The safety and potential efficacy of exosomes overexpressing CD24 (EXO-CD24) in mild-moderate COVID-19 related ARDS

INTRODUCTION

EXO-CD24 are exosomes genetically manipulated to over-express Cluster of Differentiation (CD) 24. It consists of two breakthrough technologies: CD24, the drug, as a novel immunomodulator that is smarter than steroids without any side effects, and exosomes as the ideal natural drug carrier.

METHODS

A randomized, single blind, dose-finding phase IIb trial in hospitalized patients with mild to moderate Coronavirus disease 2019 (COVID-19) related Acute Respiratory Distress Syndrome (ARDS) was carried out in two medical centers in Athens. Patients received either 109 or 1010 exosome particles of EXO-CD24, daily, for five consecutive days and monitored for 28 days. Efficacy was assessed at day 7 among 91 patients who underwent randomization. The outcome was also compared in a post-hoc analysis with an income control group (n = 202) that fit the inclusion and exclusion criteria.

RESULTS

The mean age was 49.4 (± 13.2) years and 74.4% were male. By day 7, 83.7% showed improved respiratory signs and 64% had better oxygen saturation (SpO2) (p < 0.05). There were significant reductions in all inflammatory markers, most notably in C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, fibrinogen and an array of cytokines. Conversely, levels of the anti-inflammatory cytokine Interleukin-10 (IL-10) were increased (p < 0.05). Of all the documented adverse events, none were considered treatment related. No drug-drug interactions were noted. Two patients succumbed to COVID-19. Post-hoc analysis revealed that EXO-CD24 patients exhibited greater improvements in clinical and laboratory outcomes compared to an observational income control group.

CONCLUSIONS

EXO-CD24 presents a promising therapeutic approach for hyper-inflammatory state and in particular ARDS. Its unique combination of exosomes, as a drug carrier, and CD24, as an immunomodulator, coupled with inhalation administration, warrants further investigation in a larger, international, randomized, quadri-blind trial against a placebo.

Effectiveness of full (booster) COVID-19 vaccination against severe outcomes and work absenteeism in hospitalized patients with COVID-19 during the Delta and Omicron waves in Greece

AIM

We estimated vaccine effectiveness (VE) of full (booster) vaccination against severe outcomes in hospitalized COVID-19 patients during the Delta and Omicron waves.

METHODS

The study extended from November 15, 2021 to April 17, 2022. Full vaccination was defined as a primary vaccination plus a booster ≥ 6 months later.

RESULTS

We studied 1138 patients (mean age: 66.6 years), of whom 826 (72.6 %) had > 1 comorbidity. Of the 1138 patients, 75 (6.6 %) were admitted to intensive care unit (ICU), 64 (5.6 %) received mechanical ventilation, and 172 (15.1 %) died. There were 386 (33.9 %) fully vaccinated, 172 (15.1 %) partially vaccinated, and 580 (51 %) unvaccinated patients. Unvaccinated patients were absent from work for longer periods compared to partially or fully vaccinated patients (mean absence of 20.1 days versus 12.3 and 17.3 days, respectively; p-value = 0.03). Compared to unvaccinated patients, fully vaccinated patients were less likely to be admitted to ICU [adjusted relative risk (ARR: 0.49; 95 % CI: 0.29-0.84)], mechanically ventilated (ARR: 0.43; 95 % CI: 0.23-0.80), and die (ARR: 0.57; 95 % CI: 0.42-0.78), while they were hospitalized for significantly shorter periods (ARR: 0.79; 95 % CI: 0.70-0.89). The adjusted full VE was 48.8 % (95 % CI: 42.7 %-54.9 %) against ICU admission, 55.4 % (95 % CI: 52.0 %-56.2 %) against mechanical ventilation, and 22.6 % (95 % CI: 7.4 %-34.8 %) against death. For patients with ≥ 3 comorbidities, VE was 56.2 % (95 % CI: 43.9 %-67.1 %) against ICU admission, 60.2 % (95 % CI: 53.7 %-65.4 %) against mechanical ventilation, and 43.9 % (95 % CI: 19.9 %-59.7 %) against death.

CONCLUSIONS

Full (booster) COVID-19 vaccination conferred protection against severe outcomes, prolonged hospitalization, and prolonged work absenteeism.

