Infected aortic aneurysm caused by Streptococcus pyogenes: A case report

We reported the case with infected abdominal aortic aneurysm (AAA) caused by Streptococcus (S.) pyogenes. A seventy-seven-year-old man, who had the history of uncontrolled diabetes mellitus (DM), complained fever and abdominal pain. Abdominal computed tomography scan revealed the aneurysm above common iliac artery with false lumen. On admission, laboratory tests found marked elevation of inflammatory biomarkers. Thereby the infected AAA was suspected and blood culture was taken. The administration of meropenem (MEPM) and daptomycin (DAP) was started. Next day he underwent abdominal aortic replacement with prosthetic graft and debridement because of persistent abdominal pain and the enlargement of aneurysm. S. pyogenes in blood culture samples was identified by Matrix Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry. Same result was obtained from the tissue samples of the resected AAA. Then the diagnosis of infected AAA caused by S. pyogenes was made. Since isolated S. pyogenes showed the susceptibility to antibiotics tested including penicillin, antibiotics were changed to ampicillin (ABPC) for the de-escalation of antibiotics. He had kept the administration of ABPC for 4 weeks and transferred to another hospital for the further treatment of DM. The aneurysms by S. pyogenes are extremely rare, but we should note that S. pyogenes could induce the aneurysms.     

Preseptal cellulitis with Streptococcus pyogenes complicated by streptococcal toxic shock syndrome: A case report and review of literature

Preseptal cellulitis, an infection of the eyelid and skin around the eye, can be distinguished from orbital cellulitis. It is common in children and is rarely complicated. Streptococcus pyogenes is one of the major pathogens causing preseptal cellulitis. Here, we report a case of a 46-year-old man with carcinoma of unknown primary presenting preseptal cellulitis of S. pyogenes complicated by streptococcal toxic shock syndrome and multiple metastatic abscesses involving right eyelid, subcutaneous tissue in the scalp, mediastinum, bilateral pleural spaces, pericardial space, and the left knee. Although he required a prolonged hospitalization, antibiotic therapy and multiple courses of debridement led to full recovery. A literature review revealed that there were only four cases of preseptal cellulitis with S. pyogenes in adults and two cases were complicated by streptococcal toxic shock syndrome. The cases had either trauma or immunocompromising factors similar to our patient. All patients survived with antibiotic therapy and debridement, and the functional outcome was favorable. In summary, preseptal cellulitis caused by S. pyogenes can be severe in adult cases where immunocompromising factors and type of strain may play a role in the severity of the disease. Awareness of the risk of severe complications, treatment with appropriate antibiotic therapy, and timely debridement are crucial for favorable prognoses.     

Isolates and antibiotic susceptibilities of endogenous bacterial endophthalmitis: A retrospective multicenter study in Japan

Endogenous bacterial endophthalmitis, also called metastatic endophthalmitis, is a rare bacterial endophthalmitis derived from distant infectious foci via the bloodstream. This infection can potentially cause not only severe visual disturbance, but also loss of the eyeball or death, as most patients are immunocompromised. This retrospective Japanese multicenter study analyzed 32 eyes in 25 definitive cases. Twelve patients (48.0%) had diabetes mellitus. Typical ocular findings were vitreous haze (87.5%), cells in the anterior chambers (62.5%) and retinal infiltrates (50.0%). Elevated body temperature (64.0%), high serum C-reactive protein (96.0%) and leukocytosis (52.0%) were also frequently observed. Culture positivity rates for intraocular fluid were higher in the vitreous (62.5%) versus aqueous humor (28.6%). High positivity rates were also observed for blood (57.1%) and central venous catheters (100%). The most common pathogen was Staphylococcus aureus (10 cases), including methicillin-resistant S. aureus (4 cases). The next most common pathogen was Klebsiella pneumoniae (7 cases), which was highly associated with liver abscess. Compared to a previous 1991 national multicenter study, there has been a fourfold increase in the ratio of S. aureus. Antibiotic susceptibility tests revealed that all Gram-positives were susceptible to vancomycin and all Gram-negatives were susceptible to third-generation cephalosporins, imipenem/cilastatin, gentamycin and levofloxacin. Prognostic factors influencing poor visual outcome included poor initial visual acuity (p < 0.01), K. pneumoniae (p = 0.027) and gram-negative bacteria (p = 0.014) as the causative bacteria. Intravitreal antibiotic injection in combination with vancomycin and ceftazidime may be applicable for use as part of the standard treatment regimen for EBE.     

