Risk factors and outcomes of cytomegalovirus infection in the intensive care unit

INTRODUCTION

Cytomegalovirus (CMV) infection has long been recognized as an important viral syndrome in the immunocompromised host. The disease is less well described in critically-ill patients. We evaluated the risk factors for the development of CMV infection in patients admitted to the intensive care unit (ICU). We also compared the outcomes of CMV infection in ICU patients to those of patients with hematological malignancies.

METHODOLOGY

This is a retrospective study composed of three arms: patients admitted to the ICU with infection (ICU + / CMV + arm), patients admitted to the ICU who did not develop CMV infection (ICU + / CMV- arm, and patients with hematological malignancies on the hematology ward without CMV infection (ICU - / CMV + arm).

RESULTS

Patients who were admitted to ICU for surgical causes had a decreased risk of CMV infection. On the other hand, receiving corticosteroids and vasoactive drugs was associated with an increased risk of CMV infection with adjusted odds ratios (aOR) of 2.4 and 25.3, respectively. Mortality was higher in ICU + / CMV + patients compared to ICU - / CMV + patients. In the ICU + /CMV + population, male sex and being on mechanical ventilation after CMV infection were independent predictors of mortality (aOR 4.6 and 5.0, respectively).

CONCLUSIONS

CMV infection in ICU patients is a potentially serious disease requiring close attention. The findings from our study help in identifying patients in the ICU at risk for CMV infection, thereby warranting frequent screening. Patients at high risk of death (male, on mechanical ventilation) should receive prompt treatment and intensive follow-up.

Molecular Characteristics of Colistin Resistance in Acinetobacter baumannii and the Activity of Antimicrobial Combination Therapy in a Tertiary Care Medical Center in Lebanon

(1) Background: Infections with pan-drug-resistant (PDR) bacteria, such as A. baumannii, are becoming increasingly common, especially in healthcare facilities. In this study, we selected 15 colistin-resistant clinical A. baumannii isolates from a hospital in Beirut, Lebanon, to test combination therapies and determine their sequence types (STs) and the mechanism of colistin resistance using whole-genome sequencing (WGS). (2) Methods: Antimicrobial susceptibility testing via broth microdilution against 12 antimicrobials from different classes and growth rate assays were performed. A checkerboard assay was conducted on PDR isolates using six different antimicrobials, each in combination with colistin. Genomic DNA was extracted from all isolates and subjected to WGS. (3) Results: All isolates were resistant to all tested antimicrobials with the one exception that was susceptible to gentamicin. Combining colistin with either meropenem, ceftolozane-tazobactam, or teicoplanin showed synergistic activity. Sequencing data revealed that 67% of the isolates belonged to Pasteur ST2 and 33% to ST187. Furthermore, these isolates harbored a number of resistance genes, including blaOXA-23. Mutations in the pmrC gene were behind colistin resistance. (4) Conclusions: With the rise in antimicrobial resistance and the absence of novel antimicrobial production, alternative treatments must be found. The combination therapy results from this study suggest treatment options for PDR ST2 A. baumannii-infected patients.

Molecular characterization and differential effects of levofloxacin and ciprofloxacin on the potential for developing quinolone resistance among clinical Pseudomonas aeruginosa isolates

Background

Fluoroquinolones are some of the most used antimicrobial agents for the treatment of Pseudomonas aeruginosa. This study aimed at exploring the differential activity of ciprofloxacin and levofloxacin on the selection of resistance among P. aeruginosa isolates at our medical center.

Methods

233 P. aeruginosa clinical isolates were included in this study. Antimicrobial susceptibility testing (AST) was done using disk diffusion and broth microdilution assays. Random Amplification of Polymorphic DNA (RAPD) was done to determine the genetic relatedness between the isolates. Induction of resistance against ciprofloxacin and levofloxacin was done on 19 isolates. Fitness cost assay was done on the 38 induced mutants and their parental isolates. Finally, whole genome sequencing was done on 16 induced mutants and their 8 parental isolates.

Results

AST results showed that aztreonam had the highest non-susceptibility. RAPD results identified 18 clusters. The 19 P. aeruginosa isolates that were induced against ciprofloxacin and levofloxacin yielded MICs ranging between 16 and 256 μg/mL. Levofloxacin required fewer passages in 10 isolates and the same number of passages in 9 isolates as compared to ciprofloxacin to reach their breakpoints. Fitness cost results showed that 12 and 10 induced mutants against ciprofloxacin and levofloxacin, respectively, had higher fitness cost when compared to their parental isolates. Whole genome sequencing results showed that resistance to ciprofloxacin and levofloxacin in sequenced mutants were mainly associated with alterations in gyrA, gyrB and parC genes.

Conclusion

Understanding resistance patterns and risk factors associated with infections is crucial to decrease the emerging threat of antimicrobial resistance.

Clinical manifestations, characteristics, and outcome of infections caused by vancomycin-resistant enterococci at a tertiary care center in Lebanon: A case-case-control study

BACKGROUND

Vancomycin-resistant enterococci (VRE) are prevalent infectious agents that particularly affect critically-ill patients, and they are on the rise in Lebanon. We aim at determining the potential risk factors and complications for VRE and vancomycin-susceptible enterococci (VSE) infections in a hospital setting and identify risk factors for in-hospital mortality.

METHODS

A case-case-control study design was used where patients with VRE and VSE were included as two separate groups and each group was compared to uninfected controls. We also constructed binary regression models to detect risk factors that were associated with the acquisition of a VRE or a VSE infection. We also identified independent mortality predictors for all patients with enterococcal infection as well as patients with only a VRE infection.

RESULTS

A total of 142 patients with enterococcal infections (VRE and VSE) were compared to 142 in-patients not infected with Enterococcus spp. independent risk factors for a VRE infection were steroid therapy within 30 days and the presence of another infection preceding the VRE infection (aOR 15.4, 95 % CI 2.4-99.3 and 23.9, 95 % CI 3.9-1482, respectively). An independent risk factor for VSE was diabetes mellitus (aOR 5.4, 95 % CI 1.1-26.6). Based on these risk factors, we developed a risk score to be used in quantifying the risk of VRE in a patient with an enterococcal infection. Male sex and low albumin were significant risk factors for mortality in our patient cohort.

CONCLUSIONS

VRE and VSE infections have distinct risk factors that can be used to guide empiric antimicrobial therapy.

