Kidney Transplantation From Deceased Donors With Bloodstream Infection: A Multicenter Retrospective Study

BackgroundThe use of organs from donors with infection is limited because of the possibility of transmission. We aimed to investigate the transmission after deceased donor transplantation with bloodstream infection (BSI).MethodsA retrospective study of patients undergoing kidney or pancreas transplantation at five tertiary centers in Korea from January 2009 and November 2019 was performed. We analyzed the outcomes after transplantation from deceased donors with BSI.ResultsEighty-six recipients received transplantation from 69 donors with BSI. The most common isolated pathogens from donors were Gram-positive bacteria (72.0%), followed by Gram-negative bacteria (22.7%), and fungi (5.3%). Appropriate antimicrobial agents were used in 47.8% of donors before transplantation. Transmission occurred only in 1 of 83 recipients (1.2%) from bacteremic donors and 1 of 6 recipients (16.7%) from fungemic donors. One-year patient and graft survival was 97.5%and 96.3%, respectively. There was no significant difference in graft and patient survival between patients who received organs from infected donors and noninfected donors.ConclusionUsing organs from donors with bacteremia seems to be a safe option with low transmission risk. The overall prognosis of using organs from donors with BSI is favorable.     

Treatment duration for Escherichia coli bloodstream infection and outcomes: retrospective single-centre study

ObjectivesTo investigate the impact of treatment duration on mortality and on relapse in patients with Escherichia coli bloodstream infection (BSI).MethodsRetrospective single-centre study of patients diagnosed with E. coli BSI at our centre over a 4-year period. Exclusion criteria: age <18 years, clinical data not available, polymicrobial BSI, failure to receive in vitro active therapy, and death while receiving antibiotic therapy. Exposure variable was treatment duration dichotomized into short (≤10 days) and long (>10 days) therapy. Primary end point was all-cause mortality within 90 days after index BSI. Secondary end point was relapse, defined as repeat isolation of E. coli from blood cultures within 90 days after index BSI, in patients with documented clinical cure and completion of therapy for the initial episode.ResultsOf the 856 analysed patients: 426 received short and 430 received long therapy. All-cause mortality at day 90 occurred in 47 patients; on multivariate analysis, short therapy was not associated with a higher risk of mortality, also after adjusting the model for the propensity score of receiving short therapy. Relapse occurred in 42 patients. Independent risk factors for relapse using death as competing risk were immunosuppression (subhazard ratio 4.67, p < 0.001), and end-stage liver disease (subhazard ratio 2.58, p 0.013). The propensity-weighted estimation of the average treatment effect for relapse reduction with long therapy (>10 days) was –1.6% (p 0.26) in the total population, and –7.1% (p 0.18) in immunocompromised patients.ConclusionsWe could not identify shorter treatment duration as a risk factor for mortality and for relapse in patients with E. coli BSI.     

Staphylococcus aureus as source of catheter‐related bloodstream infection evaluated by PFGE and rep‐PCR typing in a Brazilian hospital

Staphylococci are a common cause of catheter‐related bloodstream infection (CR‐BSI), and epidemiological typing is an important tool for effective infection control. This study evaluated by PFGE and rep‐PCR whether Staphylococcus aureus strains isolated from skin and catheter tips were related to specimens isolated from blood. A prospective observational study, carried out in a clinical surgical ward at a Brazilian hospital between September 2000 and November 2002, investigated non‐tunneled central venous catheters from 179 patients. S. aureus isolates were mainly obtained from blood (41.4%), while coagulase‐negative staphylococci strains were more often isolated from the skin at the catheter insertion site (49.7%) and from the catheter tip (57.5%). Among the 21 strains isolated from 9 patients at 2 or 3 sites simultaneously, 9 were methicillin‐resistant S. aureus (MRSA) and 12 were methicillin‐susceptible S. aureus (MSSA). Seven patients harbored the same S. aureus strain isolated from the skin, blood and/or catheter tip cultures. MRSA isolates belonged to one PFGE pattern (type A‐ subtypes A₁, A₂ and A₃), and to two rep‐PCR patterns (a and b). MSSA isolates were distinguished in five PFGE (B to F) and in three rep‐PCR (c, d and e) patterns. Both PFGE and rep‐PCR methods indicated that the skin at the catheter insertion site was the origin of CR‐BSI caused by S. aureus.     

