A survey of methicillin-resistant Staphylococcus aureus control strategies in Italy

Purpose

Data regarding the implementation of state-of-the-art methicillin-resistant Staphylococcus aureus (MRSA) control procedures in Italy are lacking. There is a need to evaluate compliance with MRSA recommendations (CR) in Italian hospitals.

Methods

A 67-question closed-answer survey was sent to all Italian hospitals, in order to analyze and evaluate program consistency with CR [hand hygiene (HH), contact precautions, screening of high-risk patients, decolonization, feedback on surveillance data, and antimicrobial guidelines and education programs].

Results

205 hospitals, which account for 42 % of national admissions, returned questionnaires. 131 hospitals (64 %) did not have written MRSA control guidelines. Hospitals reported the following levels of compliance with CR: (1) HH: 67 hospitals (33 %); (2) contact precautions: 33 (16 %); (3) MRSA screening: 66 (32 %); (4) MRSA decolonization: 42 (20 %); (5) surveillance data feedback: 87 (43 %); and (6) antimicrobial guidelines and education programs: 41 (20 %). One hospital (0.5 % of responses) had implemented all recommendations and 28 hospitals (14 %) had implemented four or five recommendations. 31 % of hospitals surveyed had implemented none. Multivariate analysis showed that the only factor identified as being associated with the implementation of MRSA control recommendations was the number of meetings/year of the infection control team (ICT) (p = 0.004).

Conclusions

Written MRSA control guidelines are available in only one-third of Italian facilities. An organized system, with ≥4 interventions, has been implemented in just 1 out of 7 hospitals. HH programs and ICT activity are related to better MRSA control. In Italy, there is significant opportunity for improvement in MRSA control.     

Nationwide surveillance of antimicrobial consumption and resistance to Pseudomonas aeruginosa isolates at 203 Japanese hospitals in 2010

Purpose

In Japan, a national surveillance study of antimicrobial consumption has never been undertaken. This study aimed to describe antimicrobial consumption and resistance to Pseudomonas aeruginosa in 203 Japanese hospitals, to identify targets for quality improvement.

Methods

We conducted an ecological study using retrospective data (2010). Antimicrobial consumption was collected in the World Health Organization (WHO) anatomical therapeutic chemical/defined daily dose (ATC/DDD) format. Rates of imipenem (IPM), meropenem (MEPM), ciprofloxacin (CPFX), or amikacin (AMK) resistance were expressed as the incidence of non-susceptible isolates. Additionally, hospitals were asked to provide data concerning hospital characteristics and infection control policies. Hospitals were classified according to functional categories of the Medical Services Act in Japan.

Results

Data were collected from 203 Japanese hospitals (a total of 91,147 beds). The total antimicrobial consumption was 15.49 DDDs/100 bed-days (median), with consumptions for penicillins, carbapenems, quinolones, and glycopeptides being 4.27, 1.60, 0.41, and 0.49, respectively. The median incidences of IPM, MEPM, CPFX, and AMK resistance were 0.15, 0.10, 0.13, and 0.03 isolates per 1,000 patient-days, respectively. Antimicrobial notification and/or approval systems were present in 183 hospitals (90.1 %). In the multivariate analysis, the piperacillin/tazobactam, quinolones, and/or total consumptions and the advanced treatment hospitals showed a significant association with the incidence of P. aeruginosa resistant to IPM, MEPM, CPFX, and AMK [adjusted R ² (aR ²) values of 0.23, 0.30, 0.22, and 0.35, respectively).

Conclusion

This is the first national surveillance study of antimicrobial consumption in Japan. A continuous surveillance program in Japan is necessary in order to evaluate the association among resistance, antimicrobial restriction, and consumption.     

A one-year prospective study on the antibiotic resistance of E. coli strains isolated in urinary specimens of children hospitalized at the University Pediatric Medical Center in Novi Sad, Serbia

Purpose

Urinary tract infections (UTIs), the most common serious bacterial infections in children, are frequently caused by Escherichia coli. The purpose of this study was to investigate E. coli resistance/multidrug resistance to antibiotics most frequently used for UTIs.

Methods

Children 0–18 years of age, hospitalized at the University Pediatric Hospital in Novi Sad, Serbia, were included in a 1-year observational prospective study. The microbiological analysis was performed using the standard Kirby–Bauer disk diffusion method. The results were analyzed using WHONET 5.4 software.

