Emergence of co-production of plasmid-mediated AmpC beta-lactamase and ESBL in cefoxitin-resistant uropathogenic <Emphasis Type="Italic">Escherichia coli</Emphasis>

Plasmid-mediated AmpC (pAmpC) and ESBL co-production was detected in Escherichia coli a major etiologic agent of urinary tract infection. Isolates resistant to cefoxitin by CLSI methodology were tested for pAmpC beta-lactamase using phenylboronic acid and ESBLs by combined disk diffusion method. pAmpC/ESBL genes were characterized by PCR and sequencing. Transconjugation experiments were done to study the transfer of pAmpC and ESBL production from clinical isolates as donor to E. coli J53 AziR as recipient. Incompatibility groups of transmissible plasmids were classified by PCR-based replicon typing (PBRT). Among 148 urine culture positive isolates, E. coli was reported in 39.86 % (59/148), with 93.22 % (55/59) of cefoxitin resistance. pAmpC production was detected in 25, with varied distribution of blaCMY-2 and blaDHA-1type genes alone (n?=?13 and 7 respectively) or in combination (n?=?5). ESBL co-production was observed in 88 % (22/25) of pAmpC producing isolates with predominance of blaTEM (n?=?20). Twenty-three transconjugants showed transmission of pAmpC-and ESBL-resistant genes with co-carriage of blaCMY-2 and blaTEM (n?=?15) in plasmids of IncF type (n?=?9) being predominant, followed by IncI1 (n?=?4) and IncH1 (n?=?2) in combination. All clinical isolates were clonally diverse. Resistance against different beta-lactams in uropathogenic E. coli has been an emerging concern in resource- poor countries such as India. Knowledge on the occurrence of AmpC beta-lactamases and ESBL amongst this pathogen and its transmission dynamics may aid in hospital infection control.     

Prosthetic Joint Infection Diagnosis Using Broad-Range PCR of Biofilms Dislodged from Knee and Hip Arthroplasty Surfaces Using Sonication

Periprosthetic tissue and/or synovial fluid PCR has been previously studied for prosthetic joint infection (PJI) diagnosis; however, few studies have assessed the utility of PCR on biofilms dislodged from the surface of explanted arthroplasties using vortexing and sonication (i.e., sonicate fluid PCR). We compared sonicate fluid 16S rRNA gene real-time PCR and sequencing to culture of synovial fluid, tissue, and sonicate fluid for the microbiologic diagnosis of PJI. PCR sequences generating mixed chromatograms were decatenated using RipSeq Mixed. We studied sonicate fluids from 135 and 231 subjects with PJI and aseptic failure, respectively. Synovial fluid, tissue, and sonicate fluid culture and sonicate fluid PCR had similar sensitivities (64.7, 70.4, 72.6, and 70.4%, respectively; P > 0.05) and specificities (96.9, 98.7, 98.3, and 97.8%, respectively; P > 0.05). Combining sonicate fluid culture and PCR, the sensitivity was higher (78.5%, P < 0.05) than those of individual tests, with similar specificity (97.0%). Thirteen subjects had positive sonicate fluid culture but negative PCR, and 11 had negative sonicate fluid culture but positive PCR (among which 7 had prior use of antimicrobials). Broad-range PCR and culture of sonicate fluid have equivalent performance for PJI diagnosis.     

Tigecycline use in the outpatient parenteral antibiotic therapy setting

In the context of globally increasing antimicrobial resistance, tigecycline appears to be a useful therapeutic option. The need for prolonged courses for complex infections has prompted consideration of its use via outpatient parenteral antibiotic therapy (OPAT) programmes, although clinical outcomes when used in this setting remain unknown. We retrospectively reviewed the patient characteristics and outcomes of 11 patients who received tigecycline, most commonly delivered as 100 mg once daily, via OPAT at three tertiary Australian hospitals. Rates of co-morbidity and prior antibiotic use were high. Patients had a wide range of infections including bone and/or joint (n?=?5), intra-abdominal (n?=?3), lower respiratory tract (n?=?2) and parapharyngeal abscess (n?=?1). Mycobacterial species (n?=?5) were the most frequent pathogen, and multi-resistant organisms were common (n?=?4). The median OPAT duration was 14 days (IQR 6–30). Nausea was encountered in 45 % of cases. At completion of OPAT, 1 patient (9 %) was cured, 2 (18 %) had improved and 8 (73 %) failed therapy. Failure occurred due to either progression or non-response of infection (n?=?4), re-admission (n?=?3), premature cessation of tigecycline due to nausea (n?=?3) or death (n?=?1). Whilst OPAT delivery of tigecycline is a therapeutic option, when used as second-line therapy for complex, often multi-resistant infections in patients with multiple comorbidities, high rates of clinical failure, readmissions and adverse effects, especially nausea, should be anticipated.     

