHO hand hygiene self-assessment framework

The WHO SAVE LIVES: Clean Your Hands global hand hygiene campaign, launched in 2009 and celebrated annually on the 5th of May, features specific calls to action seeking to increase engagement from stakeholders’ collaborations in hand hygiene improvement. WHO calls on everyone to be inspired by the global movement towards universal health coverage (UHC). Infection prevention and control (IPC), including hand hygiene, is critical to achieve UHC as it has a direct impact on quality of care and patient safety across all levels of the health services. In the framework of UHC, the theme for 5 May 2019 is “Clean care for all – it’s in your hands”. In this context, the WHO has launched a global survey to assess the current level of progress of IPC programmes and hand hygiene activities in healthcare facilities (HCFs) worldwide. This involved the creation of two tools for healthcare facilities: the WHO Infection Prevention and Control Assessment Framework (IPCAF) and the WHO Hand Hygiene Self-Assessment Framework (HHSAF). The objective of this paper is to provide case scenario-based simulation for IPC specialists to simulate and fully assimilate the correct completion of the HHSAF framework in a standardized format. The three case scenarios have been tested and are proposed for the reader to assess the HHSAF of different HCFs in a variety of contexts, even in low-resouce settings. They were designed for simulation training purposes to achieve standardization and interactive learning. These scenarios are meant to be used by professionals in charge of implementing a hand hygiene improvement strategy within their HCF, as well as for simulation and standardized training purposes prior to completing and submitting data for the 2019 WHO Global Survey. Additionally, information provided by the use of the HHSAF can easily be translated into action plans to support the implementation and improvement related to specific indicators of hand hygiene promotion. We invite all HCFs to participate in the 2019 WHO global survey and monitor the level of progress of their IPC programme and hand hygiene activities.

Healthcare-associated Gram-negative bloodstream infections: antibiotic resistance and predictors of mortality

This article describes the prevalence of antibiotic resistance and predictors of mortality for healthcare-associated (HA) Gram-negative bloodstream infections (GN-BSI). In total, 831 cases of HA GN-BSI from 17 intensive care units in different centres in Turkey were included; the all-cause mortality rate was 44%. Carbapenem resistance in Klebsiella pneumoniae was 38%, and the colistin resistance rate was 6%. Multi-variate analysis showed that age >70 years [odds ratio (OR) 2, 95% confidence interval (CI) 1.22-3.51], central venous catheter use (OR 2.1, 95% CI 1.09-4.07), ventilator-associated pneumonia (OR 1.9, 95% CI 1.1-3.16), carbapenem resistance (OR 1.8, 95% CI 1.11-2.95) and APACHE II score (OR 1.1, 95% CI 1.07-1.13) were significantly associated with mortality.

In vitro susceptibility of tigecycline against multidrug-resistant gram-negative strains: Etest versus agar dilution

BACKGROUND AND AIM

Tigecycline is a semi-synthetic tetracycline with activity against most multidrug-resistant (MDR) bacteria.

METHODS

We studied in vitro activity of tigecycline by agar dilution (AD) and Etest methods to evaluate their correlation. The study included 206 isolates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli, Klebsiella pneumoniae and MDR Acinetobacter baumannii recovered from blood cultures of patients of Baskent University between 2008 and 2010.

RESULTS

ESBL-producing E. coli had MIC50/MIC90 values of 0.5/0.5 µg/ml by AD and 0.25/0.5 µg/ml by Etest. ESBL-producing K. pneumoniae had MIC50/MIC90 values of 1/2 µg/ml by AD and 0.75/2 µg/ml by Etest, whereas MDR A. baumannii had MIC50/MIC90 values of 4/4 µg/ml by AD and 2/4 µg/ml by Etest. The correlation between AD and Etest was weak for ESBL-producing E. coli and strong for ESBL-producing K. pneumoniae and MDR A. baumannii. Tigecycline MIC values for ESBL-producing E. coli were lower than the tigecycline concentration, while they were higher than the concentrations attainable by treatment doses for A. baumannii.

CONCLUSION

Tigecycline is an appropriate agent in the treatment of E. coli bacteremia, but it is not for treating A. baumannii bacteremia. Tigecycline could be used for K. pneumoniae bacteremia treatment after determining its MIC value. Determining the MIC value by gold-standard methods is more appropriate due to the correlation between Etest and AD at high MIC values.

