Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early posttransplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa(P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.     

Potential risk factors and outcomes of infection with multidrug resistance among diabetic patients having ulcers: 7 years study

Diabetes Mellitus is characterized as a hyperglycemic condition, which results due to alteration in the secretion of insulin or action of insulin. The development and spread of microorganisms is known as a key health concern, and such cases are growing drastically in hospitals and communities. Therefore, the study aims to determine the potential risk factors and infection outcomes among diabetic patients with multi drug resistance, who are suffering from foot ulcerations. A prospective cohort analysis was carried out among 192 diabetic patients admitted in the Rajiv Gandhi Centre for Diabetes and Endocrinology of Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, India. The patients having ulcer or ulcers in their foot during the period December 2008–June 2015 were included in the study. The results indicated the rate of resistance to CS and PC, which was 56.7% and 51.9%. The most common isolates included Escherichia coli (25.5%), Staphylococcus aureus (22.6%), and Klebsiella sp (5.4%). A total of 121 isolates from 278 were associated with the MDR. Furthermore, anaerobic isolates were also included in the study which included Peptostreptococcus spp, Propionibacterium spp, Clostridium perfringens, Eggerthella lenta, and Bacteroides ureolyticus. Ulcer was found among majority of patients with the duration of 1 month; whereas, the ulcer size was also the major risk factor for diabetic patients. Therefore, it is concluded that there is a major need for surveillance of resistant bacteria to reduce the risk of major complications.     

Yersinia enterocolitica: Pathogenesis,virulence and antimicrobial resistance

Yersinia enterocolitica is a heterogeneous group of strains, which are classified into 6 biogroups, and into more than 57 O serogroups. However, the human pathogenic strains most frequently isolated worldwide belong to serogroups O:3, O:5,27, O:8 and O:9. The major route of Y. enterocolitica infection is through contaminated foods or water. The primary pathogenic event is colonization of the intestinal tract where most of the pathologic effects and clinical manifestations occur. Temperature and calcium concentration regulate expression of virulence factors that guide the invading yersiniae and allow them to survive and disseminate. Gastrointestinal infections are usually self-limiting and do not merit antimicrobial therapy. Nonetheless, fluoroquinolones or third generation cephalosporins, the best therapeutic options, are warranted to treat enterocolitis in compromised hosts and in patients with septicemia or invasive infection, in which the mortality can be as high as 50%. A review of the pathogenesis, virulence and antimicrobial resistance is carried out.     

Reporting antimicrobial susceptibilities and phenotypes of resistance to vancomycin in vancomycin-resistant Enterococcus spp. clinical isolates: A nationwide proficiency study

IntroductionThe ability of Spanish microbiology laboratories to (a) determine antimicrobial susceptibility (AS), and (b) correctly detect the vancomycin resistance (VR) phenotype in vancomycin-resistant Enterococcus spp. (VRE) was evaluated.MethodsThree VRE isolates representing the VanA (E. faecium), VanB (E. faecium) and VanC (E. gallinarum) VR phenotypes were sent to 52 laboratories, which were asked for: (a) AS method used; (b) MICs of ampicillin, imipenem, vancomycin, teicoplanin, linezolid, daptomycin, ciprofloxacin, levofloxacin and quinupristin–dalfopristin, and high-level resistance to gentamicin and streptomycin; (c) VR phenotype.Results(a) The most frequently used system was MicroScan; (b) according to the system, the highest percentage of discrepant MICs was found with gradient strips (21.3%). By antimicrobial, the highest rates of discrepant MICs ranged 16.7% (imipenem) to 0.7% (linezolid). No discrepant MICs were obtained with daptomycin or levofloxacin. Mayor errors (MEs) occurred with linezolid (1.1%/EUCAST) and ciprofloxacin (5.0%/CLSI), and very major errors (VMEs) with vancomycin (27.1%/EUCAST and 33.3%/CLSI) and teicoplanin (5.7%/EUCAST and 2.3%/CLSI). For linezolid, ciprofloxacin, and vancomycin, discrepant MICs were responsible for these errors, while for teicoplanin, errors were due to a misassignment of the clinical category. An unacceptable high percentage of VMEs was obtained using gradient strips (14.8%), especially with vancomycin, teicoplanin and daptomycin; (c) 86.4% of the centers identified VanA and VanB phenotypes correctly, and 95.0% the VanC phenotype.ConclusionMost Spanish microbiology laboratories can reliably determine AS in VRE, but there is a significant percentage of inadequate interpretations (warning of false susceptibility) for teicoplanin in isolates with the VanB phenotype.