Predictors of multidrug-resistant Pseudomonas aeruginosa in neutropenic patients with bloodstream infection

ObjectivesTo assess risk factors for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infection in neutropenic patients.MethodsSingle-centre retrospective analysis of consecutive bloodstream infection (BSI) episodes (2004–2017, Barcelona). Two multivariate regression models were used at BSI diagnosis and P. aeruginosa detection. Significant predictors were used to establish rules for stratifying patients according to MDR-PA BSI risk.ResultsOf 661 Gram-negative BSI episodes, 190 (28.7%) were caused by P. aeruginosa (70 MDR-PA). Independent factors associated with MDR-PA among Gram-negative organisms were haematological malignancy (OR 3.30; 95% CI 1.15–9.50), pulmonary source of infection (OR 7.85; 95% CI 3.32–18.56), nosocomial-acquired BSI (OR 3.52; 95% CI 1.74–7.09), previous antipseudomonal cephalosporin (OR 13.66; 95% CI 6.64–28.10) and piperacillin/tazobactam (OR 2.42; 95% CI 1.04–5.63), and BSI occurring during ceftriaxone (OR 4.27; 95% CI 1.15–15.83). Once P. aeruginosa was identified as the BSI aetiological pathogen, nosocomial acquisition (OR 7.13; 95% CI 2.87–17.67), haematological malignancy (OR 3.44; 95% CI 1.07–10.98), previous antipseudomonal cephalosporin (OR 3.82; 95% CI 1.42–10.22) and quinolones (OR 3.97; 95% CI 1.37–11.48), corticosteroids (OR 2.92; 95% CI 1.15–7.40), and BSI occurring during quinolone (OR 4.88; 95% CI 1.58–15.05) and β-lactam other than ertapenem (OR 4.51; 95% CI 1.45–14.04) were independently associated with MDR-PA. Per regression coefficients, 1 point was assigned to each parameter, except for nosocomial-acquired BSI (3 points). In the second analysis, a score >3 points identified 60 (86.3%) out of 70 individuals with MDR-PA BSI and discarded 100 (84.2%) out of 120 with non-MDR-PA BSI.ConclusionsA simple score based on demographic and clinical factors allows stratification of individuals with bacteraemia according to their risk of MDR-PA BSI, and may help facilitate the use of rapid MDR-detection tools and improve early antibiotic appropriateness.     

Bloodstream infections in patients with rectal colonization by Klebsiella pneumoniae producing different type of carbapenemases: a prospective,cohort study (CHIMERA study)

ObjectiveTo investigate the hypothesis that intestinal colonization by different types of carbapenemase-resistant Klebsiella pneumoniae (CR-Kp) leads to different risks for bloodstream infections (BSI) caused by the same colonizing organism.MethodsProspective observational study including consecutive CR-Kp rectal carriers admitted to the Pisa University Hospital (December 2018 to December 2019). Patients underwent rectal swabbing with molecular testing for the different carbapenemases at hospital admission and during hospitalization. Rectal carriers were classified as: NDM, KPC, VIM and OXA-48. The primary end point was the rate of BSI by the same colonizing organism in each study group. A multivariate logistic regression analysis was performed to identify factors independently associated with the risk for BSI by the colonizing organism.ResultsOf 677 rectal carriers, 382/677 (56.4%) were colonized by NDM, 247/677 (36.5%) by KPC, 39/677 (5.8%) by VIM and 9/677 (1.3%) by OXA-48. Dissemination of NDM-Kp was mostly sustained by ST147, while KPC-Kp belonged to ST512. A higher rate of BSI was documented in NDM rectal carriers compared with KPC rectal carriers (59/382, 15.4% versus 20/247, 8.1%, p 0.004). Incidence rates of BSI per 100 patients/month were significantly higher in the NDM group (22.33, 95% CI 17.26–28.88) than in the KPC group (9.56, 95% CI 6.17–14.82). On multivariate analysis, multi-site extraintestinal colonization, solid organ transplantation, invasive procedures, intravascular device, admission to intensive care unit, cephalosporin, fluoroquinolones and NDM rectal colonization (OR 3.27, 95% CI 1.73–6.18, p < 0.001) were independently associated with BSI.ConclusionsNDM-Kp was associated with increased risk of BSI compared with KPC-Kp. This finding seems to be strongly related to the high-risk clone ST147.     

