Clinical characteristics and outcomes of patients with vancomycin-susceptible Enterococcus faecalis and Enterococcus faecium bacteraemia in cancer patients

The purpose of this investigation was to compare the risk factors, clinical features and outcomes in cancer patients with bacteraemia caused by vancomycin-susceptible Enterococcus faecalis and E. faecium. A retrospective, observational 7-year study was carried out in a 450-bed, acute-care university-affiliated hospital. We performed univariate comparisons between the two groups and then multivariate analysis to identify patient risk factors for E. faecium isolation. Seventy-three patients were included in the analysis: 54 (74.0%) with bacteraemia caused by E. faecalis and 19 (26.0%) by E. faecium. The Simplified Acute Physiological Score (SAPS) value was significantly greater in E. faecium isolates (40.7 vs. 35.2; p = 0.009). Diabetes mellitus was more frequently diagnosed in patients with E. faecium bacteraemia (52.6% vs. 24.1%; p = 0.021). Prior penicillin exposure was more frequent in patients with E. faecium bacteraemia (68.4% vs. 29.6%; p = 0.003). There was a trend toward higher mortality in E. faecium bacteraemia patients (47.4% vs. 25.9%; p = 0.084). Independent patient risk factors for E. faecium isolation were prior penicillin exposure (odds ratio [OR], 6.479; p = 0.003) and SAPS > 34 (OR, 6.896; p = 0.009). When compared to E. faecalis bacteraemia, E. faecium bacteraemia in cancer patients is independently associated with more severe illness and prior use of penicillins; therefore, empiric treatment which would cover E. faecium should be considered in cancer patients suspected of having bacteraemia.     

Candidemia in a Portuguese tertiary care hospital: Analysis of a 2-year period

BackgroundCandidemia is a nosocomial infection of increasing importance, associated with high morbidity and mortality. The aim of this study is to describe the species distribution, risk factors, management and outcomes of patients with candidemia.MethodsWe conducted a retrospective study at Centro Hospitalar Universitário de São João, Portugal, between January 2016 and December 2017.ResultsA total of 117 candidemia episodes (n = 114 patients) were included. Median age was 65 years, with an increased prevalence of older ages. Candida albicans (51.3%) was the most prevalent species, followed by C. glabrata (22.2%), C. parapsilosis (15.4%), C. tropicalis (4.3%) and C. lusitaniae (2.6%). Forty-two patients (35.9%) did not receive antifungal drugs after diagnosis of candidemia. Echinocandins were used as first-line drug therapy in half of the treated patients (50.7%). The median EQUAL Candida Score was 6/17 (IQR 6-9) for patients without central venous catheter (CVC) and 11/20 (IQR 6-14) for patients with CVC. The 30 days-mortality was 31,6% and was not significantly associated with the timing of antifungal therapy and the EQUAL Candida Score.ConclusionThe distribution of Candida species has changed in recent years, with an increase in the proportion of C. albicans and C. glabrata. Rapid diagnostic tests, empiric antifungal therapy and source control are essential to improve the prognosis of patients with candidemia. More multicentric prospective studies are needed to evaluate the association of mortality with the timing of antifungal therapy or the EQUAL Candida Score.     

Serum dependent expression of Enterococcus faecalis adhesins involved in the colonization of heart cells

Our previous studies have shown that the adhesive ability of Enterococcus faecalis is dependent on the strain and is further modified by growth in serum. The data reported here demonstrate that E. faecalis adherence is mediated by carbohydrate residues present on the bacterial cell surface. Some of these ( -mannose and -glucose) are expressed by strains isolated from both urinary tract infections (UTI) and endocarditis (EN) when the cells are grown in brain-heart infusion broth (BHIB), and mediate adherence to either urinary tract epithelial cells or the Girardi Heart (GH) cell line. Other residues are present only on EN strains ( -galactose and -fucose) and mainly mediate adherence to GH cells. These ligands can also be expressed by UTI isolates after growth in serum. -galactose-bearing adhesins also seem to be involved in internalization of serum grown UTI strains and BHIB or serum grown EN isolates into GH cells.     

Incidence of anesthesia-related medication errors over a 15-year period in a university hospital.

To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the "Investigation of anesthesia-related medication incidents" by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.     