Critical care staff wellbeing: A new paradigm for understanding burnout

BackgroundThe wellbeing of paediatric intensive care unit (PICU) staff members influences their engagement with work and the quality of care they provide to patients. Baseline burnout measures in research provide inconclusive evidence of the determinants of burnout and how to target interventions to promote staff wellbeing.ObjectivesThe objectives of this study were to determine the prevalence of burnout using the Maslach Burnout Inventory (MBI) burnout-engagement workplace profiles in a sample of Australian PICU staff and investigate associations between demographic characteristics, meaningful work, satisfaction with life, and psychological distress on burnout.MethodsA cross-sectional survey was administered to a multidisciplinary sample of PICU staff (target n = 464) from three tertiary paediatric hospitals in Australia. The survey tool was comprised of the MBI, Work and Meaning Inventory, Satisfaction with Life Scale, Kessler Psychological Distress Scale, and demographic questions. Hierarchical multiple regressions examined the relationships between burnout and these variables of interest.ResultsA sample of 258 participants (56%) completed the survey. For most respondents, burnout was scored as a low to moderate risk, with over half the participants scoring low risk for emotional exhaustion (EE) (56%) and depersonalisation (DP) (54%). Personal accomplishment (PA) was more evenly distributed (range of burnout risk: low, 32%; moderate, 32%; high, 36%). MBI scores were classified using the burnout-engaged workplace profile system, identifying low levels of burnout (8% burnout, 3% disengaged, 21% overextended, 29% ineffective, and 39% engaged). Psychological distress significantly increased burnout risk across all three dimensions EE (β = 0.253, p < 0.001), DP (β = 0.145, p < 0.05), and PA (β = ?0.13, p < 0.05), and being aged between 41 and 55 years was protective of depersonalisation (β = ?0.214, p < 0.05).ConclusionUtilising MBI workplace profiles, this study has built upon the demand for a more comprehensive assessment of burnout. Research that helps improve our understanding of contributory factors to burnout and wellbeing will inform the development of effective interventions that promote wellbeing of staff.     

Impact of fibrin glue versus suture closure on double-headed pterygia in Asian eyes – a 7-year study in a tertiary institution

BackgroundTo compare the recurrence rate and outcomes of double-headed pterygia using fibrin glue versus suture closure of conjunctival autograft.MethodsAll patients with double-headed pterygia who underwent pterygia excision with conjunctival autograft from January 2012 to January 2019 in the National University Hospital of Singapore were included. Patients were divided into 2 groups depending on whether fibrin glue or sutures were used to secure the conjunctival autograft in place. All patients had a minimum of 6 months follow-up.ResultsA total (26 patients) of 22 eyes had fibrin glue, while eight eyes underwent suture closure of their conjunctival autograft. Fibrin glue group had 4.5% recurrence rate, while suture group had 37.5% recurrence rate (p = .021). There is statistically significant improvement for overall visual acuity (p = .009) and cylinder (p = .002). There is also statistically significant improvement for visual acuity in the glue group (p = .026), but not in the suture group. Fibrin glue group had a shorter operation duration time compared to suture group (p < .001).There were no cases of graft dislocation, contraction or limbal stem cell deficiency.ConclusionsLow recurrence rates and good postoperative visual outcomes can be achieved with the split conjunctival autograft technique. Our study suggests that fibrin glue has an additional benefit over the use of sutures in the management of these complex cases.     