Results

E. coli was isolated from 61.7 % of positive urine specimens. In general, higher average E. coli antibiotic resistance was found in infants and toddlers compared to children and adolescents (33.4 vs. 25.0 %) (p < 0.0001). Furthermore, it was observed that the average resistance to all the tested antibiotics was higher in boys than in girls (37.0 vs. 25.1 %) (p < 0.0001). E. coli was highly susceptible to piperacillin/tazobactam (>93.1 %), amikacin (86.3 %), quinolones (>75.0 %), and penems (>96.6 %). The prevalence of multiresistant E. coli strains was significantly higher in infants and toddlers (72.3 vs. 36.8 %) (p < 0.0001).

Conclusions

E. coli, a common cause of UTIs in children admitted to pediatric hospitals, is highly resistant/multidrug-resistant to commonly used antibiotics. Higher average resistance is found in infants and toddlers than in children and adolescents, as well as in boys compared to girls. These findings are important for the regional empiric therapy of UTIs and call for actions to decrease E. coli antibiotic resistance.     

Epidemiology of invasive fungal infections in the intensive care unit: results of a multicenter Italian survey (AURORA Project)

Purpose

The aims of this study are to evaluate the epidemiology of invasive fungal infections (IFIs) in patients admitted to an intensive care unit (ICU) in Southern Italy and the in vitro antifungal susceptibility of isolates.

Methods

A surveillance program was implemented in 18 ICUs. IFI cases were recorded using a standardized form.

Results

A total of 105 episodes of IFIs occurred in 5,561 patients during the 18-month study. The main infections were caused by yeasts, more than filamentous fungi (overall incidence of 16.5 cases per 1,000 admissions and 2.3 cases per 1,000 admissions, respectively). The overall crude mortality rate was high (42.8 %), particularly for mold infections (61.5 %). All yeast infections were Candida bloodstream infections. Over half (59.8 %) were caused by Candida non-albicans, with C. parapsilosis being the most common (61.8 %). In the multivariate model, trauma admission diagnosis, prolonged stay in the ICU, and parenteral nutrition were independently associated with candidemia due to C. parapsilosis [odds ratio (OR) 3.5, (1.8–5.2); OR 3.5, (1.02–3.5); OR 3.6, (1.28–6.99), respectively]. Among mold infections, 12 patients suffered from invasive pulmonary aspergillosis, with Aspergillus fumigatus as the predominant pathogen (41.7 %). One case of brain scedosporiosis was identified. Overall, azoles and echinocandins resistance was uncommon.

Conclusions

Candida non-albicans species are the most frequent cause of candidemia in ICU patients. Mold infections are associated with a high mortality rate. This study confirms the importance of the epidemiological surveillance on IFIs in the ICU setting for documenting species distribution and antimicrobial susceptibility patterns to guide therapeutic choices.     

Adherence to an antibiotic stewardship bundle targeting Staphylococcus aureus blood stream infections at a 200-bed community hospital

Purpose

Bacteremia with Staphylococcus aureus (SAB) is a serious clinical condition and is associated with a high mortality, ranging from 20 to 40 %. Different trials from tertiary referral hospitals demonstrate that infectious disease consultation and adherence to standard of care indicators reduce the high mortality. Data from <250-bed general hospitals are lacking in this context.

Methods

Patient cases at a community 200-bed general hospital with documented SAB were retrospectively analyzed from January 2010 to March 2013 regarding defined standard of care indicators. In April 2013, an antibiotic stewardship bundle approach was implemented targeting SAB. Follow-up was available until December 2013. Adherence to the different components of the bundle was analyzed.

Results

There were 64 cases of SAB reported. After exclusion of five cases, 39 cases were included in the pre-intervention period and 20 patients in the post-intervention period. Mean average bundle adherence increased from a baseline score of 0.8–3.7 (p < 0.001) in the post-intervention period, whereas in-hospital mortality decreased significantly (44 vs. 10 %, p < 0.001) despite or even because the absolute number of detected cases of SAB increased substantially after the intervention was initiated.

Conclusion

Although we were unable to identify whether the bundle, one of its components, or procedural improvements are responsible for the success of the intervention, our study indicates that the applied approach is feasible and is accompanied by a significant reduction of in-hospital mortality in the secondary care setting. The intervention may serve as a model for other hospitals with similar structures and baseline situations.     

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

Purpose

To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey.

Methods

A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach.

Results

In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42–0.7; P value, 0.0001.)

Conclusions

The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.     