Increased resistance amongStaphylococcus epidermidis isolates in a large teaching hospital over a 12-year period

The prevalence of drug resistance among clinically significant blood isolates ofStaphylococcus epidermidis (n=464) and consumption of antibiotics at a tertiary care teaching hospital (Meilahti Hospital, Helsinki) were analysed for the period 1983–1994. Resistance to methicillin increased from 28 to 77%. Simultaneously, usage of thirdgeneration cephalosporins increased nearly sevenfold (from 8.6 kg/ to 56.4 kg/year). A significant correlation was found between percentages of methicillin resistance and usage of penicillinase-stable -lactam agents, including cloxacillin, imipenem, and first-, second-, and third-generation cephalosporins (r=0.737, p<0.0062). The increase in ciprofloxacin resistance occurred soon after the introduction of ciprofloxacin. Moreover, there was a remarkable increase in resistance to fusidic acid (from 10 to 40%) and rifampin (from 0 to 23%) despite the low usage of these agents. Overall, the rate of multiply resistant isolates roughly tripled (from 20 to 71 %) and, by 1994, the frequency of isolates susceptible to vancomycin only was as high as 11%, which remarkably limits options for therapy.     

High-density fecal Enterococcus faecium colonization in hospitalized patients is associated with the presence of the polyclonal subcluster CC17

Enterococcus faecium belonging to the polyclonal subcluster CC17, with a typical ampicillin-resistant E. faecium (AREfm) phenotype, have become prevalent among nosocomial infections around the world. High-density intestinal AREfm colonization could be one of the factors contributing to the successful spread of these pathogens. We aimed to quantify the enterococcal intestinal colonization densities in stool samples from AREfm-colonized and non-colonized patients using fluorescent in situ hybridization (FISH). Stool samples were collected from AREfm-colonized (n = 8) and non-colonized (n = 8) patients. The relative number of Enterococcus faecalis and E. faecium was determined by FISH using specific 16S rRNA probes, while the total amount of bacterial cells was counted by staining the sample with 4′,6-diamidino-2-phenylindole (DAPI). The median bacterial cell numbers in fecal samples, counted by DAPI staining, were 7.7 × 10⁹ and 4.8 × 10⁹ cells/g for AREfm-colonized and non-colonized patients, respectively (p = 0.34). The E. faecium densities in AREfm-colonized patients, accounting for 0.5–7% of all fecal bacterial cells, exceeded E. faecalis levels by over ten-fold. E. faecium was not detected in non-colonized patients. This study demonstrated high E. faecium cell densities in stool samples from patients colonized with AREfm. Increased cell densities may contribute to host-to-host transmission and environmental contamination, facilitating the spread of AREfm in the hospital setting.     

Comparative genomic analysis for the presence of potential enterococcal virulence factors in the probiotic Enterococcus faecalis strain Symbioflor 1

Enterococci are members of the natural microbiota of animal and human intestinal tracts and are capable of causing opportunistic infections. They are also used as starter cultures in the food industry as well as in health supplements and probiotics by the pharmaceutical industry. This Janus-faced status requires a careful evaluation on the basis of pathogenic traits to ensure the safety of the strain used to produce food and pharmaceuticals. We performed gapped-genome sequencing of a probiotic strain Enterococcus faecalis Symbioflor 1 and present initial results deriving from comparative genome analysis with that of the previously sequenced pathogenic clinical isolate E. faecalis V583. There was strong overall conservation of synteny between both strains and a detailed analysis revealed the absence of large genomic regions from the chromosome of the probiotic strain, indicating gene loss. Genes absent from the Symbioflor 1 strain included those encoding the enterococcal cytolysin, enterococcal surface protein, and gelatinase (coccolysin) as well as hyaluronidase and the peptide antibiotic AS-48. This data was confirmed using PCR primers specific for the respective genes. However, other enterococcal determinants such as aggregation substance, collagen adhesion protein, the ability to resist oxygen anions as well as capsule formation were detected. The presence of these traits may be advantageous for the strain Symbioflor 1 since they potentially enable colonization and proliferation of the bacterium on mucosal surfaces thereby conferring on it probiotic traits.     