The role of cardiometabolic risk factors and endothelial dysfunction in serum albumin levels and capillary leak syndrome of patients with COVID-19

Background

Growing evidence focuses on the role of hypoalbuminemia in the COVID-19 course and the role of vascular inflammation in the progression to Capillary Leak Syndrome (CLS). CLS may be mediated by a derangement of endothelial barrier following vascular endothelial dysfunction. We investigated the role of cardiometabolic risk factors in the association of hypoalbuminemia with endothelial dysfunction of hospitalized COVID-19 patients.

Methods

In this cross-sectional study, patients hospitalized for COVID-19 at the medical ward or Intensive Care Unit (ICU) were enrolled. Medical history and laboratory examinations were collected while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD) between the first 24–72 hours of their admission to the hospital. According to the body mass index, history of hypertension, dyslipidemia, and diabetes mellitus, COVID-19 patients were categorized in those with Cardiometabolic Risk Factors (CRFact) or without CRFact (no-CRFact). From the study population, we excluded subjects with established cardiovascular disease.

Results

Sixty-six patients with COVID-19 (37% admitted in ICU) were recruited. From the study population, 41 were in the group of CRFact and 25 in the no-CRFact. Patients with CFRact were older (65±9 years vs. 53±14 years, p<0.001), had more impaired FMD (1.16±2.13% vs. 2.60±2.44%, p=0.01), and lower serum albumin levels (3.10±0.68 g/dL vs. 3.52±0.26 g/dL, p=0.006) compared to the no-CRFact group. Between CRFact and no-CRFact, there was no difference in CRP and IL-6 levels. Interestingly, serum albumin in patients with CRFact was significantly lower than the lower reference limit (LRL) (=3.5 g/dl) of albumin (p=0.001), while no such finding was noted in subjects with no CRFact (p=0.64). Furthermore, regression analysis revealed that, even after adjustment for age, the presence of CRFact was associated with decreased serum albumin levels by 0.31mg/dl (95% CI 0.08 to 0.63, p=0.04). In the CRFact population, there was a correlation of albumin with FMD (R=0.29, p=0.05) and an inverse correlation with CRP (rho=−0.48, p=0.02) and IL-6 (rho=−0.66, p<0.001), while in the no-CRFact group no such correlation were observed (p=NS for all).

Conclusion

COVID-19 patients with cardiometabolic risk factors present with low serum albumin levels early at the course of the disease, which may be driven by endothelial dysfunction and vascular inflammation. This data gives insights into the potential association of a dysfunctional endothelial layer and the progression to capillary leak syndrome.

Funding Acknowledgement

Type of funding sources: None.

Ceftazidime/avibactam in the era of carbapenemase-producing Klebsiella pneumoniae: experience from a national registry study

BACKGROUND

Infections caused by KPC-producing Klebsiella pneumoniae (Kp) are associated with high mortality. Therefore, new treatment options are urgently required.

OBJECTIVES

To assess the outcomes and predictors of mortality in patients with KPC- or OXA-48-Kp infections treated with ceftazidime/avibactam with an emphasis on KPC-Kp bloodstream infections (BSIs).

METHODS

A multicentre prospective observational study was conducted between January 2018 and March 2019. Patients with KPC- or OXA-48-Kp infections treated with ceftazidime/avibactam were included in the analysis. The subgroup of patients with KPC-Kp BSIs treated with ceftazidime/avibactam was matched by propensity score with a cohort of patients whose KPC-Kp BSIs had been treated with agents other than ceftazidime/avibactam with in vitro activity.

RESULTS

One hundred and forty-seven patients were identified; 140 were infected with KPC producers and 7 with OXA-48 producers. For targeted therapy, 68 (46.3%) patients received monotherapy with ceftazidime/avibactam and 79 (53.7%) patients received ceftazidime/avibactam in combination with at least another active agent. The 14 and 28 day mortality rates were 9% and 20%, respectively. The 28 day mortality among the 71 patients with KPC-Kp BSIs treated with ceftazidime/avibactam was significantly lower than that observed in the 71 matched patients, whose KPC-Kp BSIs had been treated with agents other than ceftazidime/avibactam (18.3% versus 40.8%; P = 0.005). In the Cox proportional hazards model, ultimately fatal disease, rapidly fatal disease and Charlson comorbidity index ≥2 were independent predictors of death, whereas treatment with ceftazidime/avibactam-containing regimens was the only independent predictor of survival.