Variability of Candida albicans strains in ICU in Tunisia hospital

BackgroundCandida albicans is a saprophyte yeast for healthy body that finds in hospitals area a favourable condition for pathogenic development.ObjectivesEvaluate the relative roles of endogenous origin and the importance of patient-to-patient transmission in C. albicans colonization in intensive care units (ICU).Patients and methodsWe screened 36 strains isolated from various clinical samples from 12 patients. Genotyping of C. albicans strains was performed by using a restriction fragment length polymorphisms (RFLP) and hybridization with ribosomal DNA “3 μ probe” of Saccharomyces cerevisiae.ResultsPersons colonized or having disease due to C.albicans at two or more body sites had the same individual type. Three patients were infected by different subtypes of strains. Southern blot with rDNA revealed that variation consisted of highly repeated rDNA. Establishment of similarity coefficient between seven patients hospitalized at the same period in ICU showed that these isolates were completely unapparented.ConclusionThe acquisition of C. albicans in the ICU seems to be mainly endogenous and that cross infection was unlikely.     

Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections

BackgroundThe role of oral antimicrobial agents in the management of bloodstream infections (BSI) is currently evolving.ObjectivesThis narrative review summarizes and appraises clinical studies that examined transition from intravenous to oral antimicrobials or compared effectiveness of various oral agents for definitive therapy of uncomplicated and complicated BSI in adults.SourcesRelevant English-language studies from MEDLINE (since inception) and presented abstracts at international scientific meetings (since 2017).ContentEmerging data suggest potential utility of oral switch strategy, particularly to oxazolidinones, as an alternative to standard intravenous therapy in low-risk patients with uncomplicated Staphylococcus aureus BSI. Moreover, results of recent randomized clinical trials are promising that combination oral regimens may play a role in antimicrobial management of complicated Gram-positive BSI, including infective endocarditis, septic arthritis and osteomyelitis. Whereas oral fluoroquinolones have been used successfully for decades in both uncomplicated and complicated Gram-negative BSI, recent studies suggest that trimethoprim-sulfamethoxazole and aminopenicillins represent alternative oral options in uncomplicated Enterobacteriaceae BSI. Oral azoles have been used for definitive therapy of Candida species BSI and are currently recommended by the international management guidelines.ImplicationsRecent studies demonstrate that early transition from intravenous to oral therapy is a feasible and effective strategy in most patients with BSI due to Gram-negative bacteria, obligate anaerobic bacteria and Candida species. Oral antimicrobial combinations may be considered in select patients with complicated Gram-positive BSI after 10–14 days of intravenous therapy. Future studies will determine the role of oral agents for switch therapy in uncomplicated Gram-positive BSI.     

A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients

ObjectivesTo describe the current epidemiology of bloodstream infection (BSI) in patients with cirrhosis; and to analyse predictors of 30-day mortality and risk factors for antibiotic resistance.MethodsCirrhotic patients developing a BSI episode were prospectively included at 19 centres in five countries from September 2014 to December 2015. The discrimination of mortality risk scores for 30-day mortality were compared by area under the receiver operator risk and Cox regression models. Risk factors for multidrug-resistant organisms (MDRO) were assessed with a logistic regression model.ResultsWe enrolled 312 patients. Gram-negative bacteria, Gram-positive bacteria and Candida spp. were the cause of BSI episodes in 53%, 47% and 7% of cases, respectively. The 30-day mortality rate was 25% and was best predicted by the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure–SOFA (CLIF-SOFA) score. In a Cox regression model, delayed (>24 hours) antibiotic treatment (hazard ratio (HR) 7.58; 95% confidence interval (CI) 3.29–18.67; p < 0.001), inadequate empirical therapy (HR 3.14; 95% CI 1.93–5.12; p < 0.001) and CLIF-SOFA score (HR 1.35; 95% CI 1.28–1.43; p < 0.001) were independently associated with 30-day mortality. Independent risk factors for MDRO (31% of BSIs) were previous antimicrobial exposure (odds ratio (OR) 2.91; 95% CI 1.73–4.88; p < 0.001) and previous invasive procedures (OR 2.51; 95% CI 1.48–4.24; p 0.001), whereas spontaneous bacterial peritonitis as BSI source was associated with a lower odds of MDRO (OR 0.30; 95% CI 0.12–0.73; p 0.008).ConclusionsMDRO account for nearly one-third of BSI in cirrhotic patients, often resulting in delayed or inadequate empirical antimicrobial therapy and increased mortality rates. Our data suggest that improved prevention and treatment strategies for MDRO are urgently needed in the liver cirrhosis patients.     

