Impact of multi-drug-resistant <Emphasis Type="Italic">Acinetobacter baumannii</Emphasis> on clinical outcomes

We conducted a retrospective matched cohort study to examine the impact of isolation of multi-drug-resistant (MDR) Acinetobacter baumannii on patient outcomes. Cases from whom MDR A. baumannii was isolated in a clinical culture (n = 118) were compared with controls from whom MDR A. baumannii was not isolated (n = 118). Cases and controls were matched according to ward, calendar month of hospitalization, and duration of hospitalization before culture. The following outcomes were compared in multivariable analysis: in-hospital mortality, length of stay, need for mechanical ventilation, and functional status at discharge. MDR A. baumannii was determined to be a pathogen in 72% of cases. In 36% of cases, the patient died, versus 21% of controls (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.17–4.16, P = 0.014). Median length of stay for surviving cases was 17 days, versus 11 for surviving controls (multiplicative effect 1.55, 95% CI 0.99–2.44, P = 0.057). Fifty-two percent of cases required mechanical ventilation, versus 25% of controls (OR 3.72, 95% CI 1.91–7.25, P<0.001); 60% of surviving cases were discharged with reduced functional status, versus 38% of controls (OR 4.4, 95% CI 1.66–11.61, P = 0.003). In multivariable analysis, clinical isolation of MDR A. baumannii remained a significant predictor of mortality (OR 6.23, 95% CI 1.31–29.5, P = 0.021), need for mechanical ventilation (OR 7.34, 95% CI 2.24–24.0, P<0.001), and reduced functional status on discharge (OR 7.93, 95% CI 1.1–56.85, P = 0.039). Thus, MDR A. baumannii acquisition is associated with severe adverse outcomes, including increased mortality, need for mechanical ventilation, and reduced functional status.     

Risk Factors for Catheter-Associated Bacteriuria in a Medical Intensive Care Unit

 In a prospective study including 137 consecutive catheterised patients in a medical intensive care unit, the following variables were analysed as possible risk factors for catheter-associated bacteriuria, defined as a quantitative culture with ≥10⁵ organisms/ml: age, sex, simplified acute and physiologic score at admission, duration of catheterisation, diabetes mellitus, immunosuppression, neurologic disorders and prior systemic antibiotic exposure during hospitalisation. The frequency of catheter-associated bacteriuria was 30.7%. By multivariate analysis, female sex (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.9–13.5;P=0.001) and a duration of catheterisation  1 11 days (OR, 19.4; 95% CI, 5.5–68.7;P=0.0001) were risk factors for catheter-associated bacteriuria, and prior antibiotic exposure was a protective factor (OR, 0.06; 95% CI, 0.019–0.21;P=0.0001).     

Time for first antibiotic dose is not predictive for the early clinical failure of moderate–severe community-acquired pneumonia

The time to first antibiotic dose (TFAD) has been mentioned as an important performance indicator in community-acquired pneumonia (CAP). However, the advice to minimise TFAD to 4 hours (4 h) is only based on database studies. We prospectively studied the effect of minimising the TFAD on the early clinical outcome of moderate–severe CAP. On admission, patients’ medical data and TFAD were recorded. Early clinical failure was expressed as the proportion of patients with clinical instability, admission to the intensive care unit (ICU) or mortality on day three. Of 166 patients included in the study, 27 patients (29.7%) with TFAD <4 h had early clinical failure compared to 23 patients (37.7%) with TFAD >4 h (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.35–1.35). In multivariate analysis, the pneumonia severity index (OR 1.03; 95%CI 1.01–1.04), confusion (OR 2.63; 95%CI 1.14–6.06), Staphylococcus aureus infection (OR 7.26; 95%CI 1.33–39.69) and multilobar pneumonia (OR 2.40; 95%CI 1.11–5.22) but not TFAD were independently associated with early clinical failure. Clinical parameters on admission other than the TFAD predict early clinical outcome in moderate–severe CAP. In contrast to severe CAP necessitating treatment in the ICU directly, in the case of suspected moderate–severe CAP, there is time to establish a reliable diagnosis of CAP before antibiotics are administered. Therefore, the implementation of the TFAD as a performance indicator is not desirable.     