Novel Bacteriophage Lysin with Broad Lytic Activity Protects against Mixed Infection by Streptococcus pyogenes and Methicillin-Resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) and Streptococcus pyogenes (group A streptococcus [GrAS]) cause serious and sometimes fatal human diseases. They are among the many Gram-positive pathogens for which resistance to leading antibiotics has emerged. As a result, alternative therapies need to be developed to combat these pathogens. We have identified a novel bacteriophage lysin (PlySs2), derived from a Streptococcus suis phage, with broad lytic activity against MRSA, vancomycin-intermediate S. aureus (VISA), Streptococcus suis, Listeria, Staphylococcus simulans, Staphylococcus epidermidis, Streptococcus equi, Streptococcus agalactiae (group B streptococcus [GBS]), S. pyogenes, Streptococcus sanguinis, group G streptococci (GGS), group E streptococci (GES), and Streptococcus pneumoniae. PlySs2 has an N-terminal cysteine-histidine aminopeptidase (CHAP) catalytic domain and a C-terminal SH3b binding domain. It is stable at 50°C for 30 min, 37°C for >24 h, 4°C for 15 days, and −80°C for >7 months; it maintained full activity after 10 freeze-thaw cycles. PlySs2 at 128 μg/ml in vitro reduced MRSA and S. pyogenes growth by 5 logs and 3 logs within 1 h, respectively, and exhibited a MIC of 16 μg/ml for MRSA. A single, 2-mg dose of PlySs2 protected 92% (22/24) of the mice in a bacteremia model of mixed MRSA and S. pyogenes infection. Serially increasing exposure of MRSA and S. pyogenes to PlySs2 or mupirocin resulted in no observed resistance to PlySs2 and resistance to mupirocin. To date, no other lysin has shown such notable broad lytic activity, stability, and efficacy against multiple, leading, human bacterial pathogens; as such, PlySs2 has all the characteristics to be an effective therapeutic.     

Inhibitory Activity of Myrtus communis Oil on Some Clinically Isolated Oral Pathogens

Objectives

To determine the antimicrobial activities of Myrtus communis oil (MCO) on some oral pathogens.

Material and Methods

Thirty strains of Streptococcus mutans, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and 20 strains of Streptococcus pyogenes and Candida albicans isolated from patients with dental caries, periodontal diseases, pharyngitis and oral lesions associated with artificial dentures were used for the antimicrobial activity of MCO. The oil was prepared by hydrodistillation procedures using a Clevenger apparatus. Agar disk diffusion and broth microdilution methods were performed on various concentrations of MCO (3.9–1,000 µg/ml) using all the pathogens isolated.

Results

All isolates were sensitive to MCO at 125–1,000 µg/ml by agar disk diffusion producing inhibition zones of 8.1–41.25 mm in diameter. All of the S. pyogenes, S. mutans and C. albicans strains were sensitive to 62.5 µg/ml while 70% (21/30) of A. actinomycetemcomitans and 66.6% (20/30) of P. gingivalis were resistant to these concentrations. All S. pyogenes and S. mutans strains were sensitive to 31.25 µg/ml. All S. pyogenes strains were sensitive to 15.6 and 7.8 µg/ml of MCO. None of the clinical isolates in this study were sensitive to 3.9 µg/ml or to a lower concentration of oil. The minimum inhibitory concentrations of MCO for S. pyogenes, S. mutans, C. albicans, A. actinomycetemcomitans and P. gingivalis were 29.68 ± 4.8, 31.25 ± 0, 46.9 ± 16, 62.5 ± 0 and 62.5 ± 0 µg/ml, respectively.