Thrombocytosis and small bowel perforation: unusual presentation of abdominopelvic actinomycosis

Intrauterine devices (IUD) are frequently used as a family planning procedure in developing countries because they are easy to administer and governmental policies support their use in many countries. It is recommended that IUDs be removed or replaced after 10 years, but longer use is common, especially in developing countries. In some cases, rare infections such as pelvic inflammatory diseases, pelvic tuberculosis, or abdominopelvic actinomycosis related to IUD can develop. Pelvic actinomycosis is a rare disease and is often diagnosed incidentally during surgery. In recent years, there has been an increase in actinomycotic infections mostly due to long-term usage of IUD and forgotten intravaginal pessaries. It usually develops as an ascending infection. It is usually associated with non-specific symptoms such as lower abdominal pain, menstrual disturbances, fever, and vaginal discharge. The disease is sometimes asymptomatic. The rate of accurate preoperative diagnosis for pelvic actinomycosis is less than 10%, and symptoms and imaging studies sometimes mimic pelvic malignancy. This report details a case with abdominopelvic actinomycosis associated with an IUD presenting with highly elevated thromboctye count and small bowel perforation with abscess formation.

In vitro activity of antimicrobial agents against Legionella isolated from environmental water systems: first results from Turkey

We evaluated the in vitro activity of antimicrobial agents against Legionella obtained from hotel and hospital water systems in three different regions of Turkey. Sixty-five Legionella strains (Legionella pneumophila serogroup 6 [n=32], L. pneumophila serogroup 1 [n=27], L. pneumophila serogroup 3 [n=2], and Legionella spp. [n=4]) were tested against levofloxacin, ciprofloxacin, clarithromycin, azithromycin, and rifampicin. The minimum inhibitory concentration (MIC) values of each antimicrobial agent for these strains was determined by the microdilution method using buffered yeast extract medium supplemented with 0.1% ketoglutarate broth. L. pneumophila ATCC 33152, Staphylococcus aureus ATCC 29213, and Escherichia coli ATCC 25922 were used as controls. Minimum inhibitory concentration values were in the following ranges: clarithromycin 0.001-0.5 mg/L, azithromycin 0.001-0.5 mg/L, levofloxacin 0.001-0.5 mg/L, ciprofloxacin 0.001-0.125 mg/L, and rifampicin 0.001- 0.5 mg/L. The MIC(90) for rifampicin, levofloxacin, ciprofloxacin, azithromycin, and clarithromycin were 0.015, 0.125, 0.06, 0.125, and 0.06 mg/L, respectively. To the best of our knowledge, this is the first study to determine in vitro activities of antimicrobial agents against Legionella species in Turkey. Rifampicin had the lowest MIC(90) value. It would seem that azithromycin and clarithromycin exhibit good activity as well as levofloxacin and ciprofloxacin against Legionella isolated from environmental water systems in Turkey.

Risk factors for extended-spectrum beta-lactamase positivity in uropathogenic Escherichia coli isolated from community-acquired urinary tract infections

The aim of this prospective cohort study was to determine the risk factors for community-acquired urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-positive Escherichia coli and the distribution of the ESBL enzyme types. Structured forms were filled in for patients diagnosed with community-acquired UTI in four different geographical locations in Turkey. The forms and the isolates were sent to the central laboratory at Baskent University Hospital, Ankara. Antimicrobial susceptibility was determined according to the CLSI criteria. PCR and DNA sequencing were used to characterize the bla(TEM), bla(CTX-M) and bla(SHV) genes. Multivariate analysis was performed using logistic regression. A total of 510 patients with UTI caused by Gram-negative bacteria were included in this study. ESBLs were detected in 17 of 269 (6.3%) uropathogenic E. coli isolates from uncomplicated UTIs and 34 of 195 (17.4%) E. coli isolates from complicated UTIs (p <0.001). According to multivariate analysis, more than three urinary tract infection episodes in the preceding year (OR 3.8, 95% CI 1.8-8.1, p <0.001), use of a beta-lactam antibiotic in the preceding 3 months (OR 4.6, 95% CI 2.0-0.7, p <0.001) and prostatic disease (OR 9.6, 95% CI 2.1-44.8, p 0.004) were found to be associated with ESBL positivity. The percentages of isolates with simultaneous resistance to trimethoprim-sulphamethoxazole, ciprofloxacin and gentamicin were found to be 4.6% in the ESBL-negative group and 39.2% in the ESBL-positive group (p <0.001). Forty-six of 51 ESBL-positive isolates (90.2%) were found to harbour CTX-M-15. Therapeutic alternatives for UTI, particularly in outpatients, are limited. Further clinical studies are needed to guide the clinicians in the management of community-acquired UTIs.