The under investigated facet of the COVID-19 pandemic: Molecular analysis of secondary bacterial infections at a COVID dedicated intensive care unit within a tertiary care center in Lebanon

Background

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Secondary bacterial infections are associated with unfavorable outcomes in respiratory viral infections. This study aimed at determining the prevalence of secondary bacterial infections in COVID-19 patients admitted at a tertiary medical center in Lebanon.

Methodology

From May till November, 2020, a total of 26 Gram-negative isolates were recovered from 16 patients during the course of their COVID-19 infection with Escherichia coli being the most prevalent. The isolates were assessed for their antimicrobial susceptibility by broth microdilution against 19 antimicrobial agents from different classes. Whole genome sequencing of 13 isolates allowed the mining of antimicrobial resistance (AMR) determinants as well as mobile genetic elements and sequence types (ST). Finally, broth microdilution with three different efflux pump inhibitors [theobromine, conessine and PheArg-β-naphthylamide (PAβN)] was done.

Results

Antimicrobial susceptibility testing showed that out of the 26 Gram-negative isolates, 1 (4%) was extensively drug resistant and 14 (54%) were multi-drug resistant (MDR). Whole genome sequencing results revealed a plethora of AMR determinants among the 13 sequenced isolates. Moreover, the 9 Enterobacterales and 4 Pseudomonas aeruginosa sequenced isolates belonged to 9 and 2 different ST, respectively. Using a variety of efflux pump inhibitors we demonstrated that only PAβN had a significant effect when combined with levofloxacin, and the latter regained its activity against two P. aeruginosa isolates.

Conclusion

The identification of carbapenem and colistin resistant Gram-negative bacilli causing secondary bacterial infections in critical patients diagnosed with COVID-19 should be of high concern. Additionally, it is crucial to monitor and track AMR, post-COVID pandemic, in order to better understand the effect of this disease on AMR exacerbation.

Clinical predictors of mortality in patients with pseudomonas aeruginosa infection

BACKGROUND

Infections caused by Pseudomonas aeruginosa are difficult to treat with a significant cost and burden. In Lebanon, P. aeruginosa is one of the most common organisms in ventilator-associated pneumonia (VAP). P. aeruginosa has developed widespread resistance to multiple antimicrobial agents such as fluoroquinolones and carbapenems. We aimed at identifying risk factors associated for P. aeruginosa infections as well as identifying independent risk factors for developing septic shock and in-hospital mortality.

METHODS

We used a cross-sectional study design where we included patients with documented P. aeruginosa cultures who developed an infection after obtaining written consent. Two multivariable regression models were used to determine independent predictors of septic shock and mortality.

RESULTS

During the observed period of 30 months 196 patients were recruited. The most common predisposing factor was antibiotic use for more than 48 hours within 30 days (55%). The prevalence of multi-drug resistant (MDR) P. aeruginosa was 10%. The strongest predictors of mortality were steroid use (aOR = 3.4), respiratory failure (aOR = 7.3), identified respiratory cultures (aOR = 6.0), malignancy (aOR = 9.8), septic shock (aOR = 18.6), and hemodialysis (aOR = 30.9).

CONCLUSION

Understanding resistance patterns and risk factors associated with mortality is crucial to personalize treatment based on risk level and to decrease the emerging threat of antimicrobial resistance.

The role of preoperative albumin and white blood cell count in surgical site infections following whipple surgery

Whipple surgery is associated with a high risk of surgical sites infections (SSIs). Nutritional deficiency has been associated with an increased risk of wound infections. This study aims at exploring the role of preoperative albumin levels in predicting the risk of SSIs following Whipple surgery. A total of 23,808 individuals were identified from the ACS-NSQIP database from years 2011 to 2017. The primary exposure was pre-operative albumin while the secondary exposure was white blood cell (WBC) count. The primary outcome was divided into superficial and deep surgical site infections (S/D SSI) and organ-space SSI. All statistical analyses were conducted using IBM Statistical Package for Social Sciences version 26. Levels of pre-operative serum albumin less than 3.73 g/L, dirty and contaminated wounds and longer operative time were associated with increased odds for developing S/D SSIs (OR = 1.14, OR = 1.17, OR = 1.06, respectively, p-value < 0.05). Pre-operative WBC level (/L) was associated with a risk of developing an organ-space SSI but not S/D SSI (OR = 1.02, p-value  0.003). This study demonstrates the predictive role of pre-operative albumin in developing S/D SSIs and highlights the need to develop therapeutic strategies to optimize the pre-operative nutritional health status of patients undergoing Whipple surgery.

Clinical characteristics and outcome of infective endocarditis due to Abiotrophia and Granulicatella compared to Viridans group streptococci

OBJECTIVE

To describe the clinical characteristics and outcome of Abiotrophia and Granulicatella infective endocarditis and compare them with Viridans group streptococci infective endocarditis.

METHODS

All patients in the International Collaboration on Endocarditis (ICE) - prospective cohort study (PCS) and the ICE-PLUS cohort were included (n=8112). Data from patients with definitive or possible IE due to Abiotrophia species, Granulicatella species and Viridans group streptococci was analyzed. A propensity score (PS) analysis comparing the ABI/GRA-IE and VGS-IE groups according to a 1:2 ratio was performed.

RESULTS

Forty-eight (0.64%) cases of ABI/GRA-IE and 1,292 (17.2%) VGS-IE were included in the analysis. The median age of patients with ABI/GRA-IE was lower than VGS-IE (48.1 years vs. 57.9 years; p=0.001). Clinical features and the rate of in-hospital surgery was similar between ABI/GRA-IE and VGS-IE (52.1% vs. 45.4%; p=0.366). Unadjusted in-hospital death was lower in ABI/GRA-IE than VGS-IE (2.1% vs. 8.8%; p=0.003), and cumulative six-month mortality was lower in ABI/GRA-IE than VGS-IE (2.1% vs. 11.9%; p<0.001). After PS analysis, in-hospital mortality was similar in both groups, but six-month mortality was lower in the ABI/GRA IE group (2.1% vs. 10.4%; p=0.029).

CONCLUSIONS

Patients with ABI/GRA-IE were younger, had similar clinical features and rates of surgery and better prognosis than VGS-IE.

Knowledge, Perception, Attitudes and Behavior on Influenza Immunization and the Determinants of Vaccination

Background: We sought to determine the knowledge of, perception, attitudes, and behaviors toward influenza virus and immunization, and the determinants of vaccination among students, patients, and Healthcare Workers (HCWs) at the American University of Beirut and its affiliated Medical Center.