Bacterial and fungal bloodstream infections in solid organ transplant recipients: results from a Danish cohort with nationwide follow-up

ObjectivesBloodstream infections (BSI) are prevalent after solid organ transplantation (SOT). In this study, we aimed to investigate the incidence and risk factors for BSI in the first 5 years post-transplantation.MethodsThe study included 1322 SOT (kidney, liver, lung and heart) recipients transplanted from 2010 to 2017 with a total of 5616 years of follow-up. Clinical characteristics and microbiology were obtained from the Centre of Excellence for Personalized Medicine of Infectious Complications in Immune Deficiency (PERSIMUNE) data repository with nationwide follow-up. Incidence was investigated in the different SOT groups. Risk factors associated with BSI were assed in the combined group in time-updated multivariable Cox regressions.ResultsThe cumulative incidence of first BSI in the first 5 years post-transplantation differed in the SOT groups with a lower incidence in heart transplant recipients than in the other SOT groups (heart: 4.4%, CI 0.0–9.7%, vs. kidney: 24.6%, CI 20.9–28.2%, liver: 24.7%, CI 19.4–29.9%, and lung: 19.6%, CI 14.5–24.8%, p <0.001). Age above 55 years (HR 1.71, CI 1.2–2.4, p=0.002) and higher Charlson comorbidity index score (HR per unit increase: 1.25, CI 1.1–1.4, p<0.001) at transplantation, current cytomegalovirus (CMV) infection (HR 4.5, CI 2.6–7.9, p<0.001) and current leucopenia (HR 13.3, CI 3.7–47.9, p<0.001) were all associated with an increased risk of BSI.ConclusionIn SOT recipients, the incidence of BSI differed with the type of transplanted organ. Risk of BSI was higher in older recipients and in recipients with comorbidity, current CMV infection or leucopenia. Thus, increased attention towards BSI in recipients with these characteristics is warranted.     

Measuring patient-centred long-term outcome following a bloodstream infection: a pilot study

ObjectivesTo evaluate the sequential organ failure assessment (SOFA) and modified SOFA (mSOFA) scoring and a novel performance score based on the Karnofsky score for measuring outcome following a bloodstream infection (BSI).MethodThis prospective observational cohort study assessed patients with BSI for mortality and functional outcomes with a novel performance score: the functional bloodstream infection score (FBIS). We also tested the SOFA and, given the difficulties with measuring SOFA on ward-based patients, the mSOFA over the first 7 days following a BSI for their association with outcomes.ResultsOne hundred participants were prospectively recruited. Mortality at 52 weeks following BSI was 21% (21/100). Only 57% of survivors (39/69) were at their baseline functional status at 52 weeks. Stable or improved SOFA/mSOFA over the first 7 days was associated with survival and return to premorbid performance score (risk ratio 3.2, 95%CI 1.3–9.4, p < 0.01).ConclusionsThe acute change in SOFA/mSOFA was associated with 52-week survival and return to premorbid functional performance. The FBIS measurement represents a simple and easy-to-apply measure of functional performance for patients with BSI and was associated with a high response rate (89%) from participants.     