Effect of early antibiotic prophylaxis with ertapenem and meropenem in experimental acute pancreatitis in rats

Background

The clinical course in acute necrotizing pancreatitis is mainly influenced by bacterial infection of pancreatic and peripancreatic necrosis. The effect of two antibiotic treatments for early prophylaxis was studied in the taurocholate model of necrotizing pancreatitis in the rat.

Methods

Sixty male Sprague-Dawley rats were divided into three pancreatitis groups (15 animals each) and a sham-operated group (15 animals, control group). Pancreatitis was induced by intraductal infusion of 3% taurocholate under sterile conditions. Animals were placed on one of two different antibiotic regimens (15 mg/kg ertapenem or 20 mg/kg meropenem, one shot) after the induction of pancreatitis or received no antibiotics (control). All animals were sacrificed after 24 h to study pancreatic and extrapancreatic infection.

Results

Early antibiotic prophylaxis with either erapenam or meropenem significantly decreased pancreatic infection from 12/15 (control group) to 4/15 (ertapenem antibiotic group) and 3/15 (meropenem antibiotic group) (P < 0.05).

Conclusions

In our animal model of necrotizing pancreatitis, early antibiotic prophylaxis with ertapenem and meropenem reduced bacterial infection of the pancreas. The efficacy of early antibiotic prophylaxis with ertapenem in the clinical setting should be subject to further research.     

Incidence and risk factors for surveillance failure in patients with regular hepatocellular carcinoma surveillance

Background

Initial presentation of hepatocellular carcinoma (HCC) at an advanced stage in patients under a regular surveillance program is a devastating problem.

Aims

We assessed the prevalence and factors associated with this surveillance failure.

Methods

A total of 304 HCC patients who received regular surveillance were retrospectively reviewed. Surveillance failure was defined when the tumor was diagnosed at beyond the Milan criteria.

Results

Surveillance failure rate was 5.9 %. Macronodular cirrhosis (MC), ultrasonography-only surveillance (US-S) and infiltrative tumor type were independent factors associated with surveillance failure. The surveillance failure rate was higher in patients with MC (10.3 vs. 3.2 %, p = 0.022), US-S (14.6 vs. 4.3 %, p = 0.013) and when the tumor was infiltrative type (57.1 vs. 2.1 %, p < 0.001). Based on the two baseline factors (MC and US-S), the surveillance failure rates were 35.7, 6.8, 5.9 and 2.6 % for MC(+)/US-S(+), MC(+)/US-S(?), MC(?)/US-S(+) and MC(?)/US-S(?), respectively (p < 0.001).

Conclusion

The HCC surveillance failure was not rare in clinical practice. These data suggest that special attention for surveillance failure might be needed for patients with MC who receive US-S.     

Methicillin-resistant Staphylococcus aureus (MRSA) in Europe: which infection control measures are taken?

Background

The prevalence of hospital-acquired Methicillin-resistant Staphylococcus aureus (MRSA) infections shows a huge variety across Europe. Some countries reported a reduction in MRSA frequency, while in others countries increasing MRSA rates have been observed. To reduce the spread of MRSA in the healthcare setting, a sufficient MRSA management is essential. In order to reflect the MRSA management across Europe, MRSA prevention policies were surveyed in ten countries.

Materials and methods

The survey was performed by questionnaires in European intensive care units (ICUs) and surgical departments (SDs) in 2004. Questionnaires asked for availability of bedside alcohol hand-disinfection, isolation precautions, decolonization and screening methods. The study was embedded in the Hospital in Europe Link for Infection Control through Surveillance (HELICS) Project, a European collaboration of national surveillance networks. HELICS was initiated in order to harmonize the national surveillance activities in the individual countries. Therefore, HELICS participants developed surveillance modules for nosocomial infections in ICUs and for surgical site infections (SSI). The coordination of this surveillance has now been transferred to the European Centre for Disease Prevention and Control (ECDC).

Results

A total of 526 ICUs and 223 SDs from ten countries sent data on organisational characteristics and policies, demonstrating wide variations in care. Substantial variation existed in availability of bedside alcohol hand-disinfection, which was much higher in participating ICUs rather than in SDs (86 vs. 59%). Surveillance cultures of contact patients were obtained in approximately three-fourths of all SDs (72%) and ICUs (75%). Countries with decreasing MRSA proportions showed especially strict implementation of various prevention measures.

Conclusion

The data obtained regarding MRSA prevention measures should stimulate infection control professionals to pursue further initiatives. Particularly, the vigorous MRSA management in countries with decreasing MRSA proportions should encourage hospitals to implement preventive measures in order to reduce the spread of MRSA.     