Rapid Molecular Microbiologic Diagnosis of Prosthetic Joint Infection

We previously showed that culture of samples obtained by prosthesis vortexing and sonication was more sensitive than tissue culture for prosthetic joint infection (PJI) diagnosis. Despite improved sensitivity, culture-negative cases remained; furthermore, culture has a long turnaround time. We designed a genus-/group-specific rapid PCR assay panel targeting PJI bacteria and applied it to samples obtained by vortexing and sonicating explanted hip and knee prostheses, and we compared the results to those with sonicate fluid and periprosthetic tissue culture obtained at revision or resection arthroplasty. We studied 434 subjects with knee (n = 272) or hip (n = 162) prostheses; using a standardized definition, 144 had PJI. Sensitivities of tissue culture, of sonicate fluid culture, and of PCR were 70.1, 72.9, and 77.1%, respectively. Specificities were 97.9, 98.3, and 97.9%, respectively. Sonicate fluid PCR was more sensitive than tissue culture (P = 0.04). PCR of prosthesis sonication samples is more sensitive than tissue culture for the microbiologic diagnosis of prosthetic hip and knee infection and provides same-day PJI diagnosis with definition of microbiology. The high assay specificity suggests that typical PJI bacteria may not cause aseptic implant failure.     

Surgical pathology in sub-Saharan Africa—volunteering in Malawi

The breadth of material found in surgical pathology services in African countries differs from the common spectrum of “the West”. We report our experience of a voluntary work in the pathology departments of Blantyre and Lilongwe, Malawi. During a 6-week period, 405 cases (378 histology and 27 cytology cases) were processed. The vast majority showed significant pathological findings (n?=?369; 91.1 %): 175 cases (47.4 %) were non-tumoral conditions with predominance of inflammatory lesions, e.g., schistosomiasis (n?=?11) and tuberculosis (n?=?11). There were 39 (10.6 %) benign tumors or tumor-like lesions. Intraepithelial neoplasia of the cervix uteri dominated among premalignant conditions (n?=?15; 4.1 %). The large group of malignancies (n?=?140; 37.9 %) comprised 11 pediatric tumors (e.g., rhabdomyosarcoma, small blue round cell tumors) and 129 adult tumors. Among women (n?=?76), squamous cell carcinomas (SCCs) of the cervix uteri predominated (n?=?25; 32.9 %), followed by breast carcinomas (n?=?12; 15.8 %) and esophageal SCC (n?=?9; 11.8 %). Males (n?=?53) most often showed SCC of the esophagus (n?=?9; 17.0 %) and of the urinary bladder (n?=?7; 13.2 %). Lymphomas (n?=?7) and Kaposi's sarcomas (n?=?6) were less frequent. Differences compared to the western world include the character of the conditions in general, the spectrum of inflammatory lesions, and the young age of adult tumor patients (median 45 years; range 18–87 years). Providing pathology service in a low-resource country may be handicapped by lack of personnel, inadequate material resources, or insufficient infrastructure. Rotating volunteers offer a bridge for capacity building of both personnel and the local medical service; in addition, the volunteer's horizons are broadened professionally and personally.     

Sonication of Explanted Prosthesis Combined with Incubation in BD Bactec Bottles for Pathogen-Based Diagnosis of Prosthetic Joint Infection