Impact of nosocomial polymicrobial bloodstream infections on the outcome in critically ill patients

The aims of this study were to compare the clinical and microbiological characteristics from patients with polymicrobial bloodstream infections (BSI) to those from patients with monomicrobial BSI and to determine their influence on the prognosis. A prospective study was conducted on 371 nosocomial BSI in an intensive care unit (ICU). Seventy-five (20.2%) of them were polymicrobial. The mean APACHE II score at the onset of bacteremia in polymicrobial and monomicrobial BSI were 17.7 ± 6.6 and 18.9 ± 7.5, respectively (p=0.228). Severe sepsis and septic shock were present in 68.0% and 50.6% of polymicrobial BSI and in 73.9% and 55.1% of monomicrobial BSI, respectively (p=0.298 and p=0.494, respectively). The length of stay and the length of stay post-infection were significantly longer in patients with polymicrobial BSI. APACHE II score at the onset of BSI, high-risk microorganisms, and septic shock were predictors of related mortality, but polymicrobial BSI and inadequate empirical antimicrobial treatment were not. Our findings suggest that the clinical and microbiological characteristics of polymicrobial BSI are not different from monomicrobial BSI, and polymicrobial BSI do not have any influence on the related mortality. However, they occurred in patients with a longer length of stay in the hospital and were associated with longer stays in the hospital after the episode of BSI.     

Reducing Bloodstream Infection Risk in Central and Peripheral Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection

BackgroundAlthough few facilities focus on it, bloodstream infection (BSI) risk from peripheral intravenous catheters (PIVs) may exceed central line-related risk. Over a 6-year period, Methodist Hospitals substantially reduced BSIs in patients with central lines but not in patients with PIVs. A practice audit revealed deficiencies in manual disinfection of intravenous connectors, thereby increasing BSI risk. Methodist thus sought an engineered approach to hub disinfection that would compensate for variations in scrubbing technique.MethodsOur institution involved bedside nurses in choosing new hub disinfection technology. They selected 2 devices to trial: a disinfection cap that passively disinfects hubs with isopropyl alcohol and a device that friction-scrubs with isopropyl alcohol. After trying both, nurses selected the cap for use in the facility's 3 intensive care units. After no BSIs occurred during a 3-month span, we implemented the cap throughout the hospital for use on central venous catheters; peripherally inserted central catheters; and peripheral lines, including tubing and Y-sites.ResultsComparing the postintervention period (December 2011-August 2013) to the preintervention span (September 2009-May 2011), the BSI rate dropped 43% for PIVs, 50% for central lines, and 45% overall (PIVs + central lines). The central line and overall results are statistically significant. The PIV BSI rate drop is attributable to cap use alone because the cap was the only new intervention during the postimplementation period. The other infection reductions appear to be at least partly due to cap use.ConclusionsOur institution achieved substantial BSI reductions, some statistically significant, by applying a disinfection cap to both PIVs and central lines.     

A nationwide population-based study of Escherichia coli bloodstream infections: incidence,antimicrobial resistance and mortality

ObjectivesEscherichia coli is the leading cause of bloodstream infection (BSI). The incidence of E. coli BSI caused by antibiotic-resistant strains is increasing. We aimed to describe the nationwide incidence and resistance profile of E. coli BSI in Israel and its impact on mortality, to compare E. coli BSI mortality with all-cause mortality, and community-onset with hospital-onset E. coli BSIs.MethodsWe used mandatory BSI surveillance reports submitted by all Israeli hospitals to the Ministry of Health and the national death registry. All E. coli BSIs from 1 January 2018 to 31 December 31 2019 in patients aged 18 and over were included.ResultsA total of 11 113 E. coli BSIs occurred in 10 218 patients; 85% (9012/10 583) were community onset. Median age was 76 (IQR 65–85), and 57% (6304/11 113) of cases occurred in women. The annual incidence was 92.5 per 100 000 population. Antibiotic resistance was frequent and significantly more common in hospital-onset than in community-onset BSI; 65% (1021/1571) vs. 45% (4049/9012) were multidrug-resistant (MDR) (p < 0.001). The case fatality rate (CFR) was higher following hospital-onset BSI than community-onset: 23% (276/1214) vs. 12% (926/7620) at 14 days, 31% (378/1214) vs. 16% (1244/7620) at 30 days, and 55% (418/766) vs. 34% (1645/4903) at 1 year (p < 0.001 for all comparisons). The 1-year CFR was 47% (1258/2707) for MDR vs. 28% (928/3281) for non-MDR (p < 0.001). The annual mortality rate was 31.0 per 100 000 population, comprising 4.2% (31.0/734.8) of all causes of deaths.DiscussionE. coli BSI carries a high burden, with a large proportion of MDR isolates, which are associated with increased incidence and CFR.     