Clinical spectrum and outcome of critically ill patients suffering from prosthetic joint infections

Purpose

To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs).

Methods

Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series.

Results

A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02).

Conclusions

In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.     

Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): a matched prospective cohort study

Purpose

Central venous catheter-associated bloodstream infections (CVC BSI) are a common and serious complication among critically ill patients on intensive care units (ICUs), but also result in a financial burden for the health care system. Our aim was to determine the additional costs and length of stay (LOS) of patients with ICU-acquired CVC BSI.

Methods

We used the surveillance method of the German nosocomial infection surveillance system (Krankenhaus Infections Surveillance System, KISS) to find cases of CVC BSI. The associated costs of CVC BSI were estimated as true costs generated within our hospital. We used a matched cohort design, comparing patients with CVC BSI and patients without BSI. The study period was from January to December 2010. Patients were matched by age, sex, and Simplified Acute Physiology Score (SAPS). The LOS in the ICU of control patients needed to be at least as long as that of CVC BSI patients before the onset of CVC BSI.

Results

We matched 40 CVC BSI patients to 40 patients without BSI. The median hospital costs for CVC BSI patients were significantly higher than for patients without BSI (60,445 € vs. 35,730 €; p = 0.006) and the CVC BSI patients stayed longer in the hospital than patients without CVC BSI (44 days vs. 30 days; p = 0.110). The median attributable costs per CVC BSI was 29,909 € (p = 0.006) and the median attributable LOS was 7 days (p = 0.006).

Conclusion

CVC BSI is associated with increased hospital costs and prolonged hospital stay. Hospital management should implement control measurements to keep the incidence of CVC BSI as low as possible.     

Association of levofloxacin resistance with mortality in adult patients with invasive pneumococcal diseases: a post hoc analysis of a prospective cohort

Objective

This study was conducted to identify risk factors for mortality and to evaluate the impact of antimicrobial resistance on outcome in adult patients with invasive pneumococcal disease (IPD).

Methods

A post hoc analysis of an observational cohort study on community-acquired pneumococcal infections was conducted and a total of 136 adult patients with IPD were analyzed in this study.

Results

Pneumonia was the most common type of infection (n = 84, 61.8 %), followed by primary bacteremia (n = 15, 11.0 %) and meningitis (n = 15, 11.0 %). One hundred and three patients (75.7 %) had concomitant pneumococcal bacteremia. The overall 30-day mortality rate was 26.5 % (36/136), and factors associated with 30-day mortality were corticosteroid use, presentation with septic shock, and development of acute respiratory distress syndrome (ARDS) (all P < 0.05). While penicillin and erythromycin resistance were associated with a lower mortality, an association between levofloxacin resistance and increased mortality was found in the univariate analysis; however, statistical significance was not reached (P = 0.083). Multivariable analysis showed that presentation with septic shock, corticosteroid use, development of ARDS, and levofloxacin resistance were independent factors associated with 30-day mortality. Of the five patients with IPD caused by levofloxacin-resistant Streptococcus pneumoniae, three (60 %) died within 30 days of diagnosis.

Conclusion

Levofloxacin resistance was associated with increased mortality, along with septic shock, prior use of corticosteroids, and development of ARDS, in adult patients with IPD. Our data suggest that the emergence of levofloxacin resistance among invasive pneumococcal isolates is now becoming a challenge for clinicians managing community-acquired bacterial infections.     

High rates of quinolone-resistant strains of Shigella sonnei in HIV-infected MSM

Purpose

There is increasing evidence that shigellosis is a predominantly sexually transmitted disease among men who have sex with men (MSM) and that infection with the human immunodeficiency virus (HIV) is a risk factor for shigellosis.

Methods

Retrospective analysis of antibiotic resistance profiles of Shigella species isolated from stool specimens of patients presenting with diarrhea from January 2010 to July 2012 in three German outpatient clinics specialized in HIV care.

Results

Among 79 cases of Shigella sonnei, 56 occurred in HIV-infected MSM, while 23 were observed in HIV-negative MSM. High resistance rates (>90 %) were found for doxycycline, tetracycline, aminoglycosides, all cephalosporins of first and second generations tested, and trimethoprim/sulfamethoxazole. In total, 54 % of cases were resistant to ciprofloxacin. Compared to negative subjects, HIV-infected MSM had a significantly higher rate of quinolone resistance. For ciprofloxacin, the resistance rates were 66 versus 24 %, respectively (p = 0.0016). Individual resistance patterns did not indicate that this was due to a limited outbreak. Rates of resistance to other antibiotics than quinolones showed no differences between HIV-infected and HIV-negative cases. No resistance was found for carbapenems or newer cephalosporins such as ceftriaxone.