Isolation and characterization of glycopeptide-resistant enterococci from hospitalized patients over a 30-month period

In February 1996, a Hospital Infection Control Practices Advisory Committee-style screening program was commenced to isolate and subsequently characterize glycopeptide-resistant enterococci (GRE) from patients at a hospital trust in Glasgow, Scotland. Over the next 30 months, GRE were isolated from 154 patients. GRE were isolated from patients in traditionally high-risk areas such as the renal unit and intensive care unit and also in areas considered to be lower risk, including medical wards and associated long-stay geriatric hospitals. The majority (90%) of isolates were Enterococcus faecium vanB. The remaining isolates consisted of seven E. faecalis (vanA), three E. gallinarum (vanC), and a further six E. faecium (five vanA, one both vanA and vanB) isolates. Analysis of SmaI-digested DNA by pulsed-field gel electrophoresis revealed that 34 of 40 (85%) VanB E. faecium isolates were identical or closely related, while 11 of 13 (85%) VanA GRE were distinct. High-level aminoglycoside resistance was seen in less than 8% of isolates. VanB E. faecium isolates were almost uniformly resistant to ampicillin and tetracycline. In this study, GRE have been isolated over a prolonged period from a broad range of patients. Glycopeptide resistance within the study hospital trust appeared to be mainly due to the clonal dissemination of a single strain of E. faecium VanB.     

Papillary cystadenoma lymphomatosum (Warthin's tumor) in patients in a general hospital over a 24-year period.

One hundred thirty-seven Warthin's tumors from 120 patients seen during a 23 1/2 year period were studied as two groups. The first group consisted of 32 tumors removed by the otolaryngology department. Material from these cases was re-examined microscopically for evidence of tumor occurrence within lymph nodes located inside and outside the parotid gland. This group of 32 tumors was also studied as part of the second group, 105 additional lesions removed by the surgery department. Data on patient age, sex, and race, as well as tumor multiplicity, location, and size were incorporated into a single statistical analysis. Seventy-two percent of the tumors in the first group were intranodal in location. Second primary Warthin's tumors occurred in 13 (11%) of the patients. Eight occult tumors were identified, and their importance is discussed. A single Negro, a man, was found among 118 patients. The observed frequency of the tumor was twentyfold less than expected among the Negro population.     

Molecular epidemiology of vancomycin-resistant Enterococcus faecium in a large urban hospital over a 5-year period

To investigate the dissemination of vancomycin-resistant Enterococcus faecium (VREF) in a 728-bed tertiary-care hospital, all clinical VREF isolates recovered from June 1992 to June 1997 were typed by pulsed-field gel electrophoresis, and the transfer histories of the patients were documented. A total of 413 VREF isolates from urine (52%), wounds (16%), blood (11%), catheter tips (6%), and other sites (15%) were studied. VREF specimens mostly came from patients on wards (66%) but 34% came from patients in an intensive care unit. The number of VREF isolates progressively increased over time, with higher rates of isolation during the winter months and lower rates in the late summer months. Four distinct banding patterns were detected by pulsed-field gel electrophoresis among 316 samples (76%). Strain A (122 samples; 30%) appeared in June 1992 as the first VREF strain and was found until December 1994 throughout the entire hospital. Type B (92 samples; 22%) was initially detected in January 1994 and disappeared in November 1996. Strain C (10 samples; 2%) was limited to late 1996 and early 1997. Strain D (92 samples; 22%) showed two major peaks during March 1996 to August 1996 and January 1997 to February 1997. Unrelated strains (97 samples; 24%) appeared 1 year after the appearance of the first VREF isolate, and the numbers increased slightly over the years. Nosocomial acquisition (i.e., no known detection prior to admission and first isolation from cultures performed with samples retrieved >/=2 days after hospitalization) was found for 316 (91%) of 347 patients. Despite the implementation of Centers for Disease Control and Prevention guidelines, the proportion of related strains and high number of nosocomial cases of infection indicate a high transmission rate inside the hospital. The results imply an urgent need for stringent enforcement of more effective infection control measures.     

Characteristics of Bordetella hinzii strains isolated from a cystic fibrosis patient over a 3-year period.

Over a 3-year period, an adult cystic fibrosis patient underwent eight episodes of pulmonary exacerbation of his disease. At least one of two different strains of Bordetella hinzii could be isolated from sputum samples in every instance. The differentiation of B. hinzii from related taxa and its role as an etiologic agent of infections are discussed. The two isolates of B. hinzii reported are the third and fourth human-derived strains described in the literature.     