Risk factors for community-onset bloodstream infection with extended-spectrum β-lactamase-producing Enterobacteriaceae: national population-based case–control study

ObjectivesThe aim was to investigate risk factors for community-onset bloodstream infections with extended-spectrum β-lactamase-producing Enterobacteriaceae (EPE BSI).MethodsIt is mandatory to report EPE BSI to a national register at the Public Health Agency of Sweden. Using this register, we performed a population-based case–control study from 2007 to 2012 of 945 cases and 9390 controls. Exposure data on comorbidity, hospitalization, in- and outpatient antibiotic consumption and socio-economic status were collected from hospital and health registers.ResultsThe overall incidence of EPE BSI was 1.7 per 100 000 person-years. The 30-day mortality was 11.3%. Urological disorders inferred the highest EPE BSI risk, adjusted odds ratio (aOR) 4.32 (95% Confidence Interval (CI) 3.41–5.47), followed by immunological disorders, aOR 3.54 (CI 2.01–6.23), haematological malignancy, aOR 2.77 (CI 1.57–4.87), solid tumours, aOR 2.28 (1.76–2.94) and diabetes, aOR 2.03 (1.58–2.61). Consumption of fluoroquinolones or mostly non-EPE-active antibiotics with selective Gram-negative spectrum of activity within the previous 3 months was associated with EPE BSI, aORs 5.52 (CI 2.8–11.0) and 3.8, CI 1.9–7.7) respectively. There was a dose–response relationship in EPE BSI risk with increasing number of consecutive regimens. Antibiotic consumption >3 months before EPE BSI was not associated with increased risk. Higher age, malignancies and education ≤12 years (aORs >2) were associated with increased 30-day mortality.ConclusionsTargeted interventions should be directed towards improving care for patients with immunosuppression, urological disorders and subjects with lower socio-economic status. Antibiotic stewardship should focus on reduction of fluoroquinolones.     

Clinical outcome and costs of nosocomial and community-acquired Staphylococcus aureus bloodstream infection in haemodialysis patients

The main aim of this study was to evaluate the clinical outcome and costs of nosocomial and community-acquired methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA) bloodstream infection (BSI) in patients undergoing haemodialysis. A multicentre retrospective study was conducted that included 109 patients with end-stage renal disease and S. aureus BSI who were hospitalised in three German centres between 1999 and 2005. Nosocomial and community-acquired infections were analysed separately with regard to costs and outcome. Forty-nine (45%) patients had nosocomial infection. Compared to patients with community-acquired infection, these patients were more likely to have had BSI caused by MRSA (40.8% vs. 13.3%, p <0.05). BSI was the initial reason for admission for 33 (55%) patients who had community-acquired infection. The mean length of hospitalisation was 24 days for patients with community-acquired infection and 51 days for patients with nosocomial infection (p <0.05). Costs per treatment episode were 20,024 Euros for nosocomial infection vs. 9554 Euros for community-acquired infection (p <0.05). The average treatment costs for patients with MSSA BSI were <50% of those for patients with MRSA BSI (10,573 vs. 24,931 Euros, p <0.05). S. aureus BSI is an underlying cause of substantial health risk and high morbidity among the haemodialysis-dependent population, who are already at high-risk for other reasons. This study also highlighted differences according to the source of BSI, including costs arising from hospitalisation and treatment.     