CONCLUSIONS

Ceftazidime/avibactam appears to be an effective treatment against serious infections caused by KPC-Kp.

Management of KPC-producing Klebsiella pneumoniae infections

BACKGROUND

Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas.

AIMS

To provide practical suggestion for physicians dealing with the management of KPC-KP infections in critically ill patients, based on expert opinions.

SOURCES

PubMed search for relevant publications related to the management of KPC-KP infections.

CONTENTS

A panel of experts developed a list of 12 questions to be addressed. In view of the current lack of high-level evidence, they were asked to provide answers on the bases of their knowledge and experience in the field. The panel identified several key aspects to be addressed when dealing with KPC-KP in critically ill patients (preventing colonization in the patient, preventing infection in the colonized patient and colonization of his or her contacts, reducing mortality in the infected patient by rapidly diagnosing the causative agent and promptly adopting the best therapeutic strategy) and provided related suggestions that were based on the available observational literature and the experience of panel members.

IMPLICATIONS

Diagnostic technologies could speed up the diagnosis of KPC-KP infections. Combination treatment should be preferred to monotherapy in cases of severe infections. For non-critically ill patients without severe infections, results from randomized clinical trials are needed for ultimately weighing benefits and costs of using combinations rather than monotherapy. Multifaceted infection control interventions are needed to decrease the rates of colonization and cross-transmission of KPC-KP.

Use of nebulized antimicrobials for the treatment of respiratory infections in invasively mechanically ventilated adults: a position paper from the European Society of Clinical Microbiology and Infectious Diseases

With an established role in cystic fibrosis and bronchiectasis, nebulized antibiotics are increasingly being used to treat respiratory infections in critically ill invasively mechanically ventilated adult patients. Although there is limited evidence describing their efficacy and safety, in an era when there is a need for new strategies to enhance antibiotic effectiveness because of a shortage of new agents and increases in antibiotic resistance, the potential of nebulization of antibiotics to optimize therapy is considered of high interest, particularly in patients infected with multidrug-resistant pathogens. This Position Paper of the European Society of Clinical Microbiology and Infectious Diseases provides recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology regarding the use of nebulized antibiotics in invasively mechanically ventilated adults, based on a systematic review and meta-analysis of the existing literature (last search July 2016). Overall, the panel recommends avoiding the use of nebulized antibiotics in clinical practice, due to a weak level of evidence of their efficacy and the high potential for underestimated risks of adverse events (particularly, respiratory complications). Higher-quality evidence is urgently needed to inform clinical practice. Priorities of future research are detailed in the second part of the Position Paper as guidance for researchers in this field. In particular, the panel identified an urgent need for randomized clinical trials of nebulized antibiotic therapy as part of a substitution approach to treatment of pneumonia due to multidrug-resistant pathogens.

Reliability, Validity and Psychometric Properties of the Greek Translation of the Posttraumatic Stress Disorder Scale

The Greek version of the Davidson Trauma Scale (DTS) was developed to respond to the need of Greek-speaking individuals. The translated questionnaire was administered to 128 HIV outpatients (aged 37.1±9.1) and 166 control patients (aged 32.4±13.4). In addition to the DTS Greek scale, subjects were assessed with two other scales useful for assessing validity. For each factor analyses two components were extracted, based on Cattell’s scree test. The two components solution accounted for 55.34% of the total variation in case of frequency variables and 61.45% in case of severity variables. The Cronbach’s alpha coefficient and Guttman split-half coefficient of the DTS scale were 0.93 and 0.88 respectively. The test-retest reliability of the Greek version of DTS scale proved to be satisfactory. Individual items had good intra-class correlation coefficients higher than 0.5, which means that all questions have high levels of external validity. The psychometric strength of interview for posttraumatic stress disorder-Greek version it’s reliable for its future use, particularly for screening subjects with possible diagnosis of posttraumatic stress disorder.