Conclusions

The high rates of S. sonnei isolates resistant to quinolones and other traditional antibiotics are of concern. Innovative prevention efforts are urgently needed. The empirical use of quinolones in HIV-infected patients presenting with S. sonnei infection is no longer recommended.     

Fecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae in Korean community and hospital settings

Purpose

The assessment and early recognition of risk factors for infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are important for infection control and proper treatment. The aim of the present study was to investigate the prevalence of fecal carriage of ESBL-E in healthy individuals and hospitalized high-risk patients in Korea and to compare the characteristics of ESBL-E in these two groups.

Methods

A total of 384 samples from 290 healthy individuals and 94 high-risk patients were collected. The screening of ESBL-E was performed using a commercial chromogenic medium. Bacterial identification and antibiotic susceptibility testing were performed using the Vitek 2 system.

Results

The prevalence of ESBL-E carriage was 20.3 % in healthy individuals and 42.5 % in high-risk patients. Escherichia coli comprised a large majority (96.6 %) of the isolates from healthy individuals, but Klebsiella pneumoniae was more commonly detected (45.0 %) in high-risk patients than in healthy individuals. K. pneumoniae isolates exhibited significantly higher resistance to ceftazidime, ampicillin, and carbapenem, and E. coli exhibited higher resistance to cefotaxime. E. coli from high-risk patients exhibited significantly higher resistance to levofloxacin and cefepime than that from healthy individuals.

Conclusions

We demonstrated the high prevalence of ESBL-E carriage in Korea and clarified the characteristics of ESBL-E carriage in healthy individuals and high-risk patients. The distribution and antibiotic susceptibility of colonizing ESBL-E were different between the group of healthy individuals and the high-risk patients. Active surveillance of ESBL-E carriage is suggested for infection control, and the use of chromogenic agar appears to be an efficient method.     

Factors associated with rifampin resistance in staphylococcal periprosthetic joint infections (PJI): a matched case–control study

Purpose

Rifampin combination therapy plays an important role in the management of staphylococcal periprosthetic joint infection (PJI). However, the emergence of rifampin resistance is a feared complication. We retrospectively analysed predetermined potential risk factors in patients with rifampin-resistant staphylococcal PJI in a multicentre case–control study.

Methods

Cases (n = 48) were defined as PJI caused by rifampin-resistant staphylococci. Rifampin-susceptible controls (n = 48) were matched for microorganism and type of prosthetic joint. Uni- and multivariable conditional logistic regression analyses were performed to estimate odds ratios (OR) with 95 % confidence intervals (95 % CI).

Results

Forty-eight cases (31 men; median age 67 years; age range 39–88 years) with hip- (n = 29), knee- (n = 13), elbow- (n = 4), shoulder- (n = 1) or ankle-PJI (n = 1) were enrolled in the study. Staphylococcus aureus and coagulase-negative staphylococci were isolated in ten and 38 episodes, respectively. Most of the cases (n = 44, 92 %) had a previous PJI, and 93 % (n = 41) of these had been treated with rifampin. There was an independent association of emergence of rifampin resistance with male sex (OR 3.6, 95 % CI 1.2–11), ≥3 previous surgical revisions (OR 4.7, 95 % CI 1.6–14.2), PJI treatment with high initial bacterial load (inadequate surgical debridement, <2 weeks of intravenous treatment of the combination medication; OR 4.9, 95 % CI 1.6–15) and inadequate rifampin therapy (OR 5.4, 95 % CI 1.2–25).

Conclusions

Based on our results, extensive surgical debridement and adequate antibiotic therapy are needed to prevent the emergence of rifampin resistance.     

Erreger nosokomialer Infektionen auf Intensivstation

Methods

The hospital infection surveillance system KISS (Krankenhaus-Infektions-Surveillance-Systems) has been used to record nosocomial infections (NI) in German intensive care units (ICU) for over 10 years. KISS focuses on three of the most important types of nosocomial infections: lower respiratory tract infections (pneumonia and bronchitis), primary bloodstream infections, and urinary tract infections. Parallel special risk factors – devices like ventilation, central line and urinary catheters – are monitored. Up to four pathogens can be recorded for each infection. The reported surveillance data were collected in 483 ICUs in 340 German hospitals from January 1, 2003 to December 31, 2007.