Higher HTLV-1c proviral loads are associated with blood stream infections in an Indigenous Australian population

BackgroundAn association between blood stream infections (BSI) and HTLV-1 seropositivity in Indigenous Australians might result from HTLV-1 mediated inflammation and parasite coinfections that provide portals of entry for bacteria.ObjectivesTo determine whether BSI risk increases with HTLV-1c proviral load (PVL) and to identify the pathogens responsible in the context of HTLV-1 related conditions.Study designIndigenous adults admitted to Alice Springs Hospital, central Australia, were recruited as cases or controls according to whether they had a BSI. Clinical data were extracted from case notes and the hospital pathology database. HTLV-1 serology and PVL assays were then performed and risk factors for BSI were determined for HTLV-1 infected subjects.ResultsRisk factors were compared between 44 cases and 30 controls who were HTLV-1 Western blot positive. In a multivariable model, high HTLV-1c PVL was predictive of BSI during the study period (OR, 9.10; 95% CI, 2.40–34.4). Median (IQR) HTLV-1c PVL (copies per 100 PBL) was 39-fold higher for patients recording any BSI (0.116 (0.009, 0.277)) relative to those who had no BSI (0.003 (0.000, 0.067))(p = 0.0007). Mean (SD) PVL for subjects with no BSI (n = 27), 1 BSI (n = 37) and ≥2 BSI (n = 10) during the study period were 0.120 (0.301), 0.271 (0.622) and 0.500 (0.654) copies per 100 PBL, respectively (p = 0.0007). Five BSI were associated with possible complications of HTLV-1; strongyloidiasis (3), infective dermatitis (1), HTLV-1 associated bronchiectasis (1).ConclusionsHigher HTLV-1c PVL predicts BSI risk; however; most BSI were not associated with recognised complications of HTLV-1 infection.     

Appropriate antibiotic therapy is a predictor of outcome in patients with Stenotrophomonas maltophilia blood stream infection in the intensive care unit

Background/purposeThe study was to assess the relationship between antibiotic therapy and the outcome in intensive care unit (ICU) patients with Stenotrophomonas maltophilia bloodstream infection (BSI).MethodsICU patients with monomicrobial S. maltophilia BSI from January 2004 to December 2019 were included and divided into two groups—those with- and without appropriate antibiotic therapy after BSI—for comparison. The primary outcome was the relationship between appropriate antibiotic therapy and 14-day mortality. The secondary outcome was the influence of different antibiotic therapies: levofloxacin- and trimethoprim–sulfamethoxazole (TMP/SMX)-containing regimens, on 14-day mortality.ResultsA total of 214 ICU patients were included. Patients received appropriate antibiotic therapy (n = 133) after BSI had a lower 14-day mortality than those (n = 81) without appropriate antibiotic therapy (10.5% vs. 46.9%, p < 0.001). No difference on 14-day mortality between groups of patients by time of appropriate antibiotic therapy was observed (p > 0.05). After a propensity score matching, the results is consistent that 14-day mortality were lower in patients with appropriate antibiotic therapy than those without appropriate antibiotic therapy (11.5% vs. 39.3%, p < 0.001). Among patients with S. maltophilia BSI receiving appropriate antibiotic therapy, there was a trend levofloxacin-containing regimens is associated with lower mortality than TMP/SMX-containing regimens (HR 0.233, 95% CI 0.050–1.084, p = 0.063).ConclusionAppropriate antibiotic therapy was associated with decreased 14-day mortality in ICU patients with S. maltophilia BSI regardless of time. Levofloxacin-containing regimens may be better choice than TMP/SMX -containing regimens in treating ICU patients with S. maltophilia BSI.     

Immunomodulatory therapy,risk factors and outcomes of hospital-acquired bloodstream infection in patients with severe COVID-19 pneumonia: a Spanish case–control matched multicentre study (BACTCOVID)

ObjectivesThe effect of the use of immunomodulatory drugs on the risk of developing hospital-acquired bloodstream infection (BSI) in patients with COVID-19 has not been specifically assessed. We aim to identify risk factors for, and outcomes of, BSI among hospitalized patients with severe COVID-19 pneumonia.MethodsWe performed a severity matched case–control study (1:1 ratio) nested in a large multicentre prospective cohort of hospitalized adults with COVID-19. Cases with BSI were identified from the cohort database. Controls were matched for age, sex and acute respiratory distress syndrome. A Cox proportional hazard ratio model was performed.ResultsOf 2005 patients, 100 (4.98%) presented 142 episodes of BSI, mainly caused by coagulase-negative staphylococci, Enterococcus faecalis and Pseudomonas aeruginosa. Polymicrobial infection accounted for 23 episodes. The median time from admission to the first episode of BSI was 15 days (IQR 9–20), and the most frequent source was catheter-related infection. The characteristics of patients with and without BSI were similar, including the use of tocilizumab, corticosteroids, and combinations. In the multivariate analysis, the use of these immunomodulatory drugs was not associated with an increased risk of BSI. A Cox proportional hazard ratio (HR) model showed that after adjusting for the time factor, BSI was associated with a higher in-hospital mortality risk (HR 2.59; 1.65–4.07; p < 0.001).DiscussionHospital-acquired BSI in patients with severe COVID-19 pneumonia was uncommon and the use of immunomodulatory drugs was not associated with its development. When adjusting for the time factor, BSI was associated with a higher mortality risk.     