RELIABILITY, VALIDITY, AND PSYCHOMETRIC PROPERTIES OF THE GREEK TRANSLATION OF THE CAMBRIDGE DEPERSONALIZATION SCALE (CDS)

Introduction:

The Cambridge Depersonalisation Scale is meant to capture the frequency and duration of depersonalisation symptoms over the ‘last 6 months’.

Methods:

In order to develop a Greek version of CDS scale, the CDS scale was translated in Greek by 2 psychiatrists. Then, the Greek version of CDS scale was back-translated by a person who did not knew the original English version. The back-translated version was reviewed in order to establish whether is consistent with the original English version. After this procedure we administered the Greek version of CDS scale to a sample of 294 Greeks in order to assess the reliability and the validity of the Greek version of scale.

Results:

The five components solution accounted for 58.204% of the total variation. Initial eigenvalues of the five components were: factor 1=11.555, factor 2=1.564, factor 3=1.356, factor 4=1.247 and factor 5=1.157. Six items did not load on any factor. Correlations between factors were low ranged from 0.134 to 0.314 and no complex variables were found. Cronbach’s alpha and Guttman split-half coefficient were used to evaluate interval consistency of CDS scale in 294 individuals. The alpha coefficients and Guttman split-half coefficient of the CDS scale were 0.938 and 0.921, respectively. The test-retest reliability proved to be satisfactory. The intraclass correlation coefficients for the total CDS score was very good and equal to 0,883. The CDS scale correlated highly with the SCL-90 and all subscales (p-value<0.0001).

Conclusion:

The psychometric strength of CDS – Greek its reliable for its future use, particularly for screening for subjects with possible diagnosis of CDS.

Aseptic abscess syndrome associated with traveler's diarrhea after a trip to Malaysia

The first, to our knowledge, case of the aseptic abscesses syndrome as a complication of traveler’s diarrhea after a trip to Malaysia is presented. The patient failed to respond to several antimicrobials. The diagnosis was histologically confirmed and the patient only responded to immunomodulatory therapy with corticosteroids and methotrexate. Travel physicians should be aware of this entity reviewed herein in the context of traveler’s diarrhea.

Global survey on nebulization of antimicrobial agents in mechanically ventilated patients: a call for international guidelines

Nebulized antimicrobial agents are increasingly administered for treatment of respiratory infections in mechanically ventilated (MV) patients. A structured online questionnaire assessing the indications, dosages and recent patterns of use for nebulized antimicrobial agents in MV patients was developed. The questionnaire was distributed worldwide and completed by 192 intensive care units. The most common indications for using nebulized antimicrobial agent were ventilator-associated tracheobronchitis (VAT; 58/87), ventilator-associated pneumonia (VAP; 56/87) and management of multidrug-resistant, Gram-negative (67/87) bacilli in the respiratory tract. The most common prescribed nebulized agents were colistin methanesulfonate and sulfate (36/87, 41.3% and 24/87, 27.5%), tobramycin (32/87, 36.7%) and amikacin (23/87, 26.4%). Colistin methanesulfonate, amikacin and tobramycin daily doses for VAP were significantly higher than for VAT (p < 0.05). Combination of parenteral and nebulized antibiotics occurred in 50 (86%) of 58 prescriptions for VAP and 36 (64.2%) of 56 of prescriptions for VAT. The use of nebulized antimicrobial agents in MV patients is common. There is marked heterogeneity in clinical practice, with significantly different in use between patients with VAP and VAT. Randomized controlled clinical trials and international guidance on indications, dosing and antibiotic combinations to improve clinical outcomes are urgently required.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Bloodstream infections in ICU with increased resistance: epidemiology and outcomes

BACKGROUND

Aim of this study was to evaluate the epidemiology and outcomes of hospital-acquired bloodstream infections (HA-BSI) in Greek intensive care units (ICU).

METHODS

Secondary analysis of data from 29 ICU collected during the EUROBACT study, a large prospective, observational, multination survey of HA-BSI. First episodes of HA-BSI acquired in the ICU or within 48 hours prior to admission were recorded.

