An NDM-Producing Escherichia coli Clinical Isolate Exhibiting Resistance to Cefiderocol and the Combination of Ceftazidime-Avibactam and Aztreonam: Another Step Toward Pan-β-Lactam Resistance

Background

Cefiderocol and ceftazidime-avibactam plus aztreonam (CZA-ATM) are preferred treatment regimens for New Delhi metallo-β-lactamase (NDM)-producing infections.

Methods

We report the case of a US patient who traveled to India to receive a renal transplant. He subsequently experienced pyelonephritis by an NDM-producing Escherichia coli. Broth microdilution and the broth disk elution method indicated resistance to all β-lactams, including cefiderocol and CZA-ATM. Whole-genome sequencing investigations were undertaken to identify resistance mechanisms.

Results

An E. coli isolate belonging to sequence type (ST) 167 containing a bla_NDM-5 gene was identified on a plasmid of the IncFIA/IncFIB/IncFIC replicon groups. When compared with the genome of another ST167 E. coli clinical isolate containing bla_NDM-5 and exhibiting susceptibility to cefiderocol and CZA-ATM, a 12-base pair insertion in ftsI, translating to a 4-amino acid duplication in PBP3, was identified. Moreover, a bla_CMY-59 gene was harbored on an IncI-γ replicon type, and frameshift mutations were identified in the cirA iron transport gene.

Conclusions

This is the first clinical case of a US patient harboring an NDM-producing isolate exhibiting resistance to all available β-lactam agents. The isolate's unexpected resistance to cefiderocol and CZA-ATM was likely due to a combination of (1) a modified PBP3 (increased MICs to both regimens), (2) truncated iron-binding protein (increased cefiderocol MIC), and (3) a bla_CMY gene (reduced CZA-ATM activity). E. coli ST167 clinical isolates harboring bla_NDM-5 genes are a recognized international high-risk clone. When coupled with the additional mechanisms identified in our patient's isolate, which is not uncommon for this high-risk clone, pan-β-lactam resistance may occur.

Congenital Hydrocephalus and Associated Risk Factors: An Institution-Based Case–Control Study, Dessie Town, North East Ethiopia

Introduction

Congenital hydrocephalus is one of the commonest congenital anomalies of the central nervous system. It is characterized by extensive accumulation of cerebrospinal fluid within the ventricles of the brain due to an imbalance between synthesis and absorption of cerebrospinal fluid. This study was planned to investigate the incidence and associated risk factors of congenital hydrocephalus.

Methods

Unmatched case–control study was conducted in 34 (cases) and 104 (controls) pregnant women. Maternal data were collected from a structured questionnaire, and fetal-related data were recorded from obstetric ultrasound. Epi-info 7 and SPSS version 24 were used for data entry and analysis, respectively. The association between congenital hydrocephalus and risk factors was evaluated using binary logistic regression.

Results

The incidence of congenital hydrocephalus was 2.67 per 1000 pregnancies. The result of multivariate logistic regression indicated that alcohol use and iron with folic acid supplementation during pregnancy were significantly associated with the development of congenital hydrocephalus (OR: 7.64, 95% CI: 1.97–29.66 and p-value: 0.003 and OR: 0.186, 95% CI: 0.07–0.49 and p-value: 0.001, respectively). Maternal exposure to typhus and typhoid and use of antibiotics during early pregnancy were also significantly associated with congenital hydrocephalus. Moreover, significant association was also observed between the simultaneous development of spina bifida and congenital hydrocephalus (p-value 0.03).

Conclusion

In conclusion, alcohol consumption, unprescribed use of antibiotics and infection during pregnancy as well as absence of folic acid supplementation may predispose to congenital hydrocephalus.

Evaluation of Stress and Associated Biochemical Changes in Patients with Type 2 Diabetes Mellitus and Obesity

PURPOSE

Type 2 diabetes mellitus (T2DM), a metabolic disorder, remains associated with a physiological impairment affecting large populations worldwide. Onset of T2DM is multifactorial where obesity and abnormal basal metabolic rate are considered most critical. Of people diagnosed with T2DM, about 80% are also obese. It is also reported that obese individuals have an increased odds of developing depression, whereas T2DM is estimated to increase the incidence by two-fold. The preponderance of research data demonstrates that T2DM alters the serum level of cortisol and adiponectin which are known to be associated with neuronal physiology. The study explored, how a metabolic disorder like T2DM is linked with the altered plasma level of cortisol and adiponectin, the risk factors for stress and depression.

PATIENTS AND METHODS

A cross-sectional population study was conducted in T2DM patients using a bimodal approach. First approach used questionnaires, (1) Patient Health Questionnaire (PHQ-9) and (2) Stress Coping Inventory Questionnaire (SCQ) to assess signs and symptoms of depression and stress, respectively, in T2DM patients. In the second approach, robust biochemical analysis was conducted for serum adiponectin and cortisol levels.

RESULTS

An association of T2DM in stress and depression was evaluated in 158 subjects (105 T2DM obese patients and 53 healthy controls). A lower PHQ-9 score and adiponectin levels were seen in T2DM obese patients compared to healthy controls (p<0.05). Further, results also depicted a lower adiponectin levels in T2DM obese patients with depression compared to T2DM obese patients without depression (p<0.05). The study did not find a significant difference in cortisol serum levels among the T2DM and control groups. However, a higher level of serum cortisol was reported in T2DM obese patients with depression over those T2DM obese patients who lacked depression (p<0.05).

CONCLUSION

The findings suggest that T2DM obese patients might have a higher risk of developing stress and depression. Further, biochemical parameters, adiponectin and cortisol, might be the potential biomarkers for T2DM and may help in early diagnosis of these comorbid conditions.