Results

A total of 1,280,331 patients with 4,519,338 patient-days were included and 21,608 nosocomial infections were recorded. In lower respiratory tract infections, the five most common pathogens were S. aureus (21.3/100 NI), P. aeruginosa (18.1/100 NI), Klebsiella spp. (12.6/100 NI), E. coli (11.7/100 NI), and Enterobacter spp. (8.6/100 NI) in declining order. Primary bloodstream infections were diagnosed with coagulase-negative staphylococcus (33.5/100 NI) most frequently, followed by S. aureus (13.8/100 NI), Enterococcus spp. (13.7/100 NI), Klebsiella spp. (4.5/100 NI), and C. albicans (4.4/100 NI). After stratification for the type of ICU, differences in the distribution of pathogens could be shown. Overall 35.3% of all S. aureus isolates were MRSA, ranging from 31.1% in 2003 to 36.5% in 2007. The ratio of VRE in susceptible Entercocci was 2.7% overall. The proportion of ESBL producing bacteria was 6.4% for infections caused by E. coli and 11.2% for infections with Klebsiella spp.

Conclusions

The KISS data present an overview of the most important pathogens associated with nosocomial infections and show current trends in antimicrobial resistance in intensive care units in Germany.     

Bacteriological analysis of bile in acute cholecystitis according to the Tokyo guidelines

Background

We performed bacteriological analysis of bile in acute cholecystitis (AC) patients graded in severity according to the Tokyo guidelines.

Methods

We enrolled 163 AC patients in whom bacteriological analysis of bile was performed.

Results

Significant differences in age (60 vs. 67 years), body temperature (BT) (37.2 vs. 37.6°C), white blood cell count (13,033 vs. 15,177/mm³), and serum C-reactive protein (CRP) (8.9 vs. 16.9 mg/dL) were found between the Mild and Moderate severity groups. The prevalence of bactibilia differed significantly between Mild and Moderate patients (45.3 vs. 67.0%, P = 0.0107); however, there were no significant differences in the bacterial strains, prevalence of antimicrobial resistance, or polymicrobial isolation frequency between the 2 groups. Our local antibiogram revealed that several microorganisms showed higher resistance rates; these were also isolated even in Mild cases. Advanced age, high BT, high serum CRP, and presence of marked local infection were identified as being significantly associated with high risk of bactibilia. Receiver operating characteristic curve analysis indicated the optimal cutoff value of age to be 65 years, of BT to be 37.5°C, and of serum CRP to be 13.4 mg/dL.

Conclusion

Adequate broad-spectrum antimicrobial therapy should be administered perioperatively even for Mild patients classified according to the current Tokyo guidelines. These results suggest that more precise severity grades may need to be established, including age and CRP as additional parameters.     

A 1-year prospective survey of candidemia in Italy and changing epidemiology over one decade

Purpose

The aim of this study was to assess the epidemiology of candidemia and antifungal susceptibility profiles of Candida isolates in Italy through a prospective surveillance study and to evaluate changes compared to a previous survey performed in one Italian region (Lombardy) in 1997–1999.

Methods

A prospective laboratory-based surveillance of candidemia was performed in Italy from January to December 2009. For each case a questionnaire was filled in, and the first isolate was collected and tested for in vitro antifungal susceptibility.

Results

During our 12-month survey, 467 episodes of candidemia were reported from 34 centres (30 located in Lombardy) and 464 isolates collected. Candida albicans was the predominant species (overall incidence 50.4 %), but the proportion varied considerably from 52.1 % in Lombardy hospitals to 45.2 % hospitals located outside this region. The second most frequent species was C. glabrata in Lombardy and C. parapsilosis in other regions. Comparison of the 1997–1999 and 2009 data on episodes of candidemia in Lombardy revealed a threefold increase in incidence (from 0.38 to 1.19 per 1,000 admissions), aging of infected patients, decline in crude mortality (from 35 to 27.1 %) and an increased proportion of C. glabrata etiology (from 12.8 to 20.3 %). Susceptibility testing confirmed the broad activity of amphotericin B and echinocandins. Decreased susceptibility to fluconazole was found in 24.9 % of the tested isolates.

Conclusions

The results of this latest survey confirm the high rate of candidemia in Italy and show changes in some of the epidemiological tracts, such as aging of infected patients, increased proportion of C. glabrata infections, increased diagnosis in medical wards, and improvement in patients’ survival.