RESULTS

Gram-negative bacteria predominated namely Acinetobacter sp, Klebsiella sp, Pseudomonas sp (73.3% of monomicrobial infections) followed by Gram-positive cocci (18.3%); fungi (7.6%) and anaerobes (0.8%). Overall 73.3% of isolates were multidrug resistant (MDR), 47.1% extensively resistant (XDR) and 1.2% pan-drug resistant (PDR). Carbapenems were the most frequent empirically prescribed antibiotics, while colistin was the most frequently adequate; for both, calculated mean total daily doses were suboptimal. Overall 28-day all-cause mortality was 33.3%. In the multivariate analysis, factors adversely affecting outcome were higher SOFA score at HA-BSI onset (OR 1.19; 95% CI 1.08-1.31, P=0.0006), need for renal supportive therapy (OR 2.75; 95% CI 1.35-5.59, P=0.0053), and for vasopressors/inotropes (OR 2.68; CI 1.18-6.12, P=0.02); adequate empirical treatment had a protective effect (OR 0.48; CI 0.24-0.95, P=0.03).

CONCLUSION

TIMELY administration of adequately dosed treatment regimens and early ICU admission of critically ill patients could help in improving outcomes.

'Prostate Abscess' as the Initial Manifestation of Granulomatosis with Polyangiitis (Wegener's Granulomatosis)

Prostatic involvement in granulomatosis with polyangiitis (GWP), formerly known as Wegener's granulomatosis, is rare, mostly arising in the context of systemic involvement. Prostatic involvement as the first manifestation of this systemic disease is exceptionally rare. We hereby present the case of a 41-year-old male patient who underwent transurethral prostate resection for what was initially diagnosed as suppurative, focally necrotizing prostatitis. Prolonged postoperative fever that did not respond to various treatments, as well as the subsequent appearance of a left pleural effusion, a left upper pulmonary lobe lesion and cutaneous nodules, led to a reevaluation of histological slides which, along with the determination of serum c-ANCA/anti-PR3 antibody levels, established the diagnosis of GWP. Physicians, and especially urologists and infectious diseases specialists, should be aware of this rare association and consider GWP in the event of nonresolving prostatitis, especially when characteristic symptoms from other systems appear.

Rituximab in critically ill patients

Rituximab is a monoclonal chimeric antibody used in the treatment of CD20-positive B-cell malignancies and rheumatoid arthritis. However, it is used in several other off-label indications including acute graft-versus-host disease. We sought to critically examine the role of rituximab in the treatment of acute graft versus host disease (aGVHD) in critically ill patients and the potential associations with infectious complications in transplant recipients.

Impact of a hospital-wide antibiotic restriction policy program on the resistance rates of nosocomial Gram-negative bacteria

BACKGROUND

To evaluate the impact of an antibiotic restriction policy on antibiotic consumption and Gram-negative resistance rates, in an environment of antibiotic overconsumption and increasing resistance rates for nosocomial pathogens.

METHODS

The study was a 'before and after' trial of 18-month duration; the antibiotic restriction policy program was implemented in 1998-2000 and was based on a government program addressed by the Ministry of Health to public hospitals on a national basis. This included prescribing of all newer antibiotics on an order form, auditing of the order forms and consultation with infectious diseases (ID) specialists, dispensing of treatment and prophylaxis guidelines, feedback, and face-to-face education. Antibiotic consumption and Gram-negative resistance rates were recorded before and after the intervention.

RESULTS

Despite the addition of a new 40-bed ID department in the hospital during the 'after' period, the consumption of restricted antibiotics was significantly reduced by 42% (and their cost by 31%). Gram-negative resistance rates for Pseudomonas, Klebsiella, and Enterobacter, serving as index microorganisms for Gram-negative nosocomial pathogens, were significantly reduced during the 'after' period, even against antibiotics for which there was an increase in consumption.

CONCLUSIONS

Multidisciplinary restriction programs can reduce antibiotic consumption and Gram-negative resistance rates in the hospital setting.