Changing patterns in frequency of recovery of five methicillin-resistant Staphylococcus aureus clones in Portuguese hospitals: surveillance over a 16-year period

A total of 629 nonduplicate methicillin-resistant Staphylococcus aureus MRSA isolates were recovered between June and November 2006 from 11 hospitals located in different areas of Portugal. Selected isolates (n = 271, 43%) were typed by pulsed-field gel electrophoresis (PFGE), representatives of which were additionally characterized by spa typing, multilocus sequence typing, staphylococcal cassette chromosome mec (SCCmec) typing, and the presence of Panton-Valentine leukocidin (PVL). The 271 isolates were classified into 13 different clonal types. Three pandemic clones included the majority (n = 241, 88%) of the isolates and were observed in several hospitals: (i) EMRSA-15 (54%)-PFGE type A, ST22, spa type t022, SCCmec IV-was found in the 11 hospitals studied and was identified as the major clone in seven of them; (ii) the New York/Japan clone (17%)-PFGE B, ST5, spa type t067, SCCmec II-was identified in nine hospitals and represented the major clone in four; and (iii) the Brazilian MRSA (17%)-PFGE C, ST239, spa type t037, SCCmec IIIA-was also detected in nine hospitals but never as the main clone. All isolates tested were PVL negative. Clone EMRSA-15 is currently the predominant MRSA clonal type circulating in Portuguese hospitals, but a new wave of MRSA has emerged in the country with the recent introduction and spread of the New York/Japan clone. The Brazilian MRSA that was the leading clone in Portugal in the late 1990s is declining and being progressively replaced by the two former clones. We report the first isolate SCCmec type V (ST45) in Portugal.     

Molecular characterization of methicillin-resistant Staphylococcus aureus isolated over a 2-year period in a Qatari hospital from multinational patients

Global spread of epidemic methicillin-resistant Staphylococcus aureus (MRSA) is an issue of increasing clinical concern especially problematic community-associated (CA) -MRSA. However, data regarding MRSA epidemiology in regions of the Middle East, including Qatar, are still insufficient. A representative subset of 61 MRSA isolates from multinational patients from hospital in Qatar during a 2-year period (2009/2010) was examined. Molecular characterization for MRSA isolates was performed by pulsed-field gel electrophoresis (PFGE), SCCmec, spa and dru typing, and PCR for the presence of the arginine catabolic mobile element and genes for the Panton–Valentine leukocidin (PVL). Prevalence of MRSA among S. aureus isolated was 176/840 (21%). Of the 61 MRSA isolates examined, three (5%) represented hospital-acquired infection. By PFGE, 32 isolates (52%) were CA-MRSA USA300 (n = 4), USA400 (n = 3), USA1100/Southwest (SW) Pacific (n = 17) and ST80-MRSA-IV (n = 8) strains. The remaining isolates were well-known healthcare-associated EMRSA-15 (n = 8) and USA800 (n = 13). Three isolates were USA900, one was USA1200 and four were unrelated to any known strains in the international database. Unexpectedly, the USA900 isolates were all positive for PVL and USA400 isolates were PVL negative. Five of the eight EMRSA-15 isolates were PVL positive. ST80-MRSA-IV and USA300 strains exhibited typical dru types (dt10a and dt9g, respectively). Eleven different spa types were observed in this study. All USA300 isolates were arginine catabolic mobile element positive. The high prevalence of CA-MRSA, especially including USA300, in this setting underscores the importance of global epidemiological monitoring to better understand and hopefully help prevent the emergence and spread of these problem pathogens in patient populations.     

Performance of a rapid assay (Binax NOW) for detection of respiratory syncytial virus at a children's hospital over a 3-year period

A rapid assay, Binax NOW RSV, was compared to viral culture for 14,756 pediatric respiratory specimens obtained from 2003 to 2006. There were 794 viral culture-confirmed respiratory syncytial virus infections. Sensitivity was 81%, and specificity was 93.2%. Sensitivity was greatest for neonates (91.1% versus 80.7% [P < 0.01]).     