Methods: We conducted a cross-sectional study between October 2016 and January 2017 utilizing a self-administered questionnaire that was provided to 247 randomly selected adult participants. Data collected included socio-demographic characteristics, prior vaccination against influenza, knowledge, perception, attitudes, and behaviors toward influenza and influenza immunization. A multivariable regression model was used to evaluate for independent associations between the different variables and regular or yearly vaccination as a primary outcome.

Results: The overall survey response rate was 77%. A substantial proportion of respondents (47.4%) had never received the influenza vaccine. Only 10.2% of students, 19.1% of patients, and 35.6% of HCWs reported regular or yearly influenza vaccine uptake. HCWs had the lowest knowledge score about influenza and its vaccine despite high self-reported levels of knowledge. Barriers to vaccinations included lack of information (31%), fear of adverse effects (29%), and a perception of not being at risk (23%). Several factors were independently associated with regular or yearly vaccination uptake including having children (adjusted OR = 3.8; 95% CI 1.2–12.5), a “very good” self-reported level of knowledge (OR = 16.3; 95% CI 1.4–194.2) and being afraid of the consequences of influenza (OR = 0.2; 95% CI 0.1–0.6).

Conclusion: Adherence rates with regular or yearly vaccination against influenza remain low across all study groups. We were able to identify predictors as well as barriers to vaccination. Future awareness and vaccination campaigns should specifically aim at correcting misconceptions about vaccination, particularly among HCWs, along with addressing the barriers to vaccination. Predictors of vaccination should be integrated in the design of future campaigns.

Beta-Hemolytic Streptococcal Infective Endocarditis: Characteristics and Outcomes From a Large, Multinational Cohort

Background

Beta-hemolytic streptococci (BHS) are an uncommon cause of infective endocarditis (IE). The aim of this study was to describe the clinical features and outcomes of patients with BHS IE in a large multinational cohort and compare them with patients with viridans streptococcal IE.

Methods

The International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) is a large multinational database that recruited patients with IE prospectively using a standardized data set. Sixty-four sites in 28 countries reported patients prospectively using a standard case report form developed by ICE collaborators.

Results

Among 1336 definite cases of streptococcal IE, 823 were caused by VGS and 147 by BHS. Patients with BHS IE had a lower prevalence of native valve (P < .005) and congenital heart disease predisposition (P = .002), but higher prevalence of implantable cardiac device predisposition (P < .005). Clinically, they were more likely to present acutely (P < .005) and with fever (P = .024). BHS IE was more likely to be complicated by stroke and other systemic emboli (P < .005). The overall in-hospital mortality of BHS IE was significantly higher than that of VGS IE (P = .001). In univariate analysis, variables associated with in-hospital mortality for BHS IE were age (odds ratio [OR], 1.044; P = .004), prosthetic valve IE (OR, 3.029; P = .022), congestive heart failure (OR, 2.513; P = .034), and stroke (OR, 3.198; P = .009).

Conclusions

BHS IE is characterized by an acute presentation and higher rate of stroke, systemic emboli, and in-hospital mortality than VGS IE. Implantable cardiac devices as a predisposing factor were more often found in BHS IE compared with VGS IE.

Clinical characteristics, risk factors and microbiology of infections in patients receiving chronic hemodialysis

BACKGROUND

The infectious complications in hemodialysis patients are still among the main reasons for their increased morbidity and mortality. The possible reasons behind this might be due to impairments in the host defense mechanisms, comorbidities, invasive procedures and pathogenicity of the infecting organisms. With the increased incidence of bacteremia in hemodialysis patients and the overt use of antibiotics, we have witnessed a rise in the number of new multidrug resistant (MDR) strains in those patients.

AIM

We aim to determine the epidemiology, risk factors and complications of infections in patients receiving chronic hemodialysis, particularly bloodstream infections.

METHODS

This is a retrospective case-control study involving patients undergoing hemodialysis at a tertiary care center. We studied the prevalence of infectious complications among those patients as well as the responsible agent in each respective infectious episode and the risk factors associated with bacteremia.

FINDINGS

46.6% of the studied population had at least one documented episode of infection. The most common were blood and respiratory infections (33.2% and 32.7% respectively). Among patients with bacteremia, coagulase-negative Staphylococcus was the predominant pathogen (49% of cases), followed by Staphylococcus aureus and Escherichia coli. Mortality was higher in patients who had MDR bacteremia, and in those who had mechanical ventilation or intensive care unit (ICU) admission.

CONCLUSION

Due to the alarming increase in the incidence of infection among hemodialysis patients and its strong association with mortality, further studies are needed to look for risk factors associated with infection and for ways to control those risk factors.

Recurrent Campylobacter Bacteremia as the First Manifestation of Hypogammaglobulinemia: a Case Report and Literature Review

A 30-year-old woman with a past medical history of autoimmune hemolytic anemia presented with fever. Blood cultures grew Campylobacter. Her medical history was significant for four prior episodes of Campylobacter gastroenteritis and bacteremia. She received ciprofloxacin for the index presentation, then Meropenem de-escalated to doxycycline 6 months later following recurrence of Campylobacter. This prompted investigation for an immunodeficiency disorder. She was found to have hypogammaglobulinemia. Her Campylobacter infections resolved following the administration of intravenous immunoglobulins every 3 weeks. She did not have recurrence of Campylobacter during 5 years of follow-up. A literature search revealed additional four case reports of six hypogammaglobulinemic adult individuals presenting with recurrent Campylobacter infections. Three patients were already on intravenous immunoglobulin (IVIG) when Campylobacter infection occurred, and two patients achieved clinical cure following therapy with imipenem and IVIG. This case report highlights the importance of suspecting hypogammaglobulinemia in patients with recurrent Campylobacter infections, as this is sometimes the first manifestation of the condition.

Ten-year surveillance study of ventilator-associated pneumonia at a tertiary care center in Lebanon

BACKGROUND

Ventilator-associated pneumonia (VAP) is associated with significant adverse outcomes in critically-ill patients admitted to the Intensive Care Unit (ICU). Systematic data from Lebanon on VAP are not available and large epidemiological studies from the region are scarce.

METHODS

We conducted a retrospective study over a 10-year period at the American University of Beirut Medical Center (AUBMC), a tertiary referral center in Lebanon in order to describe the incidence, microbiology, and temporal trends of VAP in the medical/surgical ICU.

RESULTS

A total of 162 patients developed VAP over the study period and the overall incidence of VAP was 7.9 per 1000 ventilator-days. There was a statistically significant decrease over time in the incidence of VAP, from 13.1 in 2008 to 1.1 per 1000 ventilator-days in 2017. Multidrug-resistant (MDR) Acinetobacter spp. was the predominant pathogen, both in early- as well as late-onset VAP, followed by Pseudomonas aeruginosa.