Community acquired methicillin resistant Staphylococcus aureus pneumonia: an update for the emergency and intensive care physician

Pneumonia caused by community-acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) among individuals without healthcare-associated (HA) risk factors was first recognized a decade ago. CA-MRSA has now been established as a pathogen responsible for rapidly progressive, frequently fatal disease manifesting as necrotizing pneumonia, severe sepsis and necrotizing fasciitis. The frequency of occurrence, risk factors, and optimal treatment of CA-MRSA pneumonia remain unclear and vary significantly across countries. CA-MRSA is resistant to β-lactam antimicrobials due to the acquisition of novel methicillin resistance genetic cassettes. Additionally many CA-MRSA strains produce Panton-Valentine leukocidin (PVL), due to which they probably exceed the virulence of hospital-acquired MRSA isolates (HA-MRSA). CA-MRSA pneumonia requires early suspicion -especially in young otherwise healthy individuals with rapidly evolving clinical picture presenting with cavitary consolidation, bilateral infiltrates, pleural effusion and hemoptysis. Prompt hospitalization and aggressive treatment with intravenous antibiotics is warranted to improve outcomes. Therapeutic approach for severe CA-MRSA infections and particularly pneumonia is generally the same as that for invasive HA-MRSA infections. New anti-MRSA agents and possible combinations are of great importance to be evaluated in the future.

Prevalence of 16S rRNA methylase genes in Enterobacteriaceae isolates from a Greek university hospital

16S ribosomal RNA methylase-mediated high-level resistance to 4-,6-aminoglycosides has been reported in clinical isolates of gram-negative bacilli from several countries. Three of 1534 (0.2%) isolates of Klebsiella pneumoniae and three of 734 (0.4%) Proteus mirabilis isolates from a university hospital in Athens, Greece, were positive for rmtB and highly resistant to all aminoglycosides tested (MICs ≥256 mg/L). Two of the K. pneumoniae rmtB-bearing isolates, were KPC-2 and OXA-10 producers and the third was a DHA-1 producer. One of the P. mirabilis isolates was a VIM-1 and OXA-10 producer and one was an OXA-10 producer. All rmtB-harbouring isolates were clonally unrelated. None of the E. coli (n = 1398) and Enterobacter spp. (n = 414) isolates were positive for armA, rmtA, rmtB, rmtC or rmtD.

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.

First influenza season after the 2009 pandemic influenza: characteristics of intensive care unit admissions in adults and children in Vall d'Hebron Hospital

To assess potential differences in epidemiology and management of patients admitted with influenza infection in the intensive care unit (ICU) during the first post-pandemic influenza period. Observational prospective study comparing September 2009-January 2010 with September 2010-January 2011. Variables captured: demographics, co-morbidities, physiological parameters, outcomes and management. Analysis was performed using SPSS v. 13.0; significance was set at p 0.5. Data from 53 patients, 38 adults (age, median 41.5 years; interquartile range (IQR) 32.8-51.3) and 15 children (age, median 2 years, IQR 0.5-9) are presented. Vaccination rates were 0% and 4.3% during the first and second periods, respectively. Differences postpandemic were: 100% of episodes developed after December compared with 16.7% in the 2009 season. Younger children were affected (median age 0.8 years (IQR 0.3-4.8) vs 7 years (IQR 1.25-11.5), p 0.05) and influenza B caused 8.7% of ICU admissions. Influenza A (H1N1) 2009 and respiratory syncytial virus epidemics occurred simultaneously (42.8% of children) and bacterial co-infections doubled (from 10% to 21.7%); the prevalence of co-infections (viral or bacterial) increased from 10% to 39.1% (OR 5.8, 95% CI 1.3-24.8). Respiratory syndromes without chest X-ray opacities reflecting exacerbation of asthma or chronic obstructive pulmonary disease, bronchitis or bronchiolitis increased (from 6.9% to 39.1%, p<0.05) and pneumonia decreased (from 83.3% to 56.5%, p <0.05). Primary viral pneumonia predominated among ICU admissions. Postpandemic ICU influenza developed later, with some cases of influenza B, more frequent bacterial and viral co-infections and more patients with severe acute respiratory infection with normal chest X-ray. Increasing vaccination rates among risk-group individuals is warranted to prevent ICU admission and death.

Microcirculatory vascular dysfunction in HIV-1 infected patients receiving highly active antiretroviral therapy

OBJECTIVES

We investigated whether HIV-1 infected patients receiving highly active antiretroviral therapy (HAART) and HIV-1 infected patients who had never received HAART had differences in their vascular microcirculatory function.

METHODS

We assessed the forearm blood flow before and after four minutes of ischemic occlusion of the brachial artery using venous occlusion strain gauge plethysmography. The hyperaemic forearm blood flow was recorded for three minutes at 15 second intervals. We calculated the maximal percent increase of the forearm blood flow during hyperemia. Forty HIV-infected male patients receiving HAART were compared to 20 age- and BMI- matched, male HIV-infected patients who had never received HAART (control group).