A case of brucellosis with abscess of the iliacus muscle, olecranon bursitis, and sacroiliitis

Brucellosis is a systemic infection involving many organs and tissues. The musculoskeletal system is one of the most commonly affected. The disease can present with sacroiliitis, peripheral arthritis, spondylitis, paraspinal abscess, bursitis, and osteomyelitis. A 25-year-old male patient was admitted with fever of 20-day duration, right-sided hip pain, and night sweating. A Brucella standard tube agglutination test was positive at a titer of 1/160. Magnetic resonance imaging (MRI) of the hip joint showed right sacroiliitis and a hyperintense, nodular, lobulated mass within the right iliacus muscle, consistent with abscess. The patient was started on intramuscular streptomycin at a dose of 1 g/day, oral rifampin 600 mg/day, and doxycycline 200 mg/day. On day 20 of treatment, the patient was admitted with swelling and pain over the left elbow for the past week. MRI of the left elbow was performed, which showed fluid edema suggestive of olecranon bursitis. Taking the patient's complaints into consideration, rifampin and doxycycline treatment were maintained for a year. Pain at the hip joint and elbow resolved and MRI findings disappeared. Abscess of the iliacus muscle, which has not been reported before, and the olecranon bursitis that developed during treatment make this case worth presenting.

Urinary tract infections in renal transplant recipients

Urinary tract infection (UTI) is the most common infectious complication following renal transplantation. The purposes of this study were to determine the causative agents of UTIs among renal transplant recipients and to compare the antibiotic susceptibilities of Escherichia coli strains isolated from renal transplant recipients and complicated community-acquired UTIs. We evaluated 75 episodes of 63 recipients with confirmed UTI who underwent transplantation during the period 1981 to 2006 at our center. Medical records of the patients were reviewed retrospectively. To compare the susceptibility rates of E coli, 226 isolates from nontransplant patients with complicated community-acquired UTIs were also evaluated. Ten episodes (13.3%) occurred in the first month following the transplantation, 11 (14.7%) in the period of the second month to the sixth month, and 54 (72%) after the sixth month of transplantation. Forty-six (61.3%) isolates were E coli. Among these isolates, ciprofloxacin resistance rates were 50% (2/4) in the first month after transplantation, 75% (6/8) in the period of the second month to the sixth month, and 32.4% (11/34) beyond 6 months after transplantation. The resistance rates of trimethoprim/sulfamethoxazole (TMP-SMX) in the same time periods were 100% (4/4), 87.5% (7/8), and 70.6% (24/34), respectively. The rates of resistance to TMP-SMX among E coli isolated from renal recipients were significantly higher than those in community-acquired complicated UTIs. The increased resistance of urinary pathogens to this agent is a major concern. Although high resistance rates of ciprofloxacin against E coli strains were determined in this group, it was not found to be statistically significant.

[Biofilm production and antifungal susceptibility patterns of Candida species isolated from hospitalized patients]

Biofilm producing Candida species are known to be more resistant to immune response and antimicrobial agents which leads to treatment failure. The aim of this study was to investigate the biofilm production among Candida species that were isolated from hospitalized patients and to compare the in vitro activities of antifungal agents with biofilm production. A total of 116 Candida spp. (79 C. albicans and 37 non-albicans Candida spp.) isolated from various specimens (blood, sterile body fluids, mucosal and skin lesion samples) were included to the study. Fluconazole, itraconazole, amphotericin B and caspofungin susceptibilities of the isolates were determined by broth microdilution method according to CLSI M27-A2 standards. Biofilm production of Candida spp. was determined by microplate method, using brain heart infusion broth supplemented with 0.25% glucose as a growth medium. Biofilm formation was detected in 33 of 116 isolates (28%) and 11 of them (33%) were the strains isolated from hemocultures. Biofilm production was determined more commonly in blood isolates than the strains isolated from other samples (p < 0.05). The biofilm production rate of non-albicans Candida species (41%) was found higher than C. albicans (23%), which the difference was statistically significant (p < 0.05). Amphotericin B and caspofungin were found the most effective antifungals with the MIC90 values of 0.06 microg/ml and 0.5 microg/ml for C. albicans, and 0.5 microg/ml and 1 microg/ml for non-albicans Candida species respectively. The observed positive correlation between the biofilm production and amphotericin B MIC values were found significant (p < 0.05). In conclusion, high biofilm production rates of Candida species may explain the increase in the rate of catheter-related Candida infections.