CONCLUSIONS

Following significant efforts from the Infection Control and Prevention Program, a considerable reduction in the incidence of VAP was achieved at AUBMC. The predominance of MDR Acinetobacter spp. should be taken into consideration when deciding on empirical therapy in patients with VAP.

Epidemiology of common resistant bacterial pathogens in the countries of the Arab League

No uniformly organised collection of data regarding antimicrobial resistance has occurred in the countries of the Arab League. 19 countries of the Arab League have published data for antimicrobial susceptibility for the WHO priority organisms, and seven of 14 of these organisms are included in this Review (Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, Acinetobacter baumannii, Salmonella spp, Staphylococcus aureus, and Streptococcus pneumoniae). Although E coli and Klebsiella spp resistance to third-generation cephalosporins is common in all countries, with prevalence reaching more than 50% in Egypt and Syria, carbapenem resistance is emerging, albeit with a prevalence of less than 10%. Conversely, a large amount of carbapenem resistance has been reported for P aeruginosa and A baumannii across the Arab League, reaching 50% and 88% of isolates in some countries. As for Salmonella spp, the prevalence of fluoroquinolone resistance has exceeded 30% in several areas. With regards to the Gram-positive pathogens, the prevalence of meticillin resistance in S aureus is reported to be between 20% and 30% in most countries, but exceeds 60% in Egypt and Iraq. The prevalence of penicillin non-susceptibility among pneumococci has reached more than 20% in Algeria, Egypt, Morocco, Saudi Arabia, and Tunisia. These findings highlight the need for structured national plans in the region to target infection prevention and antimicrobial stewardship.

Vascular Graft Infections: An update

Vascular graft infection is a devastating complication of vascular reconstructive surgery. The infection can occur early in the postoperative period and is largely due to intraoperative contamination or by contiguous extension from a nearby infection. It can also occur years after implantation. Staphylococci remain the most common organisms and biofilm production makes eradication difficult. Factors commonly reported to predispose to vascular graft infection are periodontal disease, nasal colonization with Staphylococcus aureus, bacteremia, certain graft characteristics, diabetes mellitus, postoperative hyperglycemia, location of the incision, wound infection, and emergency procedure. Management consists of antibiotic and surgical therapy. Preventive methods are described.

Increased blaOXA-23-like prevalence in Acinetobacter baumannii at a tertiary care center in Lebanon (2007-2013)

Introduction: Acinetobacter baumannii has become one of the most feared organisms in hospital-acquired infections during the past decades. Their multi-drug resistant profiles have rendered many broad-spectrum antibiotics ineffective. The purpose of this retrospective study is to describe and compare molecular characteristics of A. baumannii isolated from patients at a tertiary care center in Lebanon from two outbreaks, the first in 2007-2008 as part of a case-controlled study involving Acinetobacter baumannii cases admitted to the ICU and the second in 2013. Methodology: A total of 148 A. baumannii clinical isolates were collected from various clinical specimens during 2007-2008 and 2013. All A. baumannii isolates were subjected to PCR amplification of blaOXA-23-like and blaOXA-51-like genes of carbapenem resistance. Random amplification of polymorphic DNA (RAPD) was also performed to assess their genomic relatedness. Results: There was an increase in the prevalence of blaOXA-23-like and blaOXA-51-like between the two time periods; however, only with 22% genomic relatedness between 2007-2008 and 2013 isolates. Taking 80% as margin of compatibility, 31 distinct clusters containing 2 to 11 strains were observed in both time periods. Conclusion: The presence of numerous clusters accompanied by a predominant increase in the prevalence of blaOXA-23-like gene between 2007 and 2013 suggests a horizontal transmission of the gene within various strains of the species, constituting a primary factor in the continued increase of carbapenem resistance over the years. As such, infection control measures ought to be taken with the highest priority and compliance among all involved healthcare workers is of utmost importance.

Emergence of Mycobacterium simiae: A retrospective study from a tertiary care center in Lebanon

Objective

The objective of this study is to describe the clinical significance of Mycobacterium simiae at a major tertiary care center in Lebanon.

Methods

This is a retrospective study of patients with positive cultures for M. simiae isolated between 2004 and 2016 at the American University of Beirut Medical Center.

Results

This study included 103 M. simiae isolates recovered from 51 patients. Their mean age was 62.7 years. The majority were males and smokers. Specimens were mostly from respiratory sources (97%). Common comorbidities included chronic lung disease (such as chronic obstructive pulmonary disease), solid tumor, systemic disease, and diabetes mellitus. Productive cough and dyspnea were the most common symptoms. Frequent radiographic findings were infiltrates and nodules on chest X-ray and nodules, infiltrates, and bronchiectasis on chest computed tomography scan. Among 18 tested isolates, 5.8% were resistant to clarithromycin, 11.7% to amikacin, and 70–100% to other antimicrobials. Out of 13 patients receiving early treatment, 5 noted improvement, one had recurrence of symptoms, two received alternative diagnosis, and five died. Two of those deaths were related to M. simiae. Common treatment regimens included clarithromycin in different combinations with trimethoprim-sulfamethoxazole, moxifloxacin, and amikacin. Moreover, clofazimine was used in only two patients whose isolates were resistant to all but one agent. Duration of treatment ranged from 6–24 months.

Conclusion

In Lebanon, M. simiae is increasingly encountered with true infection rates of at least 47%. Furthermore, the prevalence of multidrug resistance among the Lebanese M. simiae isolates is very high limiting the treatment options.

Increase of blaOXA-23-like in Acinetobacter baumannii at a tertiary care center in Lebanon between 2007 and 2013

INTRODUCTION

The multi-drug resistant nature of Acinetobacter baumannii isolates have rendered many broad-spectrum antimicrobial agents ineffective against them. The purpose of this retrospective study is to define and compare the molecular characteristics of A. baumannii isolates from patients at a tertiary care center in Lebanon from two outbreaks, the first in 2007-2008, as part of a case-controlled study involving A. baumannii cases admitted to the ICU, and the second in 2013.

METHODOLOGY

A total of 148 A. baumannii clinical isolates were collected from various clinical specimens during 2007-2008 and 2013. All A. baumannii isolates were screened for blaOXA-23-like and blaOXA-51-like genes of carbapenem resistance. Additionally, in an effort to assess the degree of the isolates' genomic relatedness, random amplification of polymorphic DNA (RAPD) was performed.