Prosthetic joint infection (PJI) is a rare but refractory complication of arthroplasty. Accurate identification of pathogens is a key step for successful treatment of PJI, which remains a challenge for clinicians and laboratory workers. We designed a combined culture method with sonication of implants and incubation in a BD Bactec system to improve the effectiveness of pathogen diagnosis in PJI. The aims of this study were to investigate the diagnostic accuracy of sonicate fluid cultures in the BD Bactec system and to compare the results with those of synovial fluid cultures in the BD Bactec system. The prosthetic components removed were sonicated in Ringer''s solution, and then sonicate fluid was incubated in Bactec bottles for 5 days. Synovial fluid was incubated in Bactec bottles for 5 days as a control. Synovial fluid cultures with Bactec bottles and sonicate fluid cultures with Bactec bottles showed sensitivities of 64% and 88%, respectively (P = 0.009), with specificities of 98% and 87% (P = 0.032), respectively. Sonicate fluid cultures with Bactec bottles were more sensitive than synovial fluid cultures with Bactec bottles regardless of whether antimicrobial agents were used within 14 days before surgery (81% versus 52%; P = 0.031) or not (93% versus 72%; P = 0.031). Sonication of explanted prostheses followed by incubation of the resulting sonicate fluid in Bactec bottles detected many more pathogens than did synovial fluid cultures with Bactec bottles. This method is also effective in cases with antibiotic treatment before surgery.     

A population-based study of aerococcal bacteraemia in the MALDI-TOF MS-era

The purpose of this study was to determine the incidence of aerococcal bacteraemia in the MALDI-TOF MS-era, to describe the clinical presentation and to determine the MIC values of aerococci for ten antibiotics. Aerococci in blood cultures were identified through searches in the laboratory database for the years 2012–2014. MALDI-TOF MS, sequencing of the 16S rRNA gene and a PYR test were used for species identification. Patients’ medical charts were systematically reviewed. Etests were used to determine MIC values. Seventy-seven patients were identified (Aerococcus urinae n?=?49, Aerococcus viridans n?=?14, Aerococcus sanguinicola n?=?13 and Aerococcus christensenii n?=?1) corresponding to incidences of 14 cases per 1,000,000 inhabitants per year (A. urinae) and 3.5 cases per 1,000,000 inhabitants per year (A. sanguinicola and A.viridans). A. urinae was in pure culture in 61 %, A. sanguinicola in 46 % and A. viridans in 36 % of the cases. The A. urinae and A. sanguinicola patients were old and many had urinary tract disorders, and a majority had a suspected urinary tract focus of the bacteraemia. Eighty percent of the A. urinae patients were men. Five A. urinae patients were diagnosed with infective endocarditis. Six patients died within 30 days. Most isolates had low MICs to penicillins and carbapenems. MALDI-TOF MS has led to an increased identification of aerococcal bacteremia. A. urinae remains the most common Aerococcus in blood cultures and in aerococcal IE.     

Prevalence,genotypes, and risk factors of <Emphasis Type="Italic">Enterocytozoon bieneusi</Emphasis> in Asiatic black bear (<Emphasis Type="Italic">Ursus thibetanus</Emphasis>) in Yunnan Province,Southwestern China

Microsporidiosis is an important zoonotic disease, even leading to severe diarrhea. However, no information about prevalence and genotypes of Enterocytozoon bieneusi infection in Asiatic black bears in southwestern China is available. The objectives of the present study were to investigate the prevalence of E. bieneusi and to characterize their genotypes using the nested PCR amplification of the internal transcribed spacer region of the ribosomal RNA gene cluster and multilocus sequence typing (MLST). The overall prevalence of E. bieneusi was 19.75% (80/405) and the rate of E. bieneusi in Xishuangbanna (33.33%) was significantly higher than that in any other regions (Honghe, 17.65%; Dehong, 13.04%; Kunming, 0; P?=?0.01). Sequence analysis revealed that 4 known genotypes (D, n?=?2; SC02, n?=?10; SC01, n?=?5; and CHB1, n?=?4) and 13 novel genotypes (designed MJ1–MJ13) were identified. When 17, 5, 14, and 34 sequences at loci MS1, MS3, MS4, and MS7 via MLST analyses, representing 4, 4, 5, and 10 genotypes, respectively, were completed, one multilocus genotype (MLG novel-ABB1) was identified. This is the first report of E. bieneusi in Asiatic black bear in Yunnan province, Southwestern China. The results indicated the potential zoonotic risk of this parasite through the Asiatic black bear in this region and provided foundation data for preventing and controlling E. bieneusi infection of many other animals and humans in these regions.     