Determinants for the Development of Oropharyngeal Colonization or Infection by Fluconazole-Resistant Candida Strains in HIV-Infected Patients

 A point prevalence study to document oral yeast carriage was undertaken. Risk factors for the development of oropharyngeal colonization or infection by fluconazole-resistant Candida strains in HIV-infected patients were investigated with a case-control design. Cases included all patients with fluconazole-resistant strains (MIC≥64 μg/ml), and controls were those with susceptible (MIC≤8 μg/ml) or susceptible-dependent-upon-dose (MIC 16–32 μg/ml) strains. One hundred sixty-eight Candida strains were isolated from 153 (88%) patients, 28 (16%) of whom had oropharyngeal candidiasis. Overall, 19 (12%) of the patients harbored at least one resistant organism (MIC≥64 μg/ml). Among patients with resistant strains, tuberculosis (P<0.001), esophageal candidiasis (P=0.001), clinical thrush (P<0.001), and a CD4+ cell count <200/mm³ (P=0.03) were more frequent. These patients had also been treated more commonly with antituberculous drugs (adjusted odds ratio [OR] 6.13; 95% confidence interval [CI] 2.11–17.80), ciprofloxacin (OR 6.0; 95% CI 1.23–29.26), fluconazole (OR 4.59; 95% CI 1.55–13.52), and steroids (OR 4.13; 95% CI 1.11–15.39). Multivariate analysis showed that the determinants for fluconazole resistance were therapy with antituberculous drugs (OR 3.61; 95% CI 1.08–12.07;P=0.03) and one of the following: previous tuberculosis (OR 3.53; 95% CI 1.08–14.57;P=0.03) or fluconazole exposure (OR 3.41; 95% CI 1.10–10.54). Findings from this study indicate that treatment with antituberculous drugs, previous tuberculosis, and fluconazole exposure are the strongest determinants for development of oropharyngeal colonization or infection by fluconazole-resistant Candida strains in HIV-infected patients.     

Risk Factors for Nasal Carriage of Staphylococcus aureus in Infectious Disease Patients, Including Patients Infected with HIV, and Molecular Typing of Colonizing Strains

Nasal carriage is an important risk factor for Staphylococcus aureus infection, particularly in HIV-infected individuals. In this analytical cross-sectional study, a variety of probable risk factors associated with nasal carriage of Staphylococcus aureus were investigated. HIV-infected patients were examined within a larger cohort of infectious diseases patients. Staphylococcus aureus strains from HIV-infected and non-HIV-infected carriers were identified by molecular biological analysis. One hundred seventy infectious disease patients, 47 of them infected with HIV, were included. All patients were admitted to the University Hospital of Vienna, Austria, between January and July 1999. Independent significant effects on Staphylococcus aureus nasal carriage were found to be HIV status (OR 2.5, 95% CI 1.1–5.6; P=0.0303), history of operation or severe wound within 3 months prior to admission (OR 4.0, 95% CI 1.3–13.0; P=0.0208), presence of an intravenous device within 2 weeks prior to admission (OR 10.8, 95% CI 2.0–59.4; P=0.0065), and intake of antibiotics within 2 weeks prior to hospitalisation (OR 0.2, 95% CI 0.09–0.6; P=0.0016). Molecular analysis of the Staphylococcus aureus strains revealed that the strains in both groups resembled those of healthy nonhospitalized carriers in the community. Electronic Publication     

A meta-analysis of DNA repair gene <Emphasis Type="Italic">XPC</Emphasis> polymorphisms and cancer risk