Determinants and outcomes of bloodstream infection in adults associated with one versus two sets of positive index blood cultures

ObjectivesTo investigate whether positivity in one or both index sets of blood cultures influences clinical determinants and mortality when diagnosing bloodstream infections (BSI).MethodsRetrospective population-based surveillance of all mono-microbial BSI was conducted among residents of the western interior of British Columbia. Clinical details were obtained by chart review and all-cause case-fatality was established at 30 days. Index cultures were defined as the first two sets of cultures initially drawn to diagnose incident BSI.ResultsA total of 2500 incident BSI were identified of which 945 (37.8%) and 1555 (62.2%) were based on one and two positive index cultures, respectively. There was an overall difference in the distribution of pathogens, with both Staphylococcus aureus and Streptococcus pneumoniae more likely to have two positive index cultures. Different foci of infection were associated with one versus two positive index cultures. Overall, 409 patients died within 30 days of index BSI for an all-cause case-fatality of 16.4%; with no difference between two positive (250/1555; 16.1%) and one positive (159/945; 16.8%; p 0.3) index blood culture. The number of positive index blood cultures was not associated with 30-day case-fatality after adjustment for confounding variables using logistic regression analysis.ConclusionsAlthough approximately one-third of BSI are diagnosed on the basis of a single positive blood culture and are associated with different clinical determinants, whether one or both index blood cultures are positive is not associated with lethal outcome.     

High-risk HPV detection and concurrent HPV 16 and 18 typing with Abbott RealTime High Risk HPV test

BackgroundHigh-risk human papillomavirus (HPV) is the causative agent of cervical cancer. Among the high-risk types, infection with HPV 16 and 18 is associated with significantly higher risk of disease progression, and consequently these two types together cause approximately 70% of invasive cervical cancer worldwide. Identification of HPV 16 and HPV 18 can provide valuable information for risk stratification and clinical management of patients infected with these two types in both ASC-US triage and primary screening in women over age 30. It may also be valuable in the assessment of HPV vaccine efficacy. Abbott RealTime High Risk (HR) HPV is a recently developed test for the detection of 14 high-risk HPV types with the ability to concurrently identify HPV 16 and 18.ObjectiveTo evaluate the clinical performance of Abbott RealTime HR HPV test. Study design: Abbott RealTime HR HPV was evaluated with 253 cervical specimens obtained from patients with CIN 3 and 340 specimens from patients with cervical cancer to determine clinical sensitivity of the test and the prevalence of types 16 and 18. Additionally, 757 cervical specimens obtained from women 30 years of age or older with normal cytology in a general screening population were tested to determine high-risk HPV positivity rate.ResultsThe Abbott RealTime HR HPV test detected 97.2% (246/253) of CIN 3 specimens and 98.5% (335/340) of cancer specimens. HPV 16 was the most prevalent type in both CIN 3 (72.8%) and cancer specimens (64.5%). HPV 16 and 18 combined were detected in 78.9% of high-risk HPV positive CIN 3 and 84.8% of high-risk HPV positive cancer specimens. In specimens from women 30 years of age or older with normal cytology in a screening population, the HPV positivity rate was 6.5% (49/757).ConclusionsAbbott RealTime HR HPV is a highly sensitive test for detection of high-grade cervical disease and cancer. The HPV 16 and HPV 18 typing capability of the test offers the advantage of stratifying patients at greater risk of progression and may thus aid in better patient care and management.