Microbiologic Diagnosis of Prosthetic Shoulder Infection by Use of Implant Sonication

We recently described a sonication technique for the diagnosis of prosthetic knee and hip infections. We compared periprosthetic tissue culture to implant sonication followed by sonicate fluid culture for the diagnosis of prosthetic shoulder infection. One hundred thirty-six patients undergoing arthroplasty revision or resection were studied; 33 had definite prosthetic shoulder infections and 2 had probable prosthetic shoulder infections. Sonicate fluid culture was more sensitive than periprosthetic tissue culture for the detection of definite prosthetic shoulder infection (66.7 and 54.5%, respectively; P = 0.046). The specificities were similar (98.0% and 95.1%, respectively; P = 0.26). Propionibacterium acnes was the commonest species detected among culture-positive definite prosthetic shoulder infection cases by periprosthetic tissue culture (38.9%) and sonicate fluid culture (40.9%). All subjects from whom P. acnes was isolated from sonicate fluid were male. We conclude that sonicate fluid culture is useful for the diagnosis of prosthetic shoulder infection.The frequency of shoulder replacement surgery is increasing (1). The incidence of prosthetic shoulder infection varies from 0.4 to 15.4% (6, 7). When an infection is present, the infection requires unique medical and surgical management, rendering an accurate diagnosis critical. However, since patients with prosthetic shoulder infection often present with stiffness and/or pain alone (7), the achievement of an accurate diagnosis is challenging.Periprosthetic tissue has been the specimen cultured for the microbiologic diagnosis of prosthetic shoulder infection. Specificity is an issue, as microorganisms (e.g., Propionibacterium and Staphylococcus spp.) can be contaminants, and the number of microorganisms in tissue is small. As a result, it has been suggested that multiple samples be obtained; for prosthetic hips and knees, it is recommended that five or six periprosthetic tissue specimens be cultured (2). No such data are available for shoulder implants.We recently clinically validated a sonication technique that is used to sample biofilm bacteria on the surface of removed hip and knee implants placed in solid containers. We demonstrated that the culture of samples obtained by sonication of the implant was more sensitive than the culture of periprosthetic tissue for the diagnosis of prosthetic hip and knee infections (22). The poor sensitivity of the latter likely relates to the presence of bacteria in biofilms on the prosthesis surface, a site not well sampled when periprosthetic tissue samples for culture are obtained. No data on the accuracy of sonication for the diagnosis of prosthetic shoulder infection are available.The proportion of patients with shoulder infections due to Propionibacterium acnes is significantly greater than the proportion of patients with lower limb infections due to P. acnes (12). Sperling et al. reported that Propionibacterium spp. account for 16% of prosthetic shoulder infections (16). Franta et al. reported that among 31/282 patients (11%) with unsatisfactory shoulder arthroplasties, positive intraoperative cultures were found in 23 at the time of revision surgery, with the most common organisms isolated being coagulase-negative Staphylococcus spp., followed by P. acnes (11). Cheung et al. reported the results of reimplantation of glenoid components following removal and allogeneic bone grafting in seven patients; specimens from two patients demonstrated the growth of P. acnes (5). These two patients had continuing pain and radiographic evidence of glenoid component loosening and subsequently underwent repeat revision surgery, whereas the remaining patients did well and did not require repeat revision surgery (5), suggesting a role for P. acnes in pain and component loosening. Accordingly, the accurate detection of a Propionibacterium spp. is paramount in the diagnosis of prosthetic shoulder infection.The purpose of the present study was to compare implant sonication to periprosthetic tissue culture for the diagnosis of prosthetic shoulder infection. We also evaluated immunofluorescence microscopy and PCR analysis of sonicate fluid to detect prosthetic shoulder infection caused by the two most frequently associated microorganisms. Finally, we compared patient characteristics associated with Propionibacterium prosthetic shoulder infection versus those associated with non-Propionibacterium prosthetic shoulder infection.(This work was presented in part at the 16th Annual European Congress of Clinical Microbiology and Infectious Diseases, April 2006, Nice, France, and the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, September 2007, Chicago, IL.)     