Value of automatized blood culture systems in the diagnosis of continuous ambulatory peritoneal dialysis peritonitis

Peritonitis is a common clinical problem that occurs in patients with end-stage renal disease treated by peritoneal dialysis. The aim of this study was to evaluate the value of blood culture systems for the diagnosis of continuous ambulatory peritoneal dialysis (CAPD) peritonitis among 26 samples of peritoneal fluid obtained from patients with the suspicion of CAPD peritonitis. Significant growth was detected in 12 (70.5%) of 17 bacteria-positive samples. The most striking finding was that 8 (66.6%) of these 12 results were obtained only from blood culture bottles. The identified pathogens were methicillin-sensitive coagulase-negative staphylococci (n = 5), alpha-hemolytic streptococci (n = 2), Corynebacterium spp. (n = 2), Escherichia coli (n = 2), and Enterococcus faecalis (n = 1). Using blood culture bottles inoculated with peritoneal fluid at the bedside, rather than submitting the specimen to the laboratory for later processing, is advocated in the prompt diagnosis of CAPD peritonitis.

In vitro activities of non-traditional antimicrobials alone or in combination against multidrug-resistant strains of Pseudomonas aeruginosa and Acinetobacter baumannii isolated from intensive care units

The aim of this study was to assess the in vitro activity of a number of non-traditional antibiotics (colistin, azithromycin, doxycycline and rifampicin) against multidrug-resistant (MDR) strains of Pseudomonas aeruginosa and Acinetobacter baumannii isolated from Intensive Care Units (ICUs). We also used the checkerboard method to determine whether combinations of colistin with another non-traditional antibiotic or meropenem act synergistically against these strains. Thirty-five P. aeruginosa and 25 A. baumannii strains that were found to be MDR were included the study. Isolates were collected from the specimens of patients in ICUs from 2001 to 2003. All isolates were identified by standard methods and stored at -20 degrees C until use. Antibiotic powders of azithromycin, doxycycline, rifampicin, meropenem and colistin were obtained from their manufacturers. Minimum inhibitory concentrations (MICs) were determined by the agar dilution method on Mueller-Hinton agar. Five strains of A. baumannii and five strains of P. aeruginosa, all of which had different MIC values for colistin, were selected for the synergy study using the checkerboard titration method. The susceptibility results for doxycycline and meropenem were interpreted according to National Committee for Clinical Laboratory Standards guidelines. The susceptibility breakpoints for colistin and rifampicin were established as 4 mg/L and 2 mg/L, respectively, based on previous studies. Pseudomonas aeruginosa ATCC 27853 and Escherichia coli ATCC 25922 were used as control strains. Testing against the P. aeruginosa strains revealed high MIC50 values for all the drugs except colistin. Doxycycline and colistin were both effective against the A. baumannii strains, with high susceptibility rates of 92% and 100%, respectively. Azithromycin had a high MIC50 value against these strains, whilst rifampicin had a moderate effect (susceptibility rate 64%). The combination of colistin and rifampicin was fully synergistic against four A. baumannii and two P. aeruginosa strains. Combinations of colistin with meropenem and of colistin with azithromycin each showed synergistic activity against three A. baumannii isolates, whilst the same combinations resulted in generally additive or indifferent effects against P. aeruginosa strains. The colistin and doxycycline combination was generally partially synergistic or additive against all the isolates. MDR strains of P. aeruginosa and A. baumannii, which cause nosocomial infections with an increasing ratio in recent years, have limited treatment options. According to our in vitro study results, non-traditional antibiotics such as doxycycline and colistin can be an alternative for the treatment of infections caused by these strains. Combinations of colistin with non-traditional antibiotics or meropenem could be promising alternatives for the treatment of infections due to MDR strains of A. baumannii and P. aeruginosa.

Risk factors for ciprofloxacin resistance among Escherichia coli strains isolated from community-acquired urinary tract infections in Turkey

OBJECTIVES

To determine the risk factors for community-acquired ciprofloxacin-resistant Escherichia coli urinary tract infection (UTI).