Conclusions

Data obtained in this study revealed a strong antimicrobial activity of MCO on the tested oral pathogens, and MCO could therefore be useful in the prevention of the related oral infections.Key Words: Myrtus communis oil, Streptococcus pyogenes, Candida albicans, Minimum inhibitory concentration     

ARFI elastography in patients with chronic autoimmune liver diseases: A preliminary study

ObjectiveAcoustic radiation force impulse (ARFI) is a new software-based technique that evaluates liver stiffness during B-mode ultrasonography. The purpose of this study was to evaluate the accuracy of ARFI in distinguishing patients with chronic autoimmune liver disease from healthy subjects.Material and methodsWe enrolled 9 adult patients (8 women, 1 man; age 48.1 ± 12.8 years) with chronic autoimmune disease (primary biliary cirrhosis (PBC, n = 3), autoimmune hepatitis (AIH, n = 2), primary sclerosing cholangitis (PSC, n = 1) and overlap syndromes, (n = 3) who underwent a liver biopsy and 11 healthy volunteers (age 34.7 ± 10.4 years; 7 women, 4 men). Liver stiffness was evaluated and expressed as the shear wave velocity (SWV) in m/sec. We used a US scanner Siemens-Acuson S2000, evaluating the right liver lobe and the left liver lobe.ResultsThe SWV was significantly higher in cases (right lobe: 1.51 ± 0.44; left lobe: 1.57 ± 0.40) than in controls (right lobe: 1.08 ± 0.10; left lobe: 1.12 ± 0.13) (right lobe: P = 0.002; left lobe: P = 0.013). We found no significant correlation between right and left lobe SWVs in cases (P = 0.779) or controls (P = 0.385). The SWV cut-off that best distinguished cases from controls was 1.25 m/sec (accuracy: AUC=0.885; sensitivity: 70.6%; specificity: 95.5%).ConclusionsARFI elastography is a noninvasive ultrasonographic technique that can differentiate healthy subjects from patients with fibrotic stages of chronic liver disease.     

A comparison of the prophylactic uses of topical mupirocin and nitrofurazone in murine crush contaminated wounds

Objectives

This work was conducted to study the prophylactic efficacy of 2 topical antibiotic ointments (mupirocin and nitrofurazone) against wound infection in experimental contaminated crush wounds.

Methods

Male Wistar rats underwent two 2-cm incisions at the back side and randomized into 3 groups—placebo (n = 14), mupirocin (n = 14), and nitrofurazone (n = 14)—and infected with either Staphylococcus aureus or S pyogenes. All wound edges were crushed for 5 seconds with hemostats to simulate crush injury before inoculation of the microorganisms. Half of the wounds were sutured and the other half left open. These wounds were treated 3 times daily for 6 days with topical mupirocin, nitrofurazone, or petrolatum (as placebo). At the end of 6 days, excisional biopsies were taken from wound edges and histopathologic assessments were made based on neutrophilic infiltration, edema formation, myofibroblastic proliferation, and granulation tissue formation. For the microbiologic assessments, quantitative tissue cultures were made.

Results

In S aureus-inoculated wounds, mupirocin showed higher antibacterial activity against bacterial colonization and reduced infection rates compared to placebo groups. The same effect was observed for the infection rates in S pyogenes-inoculated wounds. In S pyogenes-inoculated open wounds, nitrofurazone showed higher antibacterial activity against infection, but this effect was not observed in closed wounds. In S pyogenes- and S aureus-infected wounds, mupirocin treatment significantly lowered infection rates compared to nitrofurazone treatment. Histopathologic examination showed higher myofibroblastic proliferation and higher volume of granulation tissue in the nitrofurazon groups compared to the mupirocin groups.

Conclusion

Topical mupirocin application was effective against crush wound infections inoculated with S pyogenes and S aureus. Nitrofurazone provides better granulation tissue formation, but did not effectively prevent bacterial colonization and infection in crush contaminated wounds.     

A Novel Ultrasound Methodology for Estimating Spine Mineral Density

We investigated the possible clinical feasibility and accuracy of an innovative ultrasound (US) method for diagnosis of osteoporosis of the spine. A total of 342 female patients (aged 51–60 y) underwent spinal dual X-ray absorptiometry and abdominal echographic scanning of the lumbar spine. Recruited patients were subdivided into a reference database used for US spectral model construction and a study population for repeatability and accuracy evaluation. US images and radiofrequency signals were analyzed via a new fully automatic algorithm that performed a series of spectral and statistical analyses, providing a novel diagnostic parameter called the osteoporosis score (O.S.). If dual X-ray absorptiometry is assumed to be the gold standard reference, the accuracy of O.S.-based diagnoses was 91.1%, with k = 0.859 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral densities and corresponding dual X-ray absorptiometry values, with r² values up to 0.73 and a root mean square error of 6.3%–9.3%. The results obtained suggest that the proposed method has the potential for future routine application in US-based diagnosis of osteoporosis.     