Monitoring of abdominal<Emphasis Type="Italic"> Staphylococcus aureus</Emphasis> infection using magnetic resonance imaging: a murine animal model for hepatic and renal abscesses

To establish a routine workflow for in vivo magnetic resonance imaging (MRI) of mice infected with bacterial biosafety level 2 pathogens and to generate a mouse model for systemic infection with Staphylococcus aureus suitable for monitoring by MRI. A self-contained acrylic glass animal bed complying with biosafety level 2 requirements was constructed. After intravenous infection with 10⁵ colony-forming units (CFU) (n?=?3), 10⁶ CFU (n?=?11) or 10⁷ CFU (n?=?6) of S. aureus strain Newman, female Balb/c mice were whole-body scanned by 7T MRI. Abdominal infections such as abscesses were visualized using a standard T2-weighted scan. Infection monitoring was performed for each animal by measurements at 1, 3, and 7 days after infection. Intravenous pathogen application led to a dose-dependent decrease in survival probability (p?=?0.03). In the group with the highest infectious dose the 7-day survival rate was 33 %. An intermediate S. aureus dose showed a survival rate of 80 %, whereas at the lowest infection dose, none of the animals died. All animals with the highest infection dose exhibited hepatic abscesses 4 days after inoculation, 80 % developed renal abscesses on the 3rd day. Mice obtaining the intermediate S. aureus load reached a plateau at day 4 with 72 % liver and 60 % renal abscess probability. No abscesses were observed in other abdominal organs at any time point. The implemented experimental setup provides a suitable and reliable in vivo MRI method to study murine abdominal infection models using BSL-2 pathogen. Systemic Staphylococcus aureus infection leads to a dose-dependent development of hepatic and renal abscesses.     

Success of benznidazole chemotherapy in chronic <Emphasis Type="Italic">Trypanosoma cruzi</Emphasis>-infected patients with a sustained negative PCR result

Cure assessment in chronic Trypanosoma cruzi infection is controversial, mainly because of the lack of reliable tests to ensure parasite elimination. Here, we assess the impact of benznidazole therapy on the conventional serology and parasitaemia in chronic Chagas disease. A total of 455 patients with long-term Trypanosoma cruzi infection underwent specific chemotherapy with benznidazole. Their parasitological status was assessed by polymerase chain reaction (PCR) detection of T. cruzi DNA. Drops in the titres of antibody levels were serially measured by indirect immunofluorescence assay (IFI) and chemiluminescent microparticle immunoassay (CMIA). Patients were monitored during the treatment period and for a further 90, 150 and 240 days. Controls were repeated yearly during the 7-year follow-up. The PCR result was negative in all patients between 60-day (n?=?22) and 90-day (n?=?294) controls. Treatment failure was detected in 45 patients and was significantly more frequent in those who did not complete the therapy [12 out of 13 (92 %) vs. 33 out of 442 (7 %)] (p?=?0.0001). A significant drop in serum titres was detected after the first follow-up year in patients with sustained negative PCR results: 2nd year (p?=?0.029 by IFI; p?=?0.002 by CMIA), 5th year (p?=?0.036 by IFI; p?=?0.039 by CMIA) and 6th year (p?=?0.028 by IFI; p?=?0.019 by CMIA). The results point to a beneficial effect of benznidazole and may be the cure of chronic patients who had a consistently negative PCR result throughout the follow-up period.     

Should we expand the indications for the DAIR (debridement,antibiotic therapy,and implant retention) procedure for <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> prosthetic joint infections? A multicenter retrospective study

To evaluate factors associated with failure in patients treated with DAIR (debridement, antibiotic therapy, and implant retention) for Staphylococcus aureus prosthetic joint infections (PJIs). We retrospectively analyzed consecutive patients with stable PJI due to S. aureus treated with DAIR at six hospitals between 2010 and 2014. Cox proportional hazards regression was used to study factors associated with treatment failure at 2 years. Of 154 eligible patients, 137 were included (mean age 73?±?13 years; male 56%). The estimated success rate according to the Kaplan–Meier method was 76.2 [95% CI 68–83] at 2 years of follow-up. In multivariate analysis, longer duration of treatment (hazard ratio (HR) 0.78 [0.69–0.88]; p?<?0.001) and combination therapy including rifampin (HR 0.08 [0.018–0.36]; p?=?0.001) were independently associated with success, whereas active smoking was independently associated with failure (HR 3.6 [1.09–11.84]; p?=?0.036). When the analysis was restricted to patients with early infection onset (<?3 months), early acute infection was also predictive of a better prognosis (HR 0.25 [0.09–0.7]; p?=?0.009). Failure was not associated with time from prosthesis insertion to debridement, nor with duration of symptoms >?3 weeks and type of prosthesis (hip or knee). These results remained unchanged when the 14 patients under immunosuppressive therapy were removed from analysis. These data suggest that DAIR can be performed even if infection and symptoms are delayed but reserved to patients who are able to follow rifampin-based combination therapy for a prolonged duration that should not be different for hip and knee PJI.     