RESULTS

There was an increase in the prevalence of blaOXA-23-like and blaOXA-51-like genes between the two time periods; however, only 22% isolate genomic relatedness was calculated between 2007-2008 and 2013. Taking 80% as a margin of compatibility, 31 distinct clusters containing 2 to 11 strains were observed when both time periods were analyzed.

CONCLUSION

The presence of numerous clusters accompanied by a predominant increase in the prevalence of blaOXA-23-like between 2007 and 2013 suggests a horizontal transmission of the gene within various strains of the species, contributing to the persistent increase in carbapenem resistance over the years. Therefore, infection control measures are required with compliance among all healthcare workers.

Cutibacterium (formerly Propionibacterium) acnes infections associated with implantable devices

INTRODUCTION

Cutibacterium acnes (C. acnes), a Gram-positive biofilm-forming rod implicated in acne vulgaris, is increasingly recognized for its role in implant-associated infections. The diagnosis of C. acnes implant-associated infections remains challenging. The optimal treatment is a combination of both surgical intervention and antibiotic therapy. Areas covered: In this review, we discuss the different types of implant-associated infections caused by C. acnes. We also highlight the clinical manifestations pertaining to the various sites of infection, and identify several risk factors previously reported in the literature. We then cover the diagnostic laboratory markers, such as IL-6 and AD-1, optimizing C. acnes recovery in culture, and the specific molecular techniques. Finally, we examine the various effective antibiotic regimens and identify some preventive methods against C. acnes infections. Expert commentary: Biomarkers such as IL-6 and AD-1 should be further investigated for the diagnosis of C. acnes implant-associated infections. The use of 16S rRNA gene sequencing and other molecular techniques should be further explored in this setting. Longer incubation periods should be requested whenever C. acnes infection is suspected. If the clinical suspicion is high, sonication of the excised implant should be encouraged. Research should focus on developing effective anti-biofilm agents. Finally, preventive methods such as hair removal prior to surgery should be further explored.

Extended infusion of beta-lactam antibiotics: optimizing therapy in critically-ill patients in the era of antimicrobial resistance

INTRODUCTION

Beta-lactams are at the cornerstone of therapy in critical care settings, but their clinical efficacy is challenged by the rise in bacterial resistance. Infections with multi-drug resistant organisms are frequent in intensive care units, posing significant therapeutic challenges. The problem is compounded by a dearth in the development of new antibiotics. In addition, critically-ill patients have unique physiologic characteristics that alter the drugs pharmacokinetics and pharmacodynamics. Areas covered: The prolonged infusion of antibiotics (extended infusion [EI] and continuous infusion [CI]) has been the focus of research in the last decade. As beta-lactams have time-dependent killing characteristics that are altered in critically-ill patients, prolonged infusion is an attractive approach to maximize their drug delivery and efficacy. Several studies have compared traditional dosing to EI/CI of beta-lactams with regard to clinical efficacy. Clinical data are primarily composed of retrospective studies and some randomized controlled trials. Several reports show promising results. Expert commentary: Reviewing the currently available evidence, we conclude that EI/CI is probably beneficial in the treatment of critically-ill patients in whom an organism has been identified, particularly those with respiratory infections. Further studies are needed to evaluate the efficacy of EI/CI in the management of infections with resistant organisms.

Sites of colonization in hospitalized patients with infections caused by extended-spectrum beta-lactamase organisms: a prospective cohort study

Background

The objective of this study was to determine whether patients infected with extended-spectrum beta-lactamase (ESBL)-producing organisms are colonized at multiple body sites.

Methods

This was a prospective cohort study at a tertiary care center in Beirut, Lebanon. Hospitalized patients with infections caused by ESBL-producing organisms were included. Cultures were obtained from the primary site of infection as well as from other sites (skin, nasopharynx, urine, rectum). Molecular analysis was performed on isolates to determine clonal relatedness.

Results

One hundred patients were included in the study. Only 22 patients had positive cultures from sites other than the primary site of infection. The most common ESBL gene was CTX-M-15 followed by TEM-1. In 11 of 22 patients, isolates collected from the same patient were 100% genetically related, while in the remaining patients, genomic relatedness ranged from 42.9% to 97.1%.

Conclusions

Colonization at sites other than the primary site of infection was not common among our patient population infected with ESBL-producing organisms. The dynamics of transmission of these bacterial strains should be studied in further prospective studies to determine the value of routine active surveillance and the need for expanded precautions in infected and colonized patients.

Influence of vancomycin minimum inhibitory concentration on the outcome of methicillin-susceptible Staphylococcus aureus left-sided infective endocarditis treated with antistaphylococcal β-lactam antibiotics: a prospective cohort study by the International Collaboration on Endocarditis

OBJECTIVES

Left-sided methicillin-susceptible Staphylococcus aureus (MSSA) endocarditis treated with cloxacillin has a poorer prognosis when the vancomycin minimum inhibitory concentration (MIC) is ≥1.5 mg/L. We aimed to validate this using the International Collaboration on Endocarditis cohort and to analyse whether specific genetic characteristics were associated with a high vancomycin MIC (≥1.5 mg/L) phenotype.

METHODS

All patients with left-sided MSSA infective endocarditis treated with antistaphylococcal β-lactam antibiotics between 2000 and 2006 with available isolates were included. Vancomycin MIC was determined by Etest as either high (≥1.5 mg/L) or low (<1.5 mg/L). Isolates underwent spa typing to infer clonal complexes and multiplex PCR for identifying virulence genes. Univariate analysis was performed to evaluate the association between in-hospital and 1-year mortality, and vancomycin MIC phenotype.

RESULTS

Sixty-two cases met the inclusion criteria. Vancomycin MIC was low in 28 cases (45%) and high in 34 cases (55%). No significant differences in patient demographic data or characteristics of infection were observed between patients with infective endocarditis due to high and low vancomycin MIC isolates. Isolates with high and low vancomycin MIC had similar distributions of virulence genes and clonal lineages. In-hospital and 1-year mortality did not differ significantly between the two groups (32% (9/28) vs. 27% (9/34), p 0.780; and 43% (12/28) vs. 29% (10/34), p 0.298, for low and high vancomycin MIC respectively).

CONCLUSIONS

In this international cohort of patients with left-sided MSSA endocarditis treated with antistaphylococcal β-lactams, vancomycin MIC phenotype was not associated with patient demographics, clinical outcome or virulence gene repertoire.

HACEK endocarditis: a review

INTRODUCTION

The HACEK group, referring to Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae, is a rare cause of infective endocarditis (IE). It causes the majority of Gram-negative endocarditis cases and has an excellent prognosis and simple management if properly identified. However, delay in diagnosis and associated complications can render the infection fatal.