Prevalence of plasmid-mediated quinolone resistance determinants in ESBL Enterobacteriaceae clinical isolates over a 1-year period in a French hospital

The prevalence of plasmid-mediated quinolone resistance (PMQR) determinants (qnrA, qnrB, qnrS, aac(6′)-Ib-cr, and qepA) was investigated in a collection of 47 extended-spectrum β-lactamase (ESBL) producing enterobacterial isolates with reduced susceptibility to fluoroquinolones, recovered at Nantes University hospital, in 2006. qnr, aac(6′)-Ib-cr, and qepA genes were screened by PCR, and positive results were subsequently confirmed by sequencing. The epidemiological relationship between positive isolates was studied by pulsed-field gel electrophoresis (PFGE). qnr-positive isolates were analyzed for antimicrobial susceptibility and presence of mutations in the quinolone resistance-determining region (QRDR) of gyrA and parC genes. ESBL genes were characterized by PCR and sequencing. Conjugation experiments were performed to determine whether the qnr-carrying plasmids were self-transferable. Two Klebsiella pneumoniae isolates (4.3%), not clonally related, harboured a qnrS1 gene, whereas no qnrA- or qnrB-positive isolate was detected. The aac(6′)-Ib-cr gene was detected in 11 Escherichia coli and one K. pneumoniae isolates. None of the 47 isolates carried the qepA gene. ESBLs associated with QnrS1 were CTX-M-14 and CTX-M-15. The CTX-M-15 producing isolate was highly resistant to fluoroquinolones and harboured three mutations in the QRDR and two PMQR determinants (qnrS1 and aac(6′)-Ib-cr). The CTX-M-14-producing isolate exhibited reduced susceptibility or resistance to fluoroquinolones without resistance to nalidixic acid. This strain harboured only a qnr gene on a single 170 kb transferable plasmid, without any mutation in the QRDR. In conclusion, our study showed that aac(6′)-Ib-cr gene had occurred in multiclonal ESBL-producing enterobacterial isolates collected at Nantes University hospital in 2006, with a higher prevalence than qnr genes.     

Chromosomal DNA restriction endonuclease digestion patterns of beta-lactamase-producing Enterococcus faecalis isolates collected from a single hospital over a 7-year period.

Twenty-three beta-lactamase (beta-lac)-producing, highly gentamicin-resistant Enterococcus faecalis isolates collected over a 7-year period from the same hospital were examined by pulsed-field gel electrophoresis of SmaI-digested genomic DNA. The beta-lac+ isolates appeared to form a single clonal group, which had been previously designated the mid-Atlantic pattern. Eleven variations of the mid-Atlantic clone, differing by one to six bands, were identified; some of the changes were likely due to plasmid bands. However, a number of isolates had indistinguishable patterns, including some recovered over a 4-year period. There was a surprising lack of movement of the beta-lac determinant to other strains, although this trait was transferable in vitro by conjugation. We conclude that a single clone (the mid-Atlantic clone) of beta-lac+ E. faecalis has remained endemic in this hospital for at least 7 years. The reason(s) for the apparent lack of spread to other strains of E. faecalis is unknown.     

Pattern of in-hospital pediatric mortality over a 3-year period at University teaching hospitals in Iran

Introduction:

Causes of death are different and very important for policy makers in different regions. This study was designed to analyze the data for our in-patient children mortality.

Materials and Methods:

In this cross-sectional study from March 2011 to March 2013, all patients from 2 months to 18 years who died in pediatric intensive care unit, emergency room or medical pediatric wards in the teaching hospitals were studied.

Results:

From a total of 18,915 admissions during a 2-year-period, 256 deaths occurred with a mean age of 4.3 ± 5 years and mortality 1.35%. An underlying disease was present in 70.7% of the patients and in 88.5% of them the leading causes of death were related to the underlying diseases. The most common underlying diseases were congenital heart disease and cardiomyopathy in 50 (27.6%). The four main causes of deaths were sepsis (14.8%), pneumonia (14.5%), congestive heart failure (9.8%), and hepatic encephalopathy (9.8%).

Conclusion:

We may conclude that after sepsis and pneumonia, congestive heart failure, and hepatic encephalopathy are the leading causes of death. Most patients who died had underlying diseases including malignancies, heart and liver diseases as the most common causes.