Clinicopathological value of programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) expression in synovium of patients with rheumatoid arthritis

The etiology of rheumatoid arthritis (RA) is thought to involve dysfunction of the programmed cell death 1/programmed cell death ligand 1 (PD-1/PD-L1) pathway; PD-1 negatively regulates autoimmunity by interacting with its ligand, PD-L1. We therefore investigated PD-1/PD-L1 expression in synovial tissue of patients with RA. We immunohistochemically stained synovial specimens from 51 patients with RA and assessed the association between PD-1/PD-L1 expression and rheumatoid factor (RF), the total count of infiltrating T cells, C-reactive protein (CRP), and Krenn’s synovitis score. PD-1 expression on infiltrating lymphocytes was detected in 34/51 RA cases (66.7%), while PD-1 expression was very mildly correlated only with the number of total infiltrating T cells (R²?=?0.1011, P?=?0.0230). On the other hand, PD-L1 expression on synovial lining cells was observed in 37/51 RA cases (72.5%). Furthermore, a higher PD-L1 expression was significantly associated with RF positive state (P?=?0.0454), and the correlations between PD-L1 expression and the number of infiltrating T cells (R²?=?0.5571, P?<?0.0001), CRP (R²?=?0.4060, P?<?0.0001), and Krenn’s synovitis score (R²?=?0.7785, P?<?0.0001) were confirmed. PD-1 was expressed on infiltrating lymphocytes, while PD-L1 was expressed on synovial lining cells; the expression of PD-L1 on synovial lining cells was significantly correlated with the active state of the disease. These data suggest that PD-1/PD-L1 pathway may have an important role in the pathogenesis of RA.     

Antimicrobial combination treatment including ciprofloxacin decreased the mortality rate of <Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> bacteraemia: a retrospective cohort study

Ineffective antimicrobial therapy of Pseudomonas aeruginosa bacteraemia increases mortality. Recent studies have proposed the use of antimicrobial combination therapy composed of a beta-lactam with either ciprofloxacin or tobramycin. To determine if combination therapy correlates to lower mortality and is superior compared to monotherapy, we investigated the effect of antimicrobial treatment regimens on 30-day mortality in a cohort with Pseudomonas aeruginosa bacteraemia. All cases of P. aeruginosa bacteraemia (n?=?292) in southwest Skåne County, Sweden (years 2005–2010, adult population 361,112) and the whole county (2011–2012, 966,130) were identified. Available medical and microbiological records for persons aged 18 years or more were reviewed (n?=?235). Antimicrobial therapy was defined as empiric at admission or definitive after culture results and was correlated to 30-day mortality in a multivariate regression model. The incidence and mortality rates were 8.0 per 100,000 adults and 22.9% (67/292), respectively. As expected, multiple comorbidities and high age were associated with mortality. Adequate empiric or definitive antipseudomonal treatment was associated with lower mortality than other antimicrobial alternatives (empiric p?=?0.02, adj. p?=?0.03; definitive p?<?0.001, adj. p?=?0.007). No difference in mortality was seen between empiric antipseudomonal monotherapy or empiric combination therapy. However, definitive combination therapy including ciprofloxacin correlated to lower mortality than monotherapy (p?=?0.006, adj. p?=?0.003), whereas combinations including tobramycin did not. Our results underline the importance of adequate antipseudomonal treatment. These data also suggest that P. aeruginosa bacteraemia should be treated with an antimicrobial combination including ciprofloxacin when susceptible.     

Fecal calprotectin concentrations in cancer patients with <Emphasis Type="Italic">Clostridium difficile</Emphasis> infection

Fecal calprotectin (fCPT) has been used as a surrogate marker for assessment of intestinal inflammation. We explore the utility of fCPT values as a diagnostic aid in cancer patients with suspected Clostridium difficile infection (CDI). A total of 232 stool specimens submitted for GeneXpert C. difficile PCR testing were included in the study. All specimens were tested for fCPT and toxin/GDH antigens. Clinical severity of CDI cases was determined by the IDSA/SHEA criteria. Significant differences of median fCPT values between CDI (n?=?117, Median 183.6 μg/g) and non-CDI (n?=?115, 145.6 μg/g, p?=?0.006) patients were seen. In CDI patents, significantly lower fCPT values were found in patients with mild to moderate (n?=?95, 182.1 μg/g) than those with severe and severe to complicated (n?=?22, 218.5 μg/g, p?=?0.014) scores, and among those that were toxin positive (n?=?24, 200.2 μg/g) vs. toxin negative (n?=?86, 182.8 μg/g, p?=?0.044). Despite this overall trend, wide variations in fCPT values were found in all categories examined. A logistic regression analysis revealed that the fCPT values correlated independently with the severity of clinical manifestations (OR?=?2.021, 95%CI?=?1.132–3.608); however, it did not correlate with other clinical outcomes. Our study findings show that high fecal calprotectin levels correlate with toxin-positive and clinically severe CDI; however, wide variations in individual measurements preclude establishment of reliable cut-offs for routine diagnostic use in cancer patients.     