AREAS COVERED

Over the past few decades, there have been tremendous advancements in understanding the manifestations and progression of HACEK endocarditis (HE). This review tackles the epidemiology of HE, the microbiological characteristics of each organism in the HACEK group, the methods used to diagnose HE, the clinical manifestations, complications, and mortality of patients with HE, as well as the recommended treatment and preventive methods. Expert Commentary: The lack of robust randomized controlled trials in diagnosis and treatment of HE makes it difficult to determine the optimal management of such infections. Nevertheless, advancements in culturing methods have shown progress in isolating and identifying these fastidious organisms. Positive blood cultures for any of the HACEK organisms in the setting of no definite focus of infection is highly suggestive of HE. In such cases, treatment with ceftriaxone or a fluoroquinolone, even without obtaining antibiotic susceptibilities, should be initiated. Moreover, the decision to proceed with surgical intervention should be individualized. As is the case for other IE, HE requires the collaboration of a multidisciplinary team consisting of the infectious disease specialist, cardiologist, cardiothoracic surgeon, and the microbiologist.

Increased in vitro phenol-soluble modulin production is associated with soft tissue infection source in clinical isolates of methicillin-susceptible Staphylococcus aureus

BACKGROUND

Phenol-soluble modulins (PSM) are amphipathic proteins produced by Staphylococcus aureus that promote virulence, inflammatory response, and biofilm formation. We previously showed that MRSA isolates from soft tissue infection (SSTI) produced significantly higher levels of PSM than MRSA isolates from hospital-acquired pneumonia (HAP) or infective endocarditis (IE). In this investigation, we sought to validate this finding in methicillin-susceptible S. aureus (MSSA) isolates.

METHODS

MSSA isolates (n = 162) from patients with SSTI, HAP, and IE were matched 1:1:1 based on geographic origin of the infection to form 54 triplets (North America n = 27, Europe n = 25, Australia n = 2). All isolates underwent spa typing and were classified using eGenomics. In vitro PSM production was quantified by high-performance liquid chromatography/mass spectrometry. Fischer's Exact Test and the Kruskal-Wallis test were used for statistical analysis.

RESULTS

Spa1 was more common in SSTI (14.81% SSTI, 3.70% HAP, 1.85% IE) (p < 0.03). Spa2 was more common in HAP (0% SSTI, 12.96% HAP, 3.70% IE) (p < 0.01). Levels of PSMα1-4 all differed significantly among the three clinical groups, with SSTI isolates producing the highest levels and IE producing the lowest levels of PSMα1-4. Spa1 isolates produced significantly more delta-toxin (p < 0.03) than non-Spa1 isolates. No associations between PSM levels and clinical outcome of SSTI, HAP, or IE were identified.

CONCLUSION

Production of PSMα1-4 is highest in SSTI MSSA isolates, supporting the hypothesis that these peptides are important for SSTI pathogenesis. These findings are similar to those described in MRSA, and demonstrate that associations between PSM levels and type of infection are independent of the methicillin-resistance status of the isolate.

Telavancin (VIBATIV) for the treatment of complicated skin and skin structure infections

Methicillin-resistant Staphylococcus aureus has emerged as a major causative pathogen in complicated skin and skin structure infections (cSSSIs). Unfortunately, treatment failure with vancomycin has been increasingly reported. Over the past decade, several alternative antimicrobial agents have been studied and approved for the treatment of cSSSIs. One such agent is the lipoglycopeptide telavancin, which was approved by the US FDA 2009. Given its dual mechanism of action, telavancin is characterized by a highly bactericidal activity and low potential for resistance selection. In addition, in clinical trials, it was efficacious and safe in the treatment of cSSSI. The purpose of this review is to give a background overview of telavancin, highlighting its microbiological, pharmacokinetic and pharmacodynamics characteristics, to summarize the available evidence for its use in the treatment of cSSSIs, and to provide an updated evaluation of its safety profile.

Oritavancin for the treatment of acute bacterial skin and skin structure infections: an evidence-based review

The emergence of resistance to glycopeptide antibiotics such as vancomycin and teicoplanin among Gram-positive bacteria has spurred the search for second-generation drugs of this class. Oritavancin, a promising novel, second-generation, semisynthetic lipoglycopeptide, is distinguished by two mechanisms of action: inhibition of cell wall synthesis and disruption of the cell membrane. This dual mechanism of action has increased the activity of oritavancin against vancomycin-resistant Gram-positive bacteria compared to other glycopeptides. Oritavancin has a concentration-dependent and rapid bactericidal activity against Gram-positive bacteria, particularly enterococci, contrary to vancomycin and teicoplanin, which exhibit bacteriostatic activity. It has a long half-life of about 195.4 hours and is slowly eliminated by the liver and kidneys, allowing once-daily dosing. Oritavancin has demonstrated preliminary safety and efficacy in Phase I and Phase II clinical trials. It was recently shown to be noninferior to vancomycin in a large Phase III randomized, double-blind clinical trial. To date, adverse events have been mild and limited, the most common being administration site complaints, headache, and nausea. Oritavancin appears to be a promising antimicrobial alternative to vancomycin with additional activity against Staphylococcus and Enterococcus isolates resistant to vancomycin and a more convenient way of administration.

Ventilator-Associated Pneumonia at a Tertiary-Care Center in a Developing Country: Incidence, Microbiology, and Susceptibility Patterns of Isolated Microorganisms

Objective:

Ventilator-associated pneumonia (VAP) complicates the course of up to 24% of intubated patients. Data from the Middle East are scarce. The objective of this study was to evaluate the incidence, microbiology, and antimicrobial susceptibility patterns of isolated microorganisms in VAP in a developing country.

Design:

Prospective observational cohort study.

Setting:

The American University of Beirut Medical Center, a tertiary-care center that serves as a major referral center for Lebanon and neighboring countries.

Patients:

All patients admitted to the intensive care and respiratory care units from March to September 2001, and who had been receiving mechanical ventilation for at least 48 hours, were included in the study. Results of samples submitted for culture were recorded and antimicrobial susceptibility testing of isolated pathogens was performed.

Results:

Seventy patients were entered into the study. The incidence of VAP was 47%. Gram-negative bacilli accounted for 83% of all isolates. The most commonly identified organism was Acinetobacter anitratus, followed by Pseudomonas aeruginosa. Fifty percent of all gram-negative bacterial isolates were classified as antibiotic resistant. Compared with patients without VAP, patients with VAP remained intubated for a longer period and stayed in the intensive care unit longer. VAP was not associated with an increased mortality rate.