RESULTS

Patients on HAART had similar baseline forearm blood flow but lower maximal and percentage (%) change in forearm blood flow than control patients (4.2 +/- 1.7 vs. 4.1 +/- 1.7 l/ 100mL/min P = 0.8, 32 +/- 11.2 vs. 38.9 +/- 10.5 l/100 mL/min. P = 0.04 and 714 +/- 255 vs. 907 +/- 325%, P = 0.01, respectively). Patients receiving HAART had higher cholesterol than control patients (221 +/- 58 vs. 163 +/- 38 mg/dL, P = 0.001). HAART was associated with the percentage change in the blood flow during hyperemia (coefficient regression B = -0.32, P = 0.02) after adjustment for age, cholesterol and viral load.

CONCLUSIONS

HIV-infected patients receiving HAART present abnormalities of arterial microcirculation in comparison with never-treated patients.

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.

Association of highly active antiretroviral therapy with increased arterial stiffness in patients infected with human immunodeficiency virus

BACKGROUND

Metabolic disorders associated with atherosclerosis and cardiovascular disease have been described in "HIV-infected" individuals. We investigated (i) whether normotensive "HIV-infected" individuals and hypertensive patients have similarities regarding their arterial elastic properties and (ii) the effect of highly active antiretroviral therapy (HAART) and metabolic factors on arterial stiffness.

METHODS

In a case-control study, we compared measurements of pulse wave velocity (PWV), arterial blood pressure, and markers of metabolic profile in 56 normotensive, "HIV-infected" patients (mean age 40 +/- 13 years) to 28 age- and sex-matched newly diagnosed untreated patients with hypertension and 28 healthy individuals.

RESULTS

"HIV-infected" patients had higher PWV than healthy controls but lower PWV than hypertensives (8.1 +/- 1.4 m/s vs. 6.7 +/- 1.1 m/s vs. 9.0 +/- 1.0 m/s, P = 0.003 and 0.01, respectively). However, patients on HAART had similar PWV with hypertensives (8.4 +/- 1.4 vs. 9.0 +/- 1.0 m/s P = 0.25). Patients on HAART had higher PWV than patients without (8.4 +/- 1.4 m/s vs. 7.5 +/- 1.3 m/s, P = 0.03). Patients on HAART had higher total cholesterol, triglycerides, and diastolic blood pressure than patients naive to HAART (P < 0.05). In multivariate analysis, the independent determinants of increased PWV were HAART duration (unstandardized coefficient b v = 0.007, P = 0.04), serum cholesterol (b = 0.007, P = 0.04), mean or diastolic blood pressure (b = 0.049 and b = 0.060, P < 0.01).

CONCLUSIONS

"HIV-infected" individuals have increased arterial stiffness compared to healthy controls. Patients on antiretroviral therapy have similarities regarding their arterial elastic properties with patients with untreated hypertension. There is an independent association between duration of antiretroviral therapy, cholesterol levels, and blood pressure with increased arterial stiffness in "HIV-infected" patients.

Nationwide surveillance of Streptococcus pneumoniae in Greece: patterns of resistance and serotype epidemiology

This nationwide study assessed the antimicrobial susceptibility and seroprevalence of Streptococcus pneumoniae in paediatric carriage isolates and in clinical isolates from adult pneumococcal disease in Greece during the years 2004-2006. Among 780 isolates recovered from the nasopharynx of children <6 years old attending day-care centres, non-susceptibility rates to penicillin, cefuroxime, ceftriaxone, erythromycin, tetracycline and trimethoprim/sulfamethoxazole were 34.7%, 25.1%, 1.0%, 33.5%, 26.4% and 44.2%, respectively. Among 89 adult clinical isolates, the respective rates were 48.3%, 46.1%, 5.6%, 48.3%, 32.6% and 40.4%. High-level resistance to penicillin, cefuroxime and ceftriaxone was recorded for 14.4%, 23.3% and 0.1% of paediatric carriage isolates, whereas for clinical adult isolates the respective rates were 25.8%, 38.2% and 2.2%. No resistance to levofloxacin and moxifloxacin was recorded, although 3.5% of paediatric carriage isolates and 23.2% of adult clinical isolates had minimum inhibitory concentrations of ciprofloxacin >2mg/L. Serotypes 19F, 14, 23F and 6B were the most prevalent among carriage and clinical isolates. The 7-valent pneumococcal conjugate vaccine was estimated to provide coverage against 71.7% of paediatric carriage isolates and 51.3% of adult clinical isolates. Resistance rates among clinical isolates from adult sources were higher than those recorded among paediatric carriage S. pneumoniae isolates and displayed an increasingly resistant profile compared with previous reports from our country, warranting continuous vigilance.