Utility of oropharyngeal real-time PCR for <Emphasis Type="Italic">S. pneumoniae</Emphasis> and <Emphasis Type="Italic">H. influenzae</Emphasis> for diagnosis of pneumonia in adults

A lack of sensitive tests and difficulties obtaining representative samples contribute to the challenge in identifying etiology in pneumonia. Upper respiratory tract swabs can be easily collected and analyzed with real-time PCR (rtPCR). Common pathogens such as S. pneumoniae and H. influenzae can both colonize and infect the respiratory tract, complicating the interpretation of positive results. Oropharyngeal swabs were collected (n?=?239) prospectively from adults admitted to hospital with pneumonia. Analysis with rtPCR targeting S. pneumoniae and H. influenzae was performed and results compared with sputum cultures, blood cultures, and urine antigen testing for S. pneumoniae. Different Ct cutoff values were applied to positive tests to discern colonization from infection. Comparing rtPCR with conventional testing for S. pneumoniae in patients with all tests available (n?=?57) resulted in: sensitivity 87 %, specificity 79 %, PPV 59 % and NPV 94 %, and for H. influenzae (n?=?67): sensitivity 75 %, specificity 80 %, PPV 45 % and NPV 94 %. When patients with prior antimicrobial exposure were excluded sensitivity improved: 92 % for S. pneumoniae and 80 % for H. influenzae. Receiver operating characteristic curve analysis demonstrated for S. pneumoniae: AUC?=?0.65 (95 % CI 0.51–0.80) and for H. influenzae: AUC?=?0.86 (95 % CI 0.72–1.00). Analysis of oropharyngeal swabs using rtPCR proved both reasonably sensitive and specific for diagnosing pneumonia caused by S. pneumoniae and H. influenzae. This method may be a useful diagnostic adjunct to other methods and of special value in patients unable to provide representative lower airway samples.     

The diagnostic value of the bronchoalveolar lavage in interstitial lung diseases

Objective

Bronchoalveolar lavage (BAL) is a diagnostic tool often used during the management of interstitial lung diseases (ILD). However, its diagnostic value in discrimination between entities comprising the very heterogenous group of ILD, is still a controversial issue. The objective of our study is to assess the diagnostic value of BAL in the management of ILD, by comparing the cytological findings in BAL fluid among the different diseases of this group.

Methods

It was a retrospective, observational study of 151 patients between January 2012 and December 2015. BAL fluid cytology was performed to analyse the distribution of leucocytes population subsets in patients with ILD.

Results

The mean age was 52.78 years; 74.83% were women. The analysis of the following main groups of diseases was performed : sarcoïdosis (n?=?30), idiopathic pulmonary fibrosis (IPF; n?=?22), other idiopathic interstitial pneumonia (non specific interstitial pneumonia, cryptogenic organising pneumonia and respiratory bronchiolitis interstitial lung disease; n?=?20) and connective tissue disease (n?=?14).Overall, out of 141 patients, 22% had sarcoïdosis, 15.6% had idiopathic pulmonary fibrosis (IPF), 14.18% had other idiopathic interstitial pneumonia (IIP) and 9.9% had connective tissue disease (CTD). Mixed alveolitis was common in the 4 groups, sarcoïdosis had higher proportion of lymphocytes and IPF had higher neutrophils count. However, there was no significant statistical difference of BAL cellular count among these diseases (p?>?0.05). Also, the prevalence of studied diseases did not change with variation of BAL cellular count (p?>?0.05).

Conclusion

Alone, the BAL cytological analysis has a limited value to provide substantial information that could lead to discriminate between diseases that form ILD. Thus, it must be always associated with other diagnostic methods.