Conclusion:

Compared with other studies, the results from this referral center in Lebanon indicate a higher incidence of VAP and a high prevalence of resistant organisms. These data are relevant because they direct the choice of empiric antibiotic therapy for VAP.

Clinical and Microbiological Profile of Urinary Tract Infection at a Tertiary-Care Center in Lebanon

We compared community-acquired urinary tract infection (UTI) with hospital-acquired UTI at the American University of Beirut Medical Center. Escherichia coli was the most frequently isolated organism. Hospital-acquired E. coli isolates were often rnultidrug resistant. These results can be used to improve empiric treatment of UTI.

Osteomyelitis at two noncontiguous sites caused by Mycobacterium marinum in an immunocompetent host: case report and literature review

Nontuberculous mycobacteria are rare causes of skin, soft tissue, and musculoskeletal infections. Mycobacterium marinum remains one of the most commonly encountered mycobacterial species in humans, causing superficial cutaneous as well as deep infections. We are reporting a case of M. marinum osteomyelitis involving two primary noncontiguous sites in an immunocompetent host, which was successfully treated with surgical drainage and antibiotic therapy.

Epidemiology, clinical manifestations, and molecular typing of salmonella typhi isolated from patients with typhoid fever in Lebanon

The objective of this study was to examine the epidemiology and the clinical manifestations of typhoid fever as well as the susceptibility and strain relatedness of Salmonella typhi isolates in Lebanon from 2006 to 2007. A total of 120 patients with typhoid fever were initially identified from various areas of the country based on positive culture results for S. typhi from blood, urine, stools, bone marrow and/or positive serology. Clinical, microbiological and molecular analysis was performed on cases with complete data available. These results indicated that drinking water was an unlikely mode of transmission of the infection. Despite increasing reports of antimicrobial resistance among S. typhi isolates, the vast majority of these isolates were susceptible to various antibiotic agents, including ampicillin, cephalosporins, quinolones, and trimethoprim/sulfamethoxazole. Molecular analysis of the isolates revealed a predominance of one single genotype with no variation in distribution across the geographical regions.

Management of candidaemia and invasive candidiasis in critically ill patients

Critically ill patients in the intensive care unit (ICU) are at increased risk of encountering bloodstream infections (BSIs) with Candida spp., associated with an elevated crude mortality rate. This supports the significance of early detection of infection and identification of the most effective management approach. A review of the various antifungal treatments and an evaluation of the diverse management approaches for invasive candidiasis in critically ill patients is necessary for guiding evidence-based decision-making. Different early detection schemes for invasive candidiasis are well documented in the literature. Other than the common use of blood cultures, new methods entail the use of risk prediction scores and biomarker tests. Regarding management strategies, different options are currently supported. These include prophylaxis, empirical therapy, pre-emptive therapy, and treatment of culture-documented infections. The choice of treatment is greatly dependent on several factors related to the patient and/or to the surrounding environment. Attention needs to be given to previous exposure to azoles, epidemiological data on dominant Candida spp. in local ICUs, severity of illness and associated morbidities. This paper summarises the most recent literature as well as the guidelines issued by the Infectious Diseases Society of America. The objective is to identify the best diagnosis and management approaches for serious Candida infections in critically ill patients. In addition, this article addresses an important aspect associated with managing candidaemia in critically ill patients pertaining to the decision for intravenous catheter removal.

Epidemiology and outcome of major postoperative infections following cardiac surgery: risk factors and impact of pathogen type

BACKGROUND

Major postoperative infections (MPIs) are poorly understood complications of cardiac surgery. We examined the epidemiology, microbiology, and outcome of MPIs occurring after cardiac surgery.

METHODS

The study cohort was drawn from the Society of Thoracic Surgeon National Cardiac Database and comprised adults who underwent cardiac surgery at 5 tertiary hospitals between 2000 and 2004. We studied the incidence, microbiology, and risk factors of MPI (bloodstream or chest wound infections within 30 days after surgery), as well as 30-day mortality. We used multivariate regression analyses to evaluate the risk of MPI and mortality.

RESULTS

MPI was identified in 341 of 10,522 patients (3.2%). Staphylococci were found in 52.5% of these patients, gram-negative bacilli (GNB) in 24.3%, and other pathogens in 23.2%. High body mass index, previous coronary bypass surgery, emergency surgery, renal impairment, immunosuppression, cardiac failure, and peripheral/cerebrovascular disease were associated with the development of MPI. Median postoperative duration of hospitalization (15 days vs 6 days) and mortality (8.5% vs 2.2%) were higher in patients with MPIs. Compared with uninfected individuals, odds of mortality were higher in patients with S aureus MPIs (adjusted odds ratio, 3.7) and GNB MPIs (adjusted odds ratio, 3.0).

CONCLUSIONS

Staphylococci accounted for the majority of MPIs after cardiac surgery. Mortality was higher in patients with Staphylococcus aureus- and GNB-related MPIs than in patients with MPIs caused by other pathogens and uninfected patients. Preventive strategies should target likely pathogens and high-risk patients undergoing cardiac surgery.

Tedizolid (TR-701): a new oxazolidinone with enhanced potency

INTRODUCTION

Tedizolid phosphate (TR-701) is a new oxazolidinone prodrug that is transformed in the serum into the active drug tedizolid (TR-700). Tedizolid acts by inhibiting protein synthesis and has broad activity against Gram-positive pathogens, including strains that are resistant to linezolid.

AREAS COVERED

This review summarizes the currently available data on this new antimicrobial agent. In vitro activity, pharmacokinetics/pharmacodynamics, clinical efficacy and safety are all addressed.

EXPERT OPINION

Tedizolid will provide a useful addition to the antimicrobial armamentarium, particularly in complicated skin and skin structure infections, due to its high oral bioavailability and once-daily dosing. The results of future studies will serve to better position tedizolid among the newly approved agents for infections caused by Gram-positive organisms.

Detection of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae producing NDM-1 in Lebanon

Carbapenem resistance has been encountered globally with poor outcome of infected patients. NDM-1 (New Delhi metallo-beta-lactamase) gene containing organisms have emerged and are now spreading in all continents. This is the first report of Iraqi patients referred to Lebanon from whom carbapenem resistant Enterobacteriaceae were recovered. The genes involved in carbapenem resistance were bla-OXA-48   and the novel NDM-1. This report highlights the alarming introduction of such resistance among Enterobacteriaecae to this country.