Efficacy and safety of an anti-retroviral combination regimen including either efavirenz or lopinavir–ritonavir with a backbone of two nucleoside reverse transcriptase inhibitors

The efficacy and safety of a combination regimen including either efavirenz or lopinavir-ritonavir was examined in a cohort of 65 patients positive for human immunodeficiency virus-1 (HIV-1). Both the efavirenz (n = 33, 18 anti-retroviral naive) and lopinavir-ritonavir (n = 32, 15 naive) regimens achieved significant changes from baseline CD4 cell counts and HIV RNA levels after 108 weeks (p < 0.01). Despite diminished immunological and virological parameters at study entry, the lopinavir-ritonavir group showed greater virological effects than the efavirenz group after 108 weeks (median change 3.3 log(10), interquartile range (IQR) 2.2-3.8 log(10) vs. 2.4 log(10), IQR 0.9-3.3 log(10), respectively, p 0.004). Use of lopinavir-ritonavir, in contrast to use of efavirenz, was associated with significant hypertriglyceridaemia.

Prevalence of resistance-associated mutations in newly diagnosed HIV-1 patients in Greece

The prevalence of HIV-1 drug resistance mutations in naïve patients has been previously shown to differ greatly with the geographic origin. The purpose of this study was to prospectively estimate the prevalence of HIV-1 drug resistance in Greece by analyzing a representative sample of newly HIV-1 diagnosed patients, as part of the SPREAD collaborative study. Protease (PR) and partial reverse transcriptase (RT) sequences were determined from 101 newly diagnosed HIV-1 patients, in Greece, during the period September 2002--August 2003, representing one-third of the total newly diagnosed HIV-1 patients in the same time period. The prevalence of HIV-1 drug resistance was estimated according to the IAS-USA mutation table taking into account all mutations in RT and only major mutations in PR region. The overall prevalence of resistance was 9% [95% confidence interval (CI): 4.2--16.2%]. The prevalence of mutations associated with resistance to NRTIs was 5% (95% CI: 1.6--11.2%), for NNRTIs was 4% (95% CI: 1.1--9.8%), while no major resistance mutations were found in PR. No multi-class resistance was detected in the study population. The prevalence of resistant mutations in the recent seroconverters was 22%. For two individuals, there was clear evidence for transmitted resistance based on epidemiological information for a known source of HIV-1 transmission. The prevalence of the HIV-1 non-B subtypes and recombinants was 52%.

Assessment of Procalcitonin as a Diagnostic Marker of Underlying Infection in Patients with Febrile Neutropenia

The novel inflammatory marker procalcitonin (PCT) was assessed as an index of infection in patients with febrile neutropenia. Blood samples were obtained from 115 patients with febrile neutropenia for determination of PCT levels before onset of fever and daily until the resolution of fever. The median PCT level on the first day of fever was 8.23 ng/mL in patients with bacteremia, compared with 0.86 ng/mL in patients with localized bacterial infections (P=.017). The median PCT level on the first day of fever was 2.62 ng/mL in patients with severe sepsis, compared with 0.57 ng/mL in patients with clinically localized infections (P<.001). A dramatic decrease in PCT levels was documented after resolution of the infection; PCT levels were elevated when the infection worsened. Pronounced PCT levels were also found in patients with fever of unknown origin who were responding to antimicrobial chemotherapy, compared with those not responding to treatment with antibiotics. PCT levels were particularly elevated in patients with bacteremia and severe sepsis. These findings provide new insight into the application of PCT in clinical trials as a diagnostic tool of the severity of an infection in patients with febrile neutropenia and of the need to change antimicrobial regimen.