Effect of heart failure on the outcome of COVID-19 — A meta analysis and systematic review

BackgroundSeveral comorbidities have been associated with an increased risk of severity and mortality in coronavirus disease 2019 (COVID-19), including hypertension, diabetes, cerebrovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease.PurposeIn this systematic review and meta-analysis, we attempted to investigate the association between heart failure (HF) and poor outcome in patients with COVID-19.MethodsWe performed a systematic literature search from PubMed, EuropePMC, SCOPUS, Cochrane Central Database, and medRxiv with the search terms, “Heart failure” and “COVID-19”. The outcome of interest was mortality and poor prognosis (defined by incidence of severe COVID-19 infection, admission to ICU, and use of ventilator) in patients with preexisting heart failure with coronavirus disease.ResultsWe identified 204 potential articles from our search, and 22 duplicates were removed. After screening of the titles and abstracts of the remaining 182 articles we identified 92 potentially relevant articles. We excluded 74 studies due to the following reasons: four studies were systematic reviews, two studies were meta-analyses, three articles were literature reviews, and 65 articles did not report on the outcome of interest. Finally, we included the remaining 18 studies in our qualitative synthesis and meta-analysis. There were 21,640 patients from 18 studies. HF was associated with hospitalization in COVID19 HR was 2.37 [1.48, 3.79; p < 0.001], high heterogeneity [I², 82%; p < 0.001]. HF was associated with a poor outcome demonstrated by an OR of 2.86 [2.07; 3.95; p < 0.001] high heterogeneity [I², 80%; p < 0.001]. Patient with preexisting HF was associated with higher mortality OR of 3.46 [2.52, 4.75; p < 0.001] moderately high heterogeneity [I², 77%; p < 0.001].ConclusionPatients with heart failure are at increased risk for hospitalization, poor outcome, and death from COVID-19. A significant difference in mortality between patients with and without heart failure was observed, patients with heart failure having a higher mortality.     

Antimicrobial susceptibility of Streptococcus pyogenes in Central,Eastern, and Baltic European Countries, 2005 to 2006: the cefditoren surveillance program

The in vitro activity of penicillin, ampicillin, cefditoren, cefotaxime, erythromycin, clarithromycin, and levofloxacin against 763 clinical isolates of Streptococcus pyogenes was determined. Clinically significant isolates collected from November 2005 to December 2006 in the Czech Republic, Slovakia, Hungary, Poland, Romania, Estonia, Latvia, and Lithuania (the latter 3 analyzed as Baltic countries) were studied. No resistance to β-lactams and levofloxacin was found. The rate of erythromycin resistance in S. pyogenes varied among countries, being low (<10%) in Romania and Baltic countries, intermediate (10–20%) in Poland and Czech Republic, and high (>25%) in Hungary and Slovakia. The predominant (75.0%) erythromycin-resistant phenotype among S. pyogenes isolates was MLS_B. The identification of the prevalence of erythromycin resistance mechanism could have impact on the choice of empiric antibiotic therapy for the clinicians in such countries.     

Impact of identification of Streptococcus dysgalactiae subspecies equisimilis from throat cultures in an adult population

Streptococcus dysgalactiae subspecies equisimilis (SDSE) are isolated from the throat of patients with pharyngitis, although the clinical significance remains debated. We sought to determine the incidence and association with pharyngitis of SDSE in an adult veteran population. Organisms were phenotypically identified to subspecies and Lancefield group, with selective 16S rRNA gene sequencing. From 833 throat cultures, the overall frequency of SDSE was 3.4% (64% group C and 36% group G) as compared to 8.6% for S. pyogenes (GAS). SDSE was described as a large colony in only 29% of the original culture evaluations by bench technologists, and clinical symptoms were similar for GAS and SDSE. Laboratory algorithms that are limited to identification of only GAS or are based on Lancefield group or visual identification of “large-colony type” β hemolytic Lancefield group C and G streptococci may be missing or misidentifying SDSE along with Anginosus group streptococci.     