     

Increasing incidence of carbapenemase-producing <Emphasis Type="Italic">Escherichia coli</Emphasis> and <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> in Belgian hospitals

Carbapenemase-producing Enterobacteriaceae are increasingly reported worldwide. The aim of the study was to determine the incidence and molecular epidemiology of carbapenemase-producing (CP) Escherichia coli and Klebsiella pneumoniae (CP-E/K) in Belgium. Eleven hospital-based laboratories collected carbapenem non-susceptible (CNS) isolates of E. coli and K. pneumoniae detected in clinical specimens from January 2013 to December 2014. All CNS strains were tested for carbapenemase production and typed by multilocus sequence typing (MLST) for a 6-month period as part of the European Survey on Carbapenemase-Producing Enterobacteriaceae in Europe (EuSCAPE) structured survey. In addition, an equal number of carbapenem-susceptible isolates collected were preserved as a control group for risk factor analysis. The overall incidence rate of CP-E/K isolates in hospitals increased from 0.124 in 2013 to 0.223 per 1000 admissions in 2014. From November 2013 to April 2014, 30 CP K. pneumoniae [OXA-48 (n?=?16), KPC (n?=?13), OXA-427 (n?=?1)] and five CP E. coli [OXA-48 (n?=?3), NDM (n?=?1), OXA-427 (n?=?1)] isolates were detected in ten hospitals. The 16 OXA-48-producing K. pneumoniae strains were distributed into eight sequence types (STs), while the 13 KPC-producing K. pneumoniae clustered into three STs dominated by ST512 (n?=?7) and ST101 (n?=?5). Compared to controls, we observed among CP-E/K carriers significantly higher proportion of males, respiratory origins, previous hospitalization, nosocomial setting, and a significantly lower proportion of bloodstream infections. Our study confirms the rapid spread of CP-E/K in Belgian hospitals and the urgent need for a well-structured and coordinated national surveillance plan in order to limit their dissemination.     

Altered Cyclooxygenase-2 Expression in Pulmonary Sarcoidosis is not Related to Clinical Classifications

Elevated COX-2 activity is associated with the development of chronic lung diseases leading to bronchial obstruction, including sarcoidosis. The aim of the study was to examine expression pattern of COX-2 messenger RNA (mRNA). Expression was performed by q-PCR method in bronchoalveolar lavage (BAL) cells and peripheral blood (PB) lymphocytes in sarcoidosis patients (n?=?61) and control group (n?=?30). Analysis of COX-2 mRNA expression level in BAL fluid and PB revealed downregulation in sarcoidosis and control groups. In PB lymphocytes, the statistically significant difference between patients and controls was observed (P?=?0.003, Mann–Whitney U test), with higher expression in patients. There were no statistically significant differences between patients without and with parenchymal involvement (stages I vs. II–IV), between patients with acute vs. insidious onset of disease and between patients with abnormal vs. normal spirometry (P?>?0.05, Mann–Whitney U test). Results suggest that expression of COX-2 mRNA in patients with pulmonary sarcoidosis is not related to clinical classifications.     

Individualized significance of the −251 A/T single nucleotide polymorphism of interleukin-8 in severe infections

Based on the concept of the individualized nature of sepsis, we investigated the significance of the ?251 A/T (rs4073) single nucleotide polymorphism (SNP) of interleukin (IL)-8 in relation to the underlying infection. Genotyping was performed in 479 patients with severe acute pyelonephritis (UTI, n?=?146), community-acquired pneumonia (CAP, n?=?109), intra-abdominal infections (IAI, n?=?119), and primary bacteremia (BSI, n?=?105) by restriction fragment length polymorphism of the polymerase chain reaction (PCR) product and compared with 104 healthy volunteers. Circulating IL-8 was measured within the first 24 h of diagnosis by an immunosorbent assay. Carriage of the AA genotype was protective from the development of UTI (odds ratio 0.38, p: 0.007) and CAP (odds ratio 0.30, p: 0.004), but not from IAI and BSI. Protection from the development of severe sepsis/septic shock was provided for carriers of the AA genotype among patients with UTI (odds ratio 0.15, p: 0.015). This was accompanied by greater concentrations of circulating IL-8 among patients with the AA genotype. It is concluded that carriage of rs4073 modifies susceptibility for severe infection in an individualized way. This is associated with a modulation of circulating IL-8.