METHODS

The study was performed with isolates from community-acquired UTIs collected from 15 centres representing six different geographic regions of Turkey. All microbiological procedures were carried out in a central laboratory. Multivariate analysis was performed for detection of risk factors for resistance. Use of quinolones more than once within the last year, living in a rural area, having a urinary catheter, age >50 and complicated infections were included in the model as variables and logistic regression was performed.

RESULTS

A total of 611 gram-negative isolates were studied: 321 were isolated from uncomplicated UTI and 290 were isolated from complicated UTI. E. coli was the causative agent in 90% of the uncomplicated UTIs and in 78% of the complicated UTIs (P < 0.001). Seventeen percent of E. coli strains isolated from uncomplicated cases and 38% of E. coli strains isolated from complicated UTI were found to be resistant to ciprofloxacin. In multivariate analysis, age over 50 [odds ratio (OR): 1.6; confidence interval (CI): 1.08-2.47; P = 0.020], ciprofloxacin use more than once in the last year (OR: 2.8; CI: 1.38-5.47; P = 0.004) and the presence of complicated UTI (OR: 2.4; CI: 1.54-3.61; P < 0.001) were found to be associated with ciprofloxacin resistance. Detection of strains of E. coli producing extended-spectrum beta-lactamase (ESBL) enzymes was two times more common in the patients who received ciprofloxacin than those who did not (15% versus 7.4%).

CONCLUSIONS

The increasing prevalence of infections caused by antibiotic-resistant bacteria makes the empirical treatment of UTIs more difficult. One of the important factors contributing to these high resistance rates might be high antibiotic use. Urine culture and antimicrobial susceptibility testing are essential in Turkey for patients with UTI who have risk factors for resistance, such as previous ciprofloxacin use. Fluoroquinolone-sparing agents such as nitrofurantoin and fosfomycin should be evaluated as alternative therapies by further clinical efficacy and safety studies.

Incidence of inducible clindamycin resistance in staphylococci: first results from Turkey

In total, 408 staphylococcal isolates were tested for inducible clindamycin resistance (ICR) by the disk-diffusion induction test (D-test). ICR was detected in 5.7% of 105 methicillin-resistant Staphylococcus aureus (MRSA) isolates, 3.6% of 111 methicillin-susceptible S. aureus isolates, 30.8% of 94 methicillin-resistant coagulase-negative staphylococcal (CoNS) isolates, and 11.2% of 98 methicillin-sensitive CoNS isolates. All MRSA isolates that were erythromycin-resistant and clindamycin-susceptible were positive by the D-test. The same results were obtained with an azithromycin instead of an erythromycin disk. All isolates were susceptible to quinupristin-dalfopristin. The cost-benefit of the d-test should be evaluated locally after determining the incidence of the different resistance phenotypes.

[Invasive pulmonary aspergillosis in solid organ transplant recipients]

To discuss diagnosis, risk factors, clinical and radiologic manifestations of invasive pulmonary aspergillosis (IPA) that is accepted as an important mortality factor in organ transplant recipients. We retrospectively evaluated seven IPA cases who were diagnosed among 207 patients that had undergone organ transplantation surgery in our center between 1998-2001. Of seven patients, four was renal and three was liver recipients. Diagnosis was made histopathologically (three post-mortem, one transbronchial lung biopsy) in four patients while culture positivity (sputum and tracheal aspiration material) with clinical and radiological evaluation was the diagnostic criteria for three patients. The most common respiratory symptoms were fever, productive cough and dyspnea. The most common fiberoptic bronchoscopic findings were mucosal fragility, hemorrhage. In one patient plaque formation was found. One liver recipients had been on hemodialysis because of renal insufficiency (serum creatine was 2.6 mg/dL). All liver and kidney recipients had allograft failure. One liver and two kidney recipients had neutropenia, two liver and one kidney recipients had thrombocytopenia. Six patients had received amphotericin-B and/or itraconazole therapy. Four of the five exitus were receiving antifungal treatment. Three of them were lost in a short time while only one non-survivor had received itraconazole for three weeks. The most frequent CT findings were patchy infiltrations and nodule formation with or without cavitation. Five patients were lost in two months (mortality, 71.4 %), two survivors are under follow up. These findings showed, IPA should be thought in the differential diagnosis of pulmonary infections after organ transplantation.