Effect of in-bed cycling on acute muscle wasting in critically ill adults: A randomised clinical trial

PurposeTo examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness.Materials and methodsA single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RF_CSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission.ResultsAnalysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RF_CSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p = .52), or for secondary outcomes (p-values ranged p = .11 to p = .95).Conclusions and relevanceIn-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials.Trial registrationanzctr.org.au Identifier: ACTRN12616000948493.     

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of japanese society of chemotherapy,the japanese association for infectious diseases,and the japanese society for clinical microbiology in 2016: General view of the pathogens’ antibacterial susceptibility

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from the patients in Japan was conducted by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2016.The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period between February 2016 and August 2016 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical Laboratory Standards Institute.Susceptibility testing was evaluated in 1062 strains (143 Staphylococcus aureus, 210 Streptococcus pneumoniae, 17 Streptococcus pyogenes, 248 Haemophilus influenzae, 151 Moraxella catarrhalis, 134 Klebsiella pneumoniae, and 159 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was 48.3%, and those of penicillin-susceptible S. pneumoniae was 99.5%. Among H. influenzae, 14.1% of them were found to be β-lactamase-producing ampicillin-resistant strains, and 41.1% to be β-lactamase-non-producing ampicillin-resistant strains. Extended spectrum β-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo β-lactamase were 4.5% and 0.6%, respectively.     

Nationwide surveillance of bacterial respiratory pathogens conducted by the Surveillance Committee of Japanese Society of Chemotherapy,Japanese Association for Infectious Diseases,and Japanese Society for Clinical Microbiology in 2009: general view of the pathogens’ antibacterial susceptibility

For the purpose of nationwide surveillance of antimicrobial susceptibility of bacterial respiratory pathogens from patients in Japan, the Japanese Society of Chemotherapy (JSC) started a survey in 2006. From 2009, JSC continued the survey in collaboration with the Japanese Association for Infectious Diseases and the Japanese Society for Clinical Microbiology. The fourth-year survey was conducted during the period from January and April 2009 by the three societies. A total of 684 strains were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections. Susceptibility testing was evaluable with 635 strains (130 Staphylococcus aureus, 127 Streptococcus pneumoniae, 4 Streptococcus pyogenes, 123 Haemophilus influenzae, 70 Moraxella catarrhalis, 78 Klebsiella pneumoniae, and 103 Pseudomonas aeruginosa). A maximum of 45 antibacterial agents including 26 β-lactams (four penicillins, three penicillins in combination with β-lactamase inhibitors, four oral cephems, eight parenteral cephems, one monobactam, five carbapenems, and one penem), four aminoglycosides, four macrolides (including ketolide), one lincosamide, one tetracycline, two glycopeptides, six fluoroquinolones, and one oxazolidinone were used for the study. Analysis was conducted at the central reference laboratory according to the method recommended by the Clinical and Laboratory Standard Institute (CLSI). Incidence of methicillin-resistant S. aureus (MRSA) was as high as 58.5 %, and that of penicillin-intermediate and penicillin-resistant S. pneumoniae (PISP and PRSP) was 6.3 % and 0.0 %, respectively. Among H. influenzae, 21.1 % of them were found to be β-lactamase-non-producing ampicillin (ABPC)-intermediately resistant (BLNAI), 18.7 % to be β-lactamase-non-producing ABPC-resistant (BLNAR), and 5.7 % to be β-lactamase-producing ABPC-resistant (BLPAR) strains. A high frequency (76.5 %) of β-lactamase-producing strains has been suspected in Moraxella catarrhalis isolates. Four (3.2 %) extended-spectrum β-lactamase-producing K. pneumoniae were found among 126 strains. Four isolates (2.5 %) of P. aeruginosa were found to be metallo-β-lactamase-producing strains, including three (1.9 %) suspected multi-drug resistant strains showing resistance against imipenem, amikacin, and ciprofloxacin. Continuous national surveillance of the antimicrobial susceptibility of respiratory pathogens is crucial to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.     