Genotypes and serotype distribution of macrolide resistant invasive and non-invasive Streptococcus pneumoniae isolates from Lebanon

Background

This study determined macrolide resistance genotypes in clinical isolates of Streptococcus pneumoniae from multiple medical centers in Lebanon and assessed the serotype distribution in relation to these mechanism(s) of resistance and the source of isolate recovery.

Methods

Forty four macrolide resistant and 21 macrolide susceptible S. pneumoniae clinical isolates were tested for antimicrobial susceptibility according to CLSI guidelines (2008) and underwent molecular characterization. Serotyping of these isolates was performed by Multiplex PCR-based serotype deduction using CDC protocols. PCR amplification of macrolide resistant erm (encoding methylase) and mef (encoding macrolide efflux pump protein) genes was carried out.

Results

Among 44 isolates resistant to erythromycin, 35 were resistant to penicillin and 18 to ceftriaxone. Examination of 44 macrolide resistant isolates by PCR showed that 16 isolates harbored the erm(B) gene, 8 isolates harbored the mef gene, and 14 isolates harbored both the erm(B) and mef genes. There was no amplification by PCR of the erm(B) or mef genes in 6 isolates. Seven different capsular serotypes 2, 9V/9A,12F, 14,19A, 19F, and 23, were detected by multiplex PCR serotype deduction in 35 of 44 macrolide resistant isolates, with 19F being the most prevalent serotype. With the exception of serotype 2, all serotypes were invasive. Isolates belonging to the invasive serotypes 14 and 19F harbored both erm(B) and mef genes. Nine of the 44 macrolide resistant isolates were non-serotypable by our protocols.

Conclusion

Macrolide resistance in S. pneumoniae in Lebanon is mainly through target site modification but is also mediated through efflux pumps, with serotype 19F having dual resistance and being the most prevalent and invasive.

Telavancin versus vancomycin for hospital-acquired pneumonia due to gram-positive pathogens

The results from two methodologically identical double-blind studies indicate that telavancin is noninferior to vancomycin based on clinical response in the treatment of hospital-acquired pneumonia due to Gram-positive pathogens.

Background. Telavancin is a lipoglycopeptide bactericidal against gram-positive pathogens.

Methods. Two methodologically identical, double-blind studies (0015 and 0019) were conducted involving patients with hospital-acquired pneumonia (HAP) due to gram-positive pathogens, particularly methicillin-resistant Staphylococcus aureus (MRSA). Patients were randomized 1:1 to telavancin (10 mg/kg every 24 h) or vancomycin (1 g every 12 h) for 7–21 days. The primary end point was clinical response at follow-up/test-of-cure visit.

Results. A total of 1503 patients were randomized and received study medication (the all-treated population). In the pooled all-treated population, cure rates with telavancin versus vancomycin were 58.9% versus 59.5% (95% confidence interval [CI] for the difference, –5.6% to 4.3%). In the pooled clinically evaluable population (n = 654), cure rates were 82.4% with telavancin and 80.7% with vancomycin (95% CI for the difference, –4.3% to 7.7%). Treatment with telavancin achieved higher cure rates in patients with monomicrobial S. aureus infection and comparable cure rates in patients with MRSA infection; in patients with mixed gram-positive/gram-negative infections, cure rates were higher in the vancomycin group. Incidence and types of adverse events were comparable between the treatment groups. Mortality rates for telavancin-treated versus vancomycin-treated patients were 21.5% versus 16.6% (95% CI for the difference, –0.7% to 10.6%) for study 0015 and 18.5% versus 20.6% (95% CI for the difference, –7.8% to 3.5%) for study 0019. Increases in serum creatinine level were more common in the telavancin group (16% vs 10%).

Conclusions. The primary end point of the studies was met, indicating that telavancin is noninferior to vancomycin on the basis of clinical response in the treatment of HAP due to gram-positive pathogens.

Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa

The development of antimicrobial resistance among gram-negative pathogens has been progressive and relentless. Pathogens of particular concern include extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Classic agents used to treat these pathogens have become outdated. Of the few new drugs available, many have already become targets for bacterial mechanisms of resistance. This review describes the current approach to infections due to these resistant organisms and elaborates on the available treatment options.

Ceftaroline fosamil: drug profile and clinical data

Several studies have shown that the rates of resistant Gram-positive pathogens, such as methicillin-resistant Staphylococcus aureus, vancomycin-intermediate S. aureus (VISA), hetero-VISA, and penicillin-resistant Streptococcus pneumoniae have witnessed a substantial global increase. Ceftaroline fosamil is the prodrug form of ceftaroline, a new cephalosporin active against resistant Gram-positive pathogens and common Gram-negative organisms that do not produce extended-spectrum-β-lactamases and do not express AmpC. Ceftaroline fosamil was found to be effective and well-tolerated for the treatment of complicated skin and skin-structure infections and community-acquired bacterial pneumonia compared with standard therapy. The drug has recently been granted US FDA approval for both indications.

Profile of opportunistic infections in HIV-infected patients at a tertiary care center in Lebanon

OBJECTIVES

According to statistics published in December 2007 by the National AIDS Program, Lebanon is home to 1056 individuals infected with HIV. Little is known about the clinical profile of opportunistic infections (OIs) and AIDS defining illnesses (ADIs) and their relative contribution to the morbidity and mortality of HIV-infected patients in Lebanon. The aim of this study is to describe the spectrum of OIs and ADIs in HIV-infected patients diagnosed and/or treated at the American University of Beirut Medical Center (AUBMC) in Lebanon.

METHODS

Data on various OIs and ADIs were collected from the medical records of patients with HIV infection who were diagnosed or received their medical care at AUBMC from 1984 to January 2008.

RESULTS

Eighty-nine HIV-infected patients were included in the analysis. The incidence of ADIs was 72% (64/89). The most commonly diagnosed OIs were cerebral toxoplasmosis (21%), followed by fungal infections (17%). The majority of ADIs (75%) occurred when the CD4 count was below 200 cells/mm(3).

CONCLUSION

Clinical guidelines for the prevention of OIs in HIV-infected individuals have been developed on the basis of natural history data collected in industrialized countries. Our results can be used to define local priorities for opportunistic infection prophylaxis.

Postoperative joint infections due to Propionibacterium species: a case-control study

We compared 40 patients with Propionibacterium acnes postoperative joint infection to a cohort of uninfected patients. Infection manifested a median of 210 days after surgery. Most patients with joint prostheses underwent hardware removal. Prior joint surgery (odds ratio [OR], 28.2) and male sex (OR, 7.2) were independent risk factors for infection.