Polymorphisms (A33512C, C21151T and PAT −/+) of the xeroderma pigmentosum group C (XPC) were shown to contribute to genetic susceptibility to cancer. However, association studies on these polymorphisms in cancer have shown conflicting results. Thus, we performed a meta-analysis. Overall, there was no significant association between 33512C (9,091 patients and 11,553 controls) and cancer risk. No significant association was found in stratification analysis by tumor sites and ethnicities except an elevated lung cancer risk under the recessive genetic model in all subjects [P = 0.04, odds ratio (OR) = 1.20, 95% confidence interval (CI) 1.00–1.45, P _{heterogeneity} = 0.88]. There was no significant association between 21151T (5,227 patients and 5,959 controls) and cancer risk in all subjects but an increased cancer risk in Caucasians under the recessive genetic model (P = 0.006, OR = 1.45, 95% CI 1.11–1.90, P _{heterogeneity} = 0.75) and homozygote comparison (P = 0.02, OR = 1.41, 95% CI 1.07–1.81, P _{heterogeneity} = 0.41). It might be that 21151T increases bladder cancer risk under the recessive genetic model (P = 0.02, OR = 1.49, 95% CI 1.06–2.09, P _{heterogeneity} = 0.47) and homozygote comparison (P = 0.02, OR = 1.49, 95% CI 1.05–2.11, P _{heterogeneity} = 0.23). There was no significant association between PAT + (4,600 patients and 4,866 controls) and cancer risk in all subjects. An increased cancer risk in Caucasians was found under the recessive genetic model (P = 0.02, OR = 1.20, 95% CI 1.03–1.40, P _{heterogeneity} = 0.37) and homozygote comparison (P = 0.008, OR = 1.26, 95% CI 1.06–1.50, P _{heterogeneity} = 0.13). The XPC PAT + allele might increase head and neck cancer risk (P = 0.02, OR = 1.29, 95% CI 1.04–1.59, P _{heterogeneity} = 0.15). More studies based on larger, stratified, case–control population, especially studies investigate the combined effect of XPC A33512C, C21151T, and PAT, are required to further evaluate the role of these polymorphisms in different cancers.     

Incidence and Risk Factors for Nosocomial Infections Caused by Fluoroquinolone-Resistant<Emphasis Type="Italic"> Escherichia coli</Emphasis>

The aim of the retrospective case-control study presented here was to elucidate the incidence, risk factors, and outcomes of nosocomial infections caused by quinolone-resistant Escherichia coli (QREC). During the 3-year period studied, 51 nosocomial QREC infections were found, and the characteristics of these cases were compared with those of 102 control patients with quinolone-susceptible nosocomial infections. In the multivariate analysis, risk factors were identified as prior quinolone therapy (odds ratio [OR], 18.49; 95% confidence interval [CI], 5.53–61.82; P value <0.001), urinary tract abnormalities (OR, 6.69; 95% CI, 1.68–26.63; P=0.007), and prior therapy with other antimicrobial agents (OR, 3.57; 95% CI, 1.38–9.27; P=0.009). No difference in mortality or in length of hospital stay was found. Prudent use of quinolones, especially in patients with urinary tract abnormalities, is probably the best way to avoid an increase in the incidence of QREC infections, but further studies on interventions with restricted use of quinolones are necessary to demonstrate the effectiveness and safety of this strategy.     

Seroprevalence of and risk factors for Toxoplasma gondii antibodies among asymptomatic blood donors in Egypt

A cross-sectional study was conducted to evaluate the seroprevalence of and risk factors for Toxoplasma gondii antibodies in 260 blood donors seen at blood banks in Mansoura University Hospital, Egypt. Blood donors were interviewed about sociodemographic characteristics and risk factors for T. gondii infection. A blood sample was taken to document their T. gondii antibody status using enzyme-linked immunosorbent assay. Overall, 155 (59.6%) of 260 blood donors were positive for anti-T. gondii IgG antibodies. Multivariate logistic regression analysis showed a significant association between T. gondii seropositivity and eating meat by-products (luncheon/shawerma) (adjusted odds ratio [OR] 80.82 [95% CI 18.62–350.81], P < 0.0001) or being non-educated (adjusted OR 32.25 [95% CI 7.46–139.44], P < 0.0001). These findings highlight that T. gondii is prevalent among blood donors in Egypt.     

Different roles of MTHFR C677T and A1298C polymorphisms in colorectal adenoma and colorectal cancer: a meta-analysis

Association studies on the MTHFR polymorphisms (C677T and A1298C) in colorectal cancer (CRC) and colorectal adenoma have shown conflicting results. We performed a meta-analysis to better assess the purported associations. Overall, the 677T allele (10,131 patients and 15,362 controls) showed a small but significant protective effect against CRC compared to the 677C allele [P=0.0003, odds ratio (OR)=0.93; 95% confidence interval (CI) 0.89–0.98, P=0.22 (for heterogeneity)] for a worldwide population. Meta-analyses of other genetic contrasts suggested that the 677T allele is more likely to affect CRC in a recessive genetic model worldwide (P<0.0001, OR=0.86; 95% CI 0.76–0.96, P=0.06) and in Asians (P=0.0005, OR=0.75; 95% CI 0.64–0.88, P=0.71). Similarly, we found a significantly decreased risk of CRC for 1298C polymorphism (4,764 CRC patients and 6,592 controls) for a recessive genetic model worldwide (P=0.005, OR=0.81; 95% CI 0.70–0.94, P=0.40) and in Caucasians (P=0.04, OR=0.75 95% CI 0.57–0.99, P=0.35). No evidence of association of C677T (4,616 patients and 6,338 controls) and A1298C (1,272 patients and 1,684 controls) with colorectal adenoma were found. The evidence accumulated suggests that MTHFR may represent a low-penetrance susceptible gene for CRC, and that the two polymorphisms might protect against colorectal adenoma developing into cancer. A larger single study is required to further evaluate gene–gene and gene–environment interactions for MTHFR polymorphisms and the cancer risk in a specific population. Electronic supplementary material Supplementary material is available in the online version of this article at and is accessible for authorized users.     

A care bundle approach for prevention of ventilator-associated pneumonia

Implementation of care bundles for prevention of ventilator-associated pneumonia (VAP) and its impact on patient outcomes requires validation with long-term follow-up. A collaborative multi-centre cohort study was conducted in five Spanish adult intensive-care units. A care bundle approach based on five measures was implemented after a 3-month baseline period, and compliance, VAP rates, intensive-care unit length of stay (ICU LOS) and duration of mechanical ventilation were prospectively recorded for 16 months. There were 149 patients in the baseline period and 885 after the intervention. Compliance with all measures after intervention was <30% (264/885). In spite of this, VAP incidence decreased from 15.5% (23/149) to 11.7% (104/885), after the intervention (p <0.05). This reduction was significantly associated with hand hygiene (OR = 0.35), intra-cuff pressure control (OR = 0.21), oral hygiene (OR = 0.23) and sedation control (OR = 0.51). Use of the care bundle was associated with an incidence risk ratio of VAP of 0.78 (95% CI 0.15–0.99). We documented a reduction of median ICU LOS (from 10 to 6 days) and duration of mechanical ventilation (from 8 to 4 days) for patients with full bundle compliance (intervention period). Efforts on VAP prevention and outcome improvement should focus on achieving higher compliance in hand and oral hygiene, sedation protocols and intracuff pressure control.     

Inhaled aminoglycosides in cancer patients with ventilator-associated Gram-negative bacterial pneumonia: safety and feasibility in the era of escalating drug resistance

We sought to evaluate the safety and feasibility of inhaled aminoglycosides or colistin in cancer patients with ventilator-associated pneumonia (VAP) due to Gram-negative bacteria (GNB). A retrospective case-matched study was obtained after obtaining IRB approval in patients at the intensive care unit at our NCI-designated comprehensive cancer center between 1999 and 2005. Sixteen patients with GNB-VAP who received inhaled aminoglycosides or colistin were compared with 16 patients who had received these antibiotics intravenously alone. Eligible patients were required to have received at least six doses of inhaled therapy, or 3 or more days of intravenous therapy. Clinical Pulmonary Infection Scores were used to assess pneumonia severity. Standard ATS criteria were used to define VAP. Patients treated with inhaled antibiotics were less likely to have received corticosteroids (13% vs 50%; P < 0.02) and had a higher median baseline creatinine level (0.85 vs 0.6 mg/dL; P < 0.02) than patients treated intravenously. Pseudomonas aeruginosa (69%) was the most common cause of VAP. There were no serious adverse events associated with inhaled antibiotics. Patients who received these antibiotics intravenously developed renal dysfunction (31%); none of the patients treated with inhaled antibiotics developed nephrotoxicity (P ≤ 0.04). Patients treated with inhaled antibiotics were more likely to have complete resolution of clinical (81% vs 31% in the intravenous antibiotic group; P < 0.01) and microbiologic infection (77% vs 8% in the intravenous antibiotic group: P < 0.0006). In a multivariate analysis adjusted for corticosteroid use, inhaled antibiotic therapy was predictive of complete clinical resolution (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.1, 37.6; P < 0.04) and eradication of causative organisms (OR 36.7; 95% CI, 3.3, 412.2; P < 0.003). In critically ill cancer patients with Gram-negative VAP, inhaled aminoglycosides were tolerated without serious toxicity and may lead to improved outcome. A portion of this study was presented at the 46th Interscience Conference on Antimicrobial Agents and Chemotherapy, 27–30 September 2006, San Francisco [abstract K-0288].     

Fungal colonization and/or infection in non-neutropenic critically ill patients: results of the EPCAN observational study

The purpose of this paper is to determine the incidence of fungal colonization and infection in non-neutropenic critically ill patients and to identify factors favoring infection by Candida spp. A total of 1,655 consecutive patients (>18 years of age) admitted for ≥7 days to 73 medical-surgical Spanish intensive care units (ICUs) participated in an observational prospective cohort study. Surveillance samples were obtained once a week. One or more fungi were isolated in different samples in 59.2% of patients, 94.2% of which were Candida spp. There were 864 (52.2%) patients with Candida spp. colonization and 92 (5.5%) with proven Candida infection. In the logistic regression analysis risk factors independently associated with Candida spp. infection were sepsis (odds ratio [OR] = 8.29, 95% confidence interval [CI] 5.07–13.6), multifocal colonization (OR = 3.49, 95% CI 1.74–7.00), surgery (OR = 2.04, 95% CI 1.27–3.30), and the use of total parenteral nutrition (OR = 4.37, 95% CI 2.16–8.33). Patients with Candida spp. infection showed significantly higher in-hospital and intra-ICU mortality rates than those colonized or non-colonized non-infected (P < 0.001). Fungal colonization, mainly due to Candida spp., was documented in nearly 60% of non-neutropenic critically ill patients admitted to the ICU for more than 7 days. Proven candidal infection was diagnosed in 5.5% of cases. Risk factors independently associated with Candida spp. infection were sepsis, multifocal colonization, surgery, and the use of total parenteral nutrition.     

Clinical predictive values of extended-spectrum beta-lactamase carriage in patients admitted to medical wards

We aimed to reassess, through clinical items, populations at risk for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriage at admission to hospital and to assess the risk of further positive clinical culture of ESBL-E among carriers. We performed a 5-month cohort study in a medicine ward of a 500-bed university teaching hospital in the Parisian area of France. All admitted patients were prospectively enrolled for rectal swabbing and clinical data collection, including bacterial infection at admission and during stay. Variables associated with ESBL-E carriage were identified by univariate and multivariate analysis. Five hundred patients were included. The prevalence of ESBL-E was 6.6% (33/500) upon admission. Only previous carriage of multidrug-resistant bacteria (MDRB) was associated with carriage (odds ratio [OR]: 17.7, 95% confidence interval (CI) 5.8–54.2, p < 0.001), yet, the positive predictive value (PPV) was not higher than 50%. When prior MDRB carriage was not considered in the multivariate analysis, only prior antibiotic consumption was found to be associated with carriage at admission (OR: 2.2 [1.1–4.5], p = 0.02). Two patients had ESBL-E infection at admission, yet, no patient became infected with ESBL-E during their stay. The clinical prediction of ESBL carriage at admission in our wards was found to be poorly efficient for assessing the at-risk population.     

Clinical Demographics and Outcomes in Mechanically Ventilated Patients in Korean Intensive Care Units

Knowledge of clinical demographics and outcomes of mechanically ventilated patients is important but there are few prospectively collected data in Korea. The objective of the present study was to describe the current status of mechanically ventilated patients in Korea as of 2010. We analyzed the data of Korean patients (275 patients in 12 Korean intensive care units [ICU]) participating in a multinational prospective cohort study on mechanical ventilation. The most common indication for mechanical ventilation was pneumonia (23%). Pressure-limited ventilation modes were preferred over volume-cycled ventilation modes. Non-invasive positive pressure ventilation was used in only seven (2%) patients as the initial ventilatory support. Median duration of mechanical ventilation was 7 days and ICU mortality was 36%. The multiple logistic regression model revealed that the Simplified Acute Physiology Score II (SAPS II) score at ICU admission (odds ratio [OR], 1.034; 95% confidence interval [CI], 1.001-1.036; P=0.033), peak pressure (OR, 1.054; 95% CI, 1.016-1.095; P=0.006), and the number of failed organs (OR, 2.132; 95% CI, 1.634-2.781; P<0.001) were independently associated with ICU mortality. This study provides a snapshot of current practice of mechanical ventilation in Korea.

Graphical Abstract

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Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit

The objective of this prospective cohort study was to determine whether admission to an intensive care unit (ICU) room previously occupied by a patient with multidrug-resistant (MDR) Gram-negative bacilli (GNB) increases the risk of acquiring these bacteria by subsequent patients. All patients hospitalized for >48 h were eligible. Patients with MDR GNB at ICU admission were excluded. The MDR GNB were defined as MDR Pseudomonas aeruginosa, Acinetobacter baumannii and extended spectrum β-lactamase (ESBL) -producing GNB. All patients were hospitalized in single rooms. Cleaning of ICU rooms between two patients was performed using quaternary ammonium disinfectant. Risk factors for MDR P. aeruginosa, A. baumannii and ESBL-producing GNB were determined using univariate and multivariate analysis. Five hundred and eleven consecutive patients were included; ICU-acquired MDR P. aeruginosa was diagnosed in 82 (16%) patients, A. baumannii in 57 (11%) patients, and ESBL-producing GNB in 50 (9%) patients. Independent risk factors for ICU-acquired MDR P. aeruginosa were prior occupant with MDR P. aeruginosa (OR 2.3, 95% CI 1.2–4.3, p 0.012), surgery (OR 1.9, 95% CI 1.1–3.6, p 0.024), and prior piperacillin/tazobactam use (OR 1.2, 95% CI 1.1–1.3, p 0.040). Independent risk factors for ICU-acquired A. baumannii were prior occupant with A. baumannii (OR 4.2, 95% CI 2–8.8, p <0.001), and mechanical ventilation (OR 9.3, 95% CI 1.1– 83, p 0.045). Independent risk factors for ICU-acquired ESBL-producing GNB were tracheostomy (OR 2.6, 95% CI 1.1–6.5, p 0.049), and sedation (OR 6.6, 95% CI 1.1–40, p 0.041). We conclude that admission to an ICU room previously occupied by a patient with MDR P. aeruginosa or A. baumannii is an independent risk factor for acquisition of these bacteria by subsequent room occupants. This relationship was not identified for ESBL-producing GNB.     

Prognostic Evaluation of Bacteremia and Fungemia in Patients with Acquired Immunodeficiency Syndrome

The incidence of bacterial infections in general and of bacteremia in particular is high among patients with acquired immunodeficiency syndrome (AIDS). The factors influencing the prognosis of bacteremia in these patients are not well known. In order to better define those factors associated with a poor prognosis, all episodes of bacteremia or fungemia in patients with AIDS who were hospitalized in four general hospitals between 1 September 1987 and 31 December 1996 were studied prospectively. Among 1,390 patients diagnosed with AIDS, 238 (17.1%) developed 274 episodes of bacteremia or fungemia. Mortality related to bacteremia was 21.3%. Variables associated with high mortality were fungemia (odds ratio [OR], 6.19; 95% confidence interval [CI], 1.99–19.28), hypotension (OR, 19.65; 95%CI, 7.42–52.07), inappropriate antimicrobial treatment (OR, 16.94; 95%CI, 4.92–58.32), and unknown origin of bacteremia (OR, 3.93; 95%CI, 1.58–9.76). The mortality rate among patients with at least one of these factors was 46.7%, whereas in patients without any of these factors, the rate was 4.9% (P<0.001). Bacteremic episodes of unknown origin were significantly more frequently associated with community acquisition (P=0.001), inappropriate antimicrobial treatment (P=0.04), and etiology by gram-negative microorganisms or fungi (P<0.001) and were significantly less frequently associated with the presence of a previous intravenous catheter (P