Recent trends in pediatric bacterial meningitis in Japan, 2016–2018 – S. agalactiae has been the most common pathogen

BackgroundHaemophilus influenzae type b (Hib) vaccine and pneumococcal conjugated vaccine (PCV) have been widely used since 2010 in Japan. The overall incidence of bacterial meningitis decreased thereafter. Streptococcus agalactiae has become the main organism.ObjectivesThe purpose of the present study was to investigate the incidence rate per 1000 admissions of bacterial meningitis and the change in causative organisms in subsequent years.MethodsA cross-sectional, multicenter, non-interventional retrospective study regarding pediatric bacterial meningitis was conducted in Japan in 2019. We analyzed the epidemiological and clinical data for 2016–2018, and compared the information obtained in our previous nationwide survey database. We also investigated the risk factors for disease outcome.ResultsIn the 2016–2018 surveys, 197 patients from 153 hospitals from all prefectures were evaluated. S. agalactiae (0–3 months, 39%), Streptococcus pneumoniae (2–112 months, 20%), and E. coli (0–136 months, 13%) were the main organisms. The total number of patients hospitalized with bacterial meningitis per 1000 admissions decreased from 1.00 to 1.68 in 2000–2010 to 0.38 in 2013–2015, bu remained stable thereafter (0.35–0.40 in 2016–2018). Only one case with Neisseria meningitidis was reported. Nine cases with death were reported, including four cases with S. agalactiae. Risk factors for death and sequelae were consciousness disturbance, duration of convulsion, low CSF glucose levels, and disuse of dexamethasone (p < 0.05).ConclusionsThe incidence in pediatric bacterial meningitis remained low, and S. agalactiae remains the most common cause of bacterial meningitis in Japan since 2012. S. pneumoniae is the most common cause after 3 months of age.     

Prevalence and Clonal Characterization of Streptococcus pyogenes Clinical Isolates with Reduced Fluoroquinolone Susceptibility in Spain

The aim of this study was to determine the prevalence and characteristics of non-fluoroquinolone (FQ)-susceptible Streptococcus pyogenes isolates and to study their mechanisms of resistance. We performed a prospective prevalence study with 468 isolates collected from 2005 to 2007 and a retrospective study that was based on the examination of existing data collected from 1999 to 2008. The retrospective study included data for isolates with high-level resistance (HR) to ciprofloxacin (MIC ≥ 32 μg/ml) (HR isolates) and isolates with the same emm types as those reported in the literature with low-level resistance (LR) to ciprofloxacin (MICs, 2 to 8 μg/ml) (LR isolates, n = 205). Genetic characterization of the isolates was performed by means of emm typing and multilocus sequence typing. The prevalence of LR ranged from 1.9% in 2005 to 30.8% in 2007. This increase was mainly due to the circulation of an emm6 subtype (emm6.4) that represented 77.1% of the LR isolates in 2007. Notably, another emm6 subtype, also detected in 2007 (emm6.37), showed coresistance to 14- and 15-membered macrolides mediated by the mefA gene. Only three HR isolates were detected (isolates emm68.1/ST247/T3,13,B3264, emm77/ST399/T28, and emm28/ST52/T28), and all were identified in the retrospective study. Overall, the 673 isolates represented 25 emm types. All LR isolates were clustered into two emm types: emm6 (six emm6 subtypes) and emm75. All the 156 emm6 isolates had LR, harbored the Ser79/Ala mutation in the parC gene product, and had the same sequence type (ST), ST382. Most (21/33) of the emm75 isolates had LR, showed the Ser79/Phe plus Asp91/Asn double mutation in the parC gene product, and were ST150. The Asp91/Asn mutation by itself did not confer resistance to FQs.Streptococcus pyogenes is among the most prevalent pathogens in humans. These pathogens cause a broad spectrum of infections, ranging from streptococcal sore throat, skin, and soft tissue infections to severe invasive disease. S. pyogenes also causes severe postinfectious syndromes, such as glomerulonephritis and acute rheumatic fever (8). S. pyogenes is an important cause of morbidity and mortality worldwide.S. pyogenes remains susceptible to penicillin, which is still the drug of choice for the treatment of many infections caused by this pathogen. Macrolides and lincosamides are the primary treatment for S. pyogenes infections in patients with hypersensitivity to beta-lactam antibiotics, and clindamycin is the first choice for the treatment of patients with life-threatening soft tissue infections, such as necrotizing fasciitis, because it halts exotoxin production (7, 24). Resistance to macrolides and lincosamides is not infrequently found in S. pyogenes (18, 20, 25), and when it is detected, fluoroquinolones (FQs) are a useful therapeutic alternative. FQs have been used with great success for the treatment of pneumococcal and staphylococcal infections in adults (5, 14).The mechanisms of FQ resistance among Streptococcus spp. are mainly mediated by point mutations in the quinolone resistance-determining region of the bacterial topoisomerase II enzymes, namely, DNA gyrase and topoisomerase IV (16). DNA gyrase and topoisomerase IV enzymes are homologues, with each enzyme consisting of a tetramer with two subunits (two gyrA and two gyrB molecules in DNA gyrase, two parC and two parE molecules in topoisomerase IV). In the last few years, S. pyogenes isolates with low-level resistance to FQs have been reported by several authors (1, 3, 8, 11, 12, 15, 23, 27), but isolates with a high level of resistance have been detected very infrequently (2, 13, 21, 22, 26). To our knowledge, S. pyogenes isolates with low- or high-level resistance to ciprofloxacin (LR and HR isolates, respectively) without a mutation in the parC gene have not been described. Although isolates with high-level resistance to FQs (levofloxacin or ciprofloxacin MICs ≥ 16 μg/ml) are easily detected in routine laboratory work, those with reduced susceptibility frequently remain undetectable.The serologically based M-protein typing scheme was replaced approximately 12 years ago by a highly correlated emm typing scheme based on sequence analysis of the portion of the emm gene that encodes the M-protein serospecificity of S. pyogenes. More than 200 emm types are currently listed in the online Centers for Disease Control and Prevention database (http://www.cdc.gov/ncidod/biotech/strep/strepindex.htm). Multilocus sequencing typing (MLST) is routinely used to define S. pyogenes clones and has a precision greater than that of other typing methods (6).The aim of this study was to determine the susceptibilities of S. pyogenes isolates to FQs and their mechanisms of FQ resistance and to characterize clinical S. pyogenes clones in Spain, a country with a high percentage of S. pyogenes isolates resistant to several antimicrobial agents (4, 17-19).     

Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial

AimRecently three large post product placement studies, comparing mechanical chest compression (cc) devices to those who received manual cc, found equivalent outcome results for both groups. Thus the question arises whether those results could be replicated using the devices on a daily routine.MethodsWe prospectively enrolled 948 patients over a 12 months period. Chi-Square test and Mann–Whitney-U test were used to assess differences between “manual” and “mechanical” cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the influence of cc type on survival.ResultsA mechanical cc device was used in 30.1% (n = 283) cases. Patients who received mechanical cc had a significantly worse neurological outcome – measured in cerebral performance category (CPC) – than the manual cc group (56.8% vs. 78.6%, p = 0.009). Patients receiving mechanical cc were significantly younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical cc patients.ConclusionEven with high quality CPR in both, manual and mechanical cc groups, outcome in patients who received mechanical cc was significantly worse. The anticipated benefits of a higher compression ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection for mechanical cc was not standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used should be considered.Clinical trial registration: https://ekmeduniwien.at/core/catalog/2013/ (EK-Nr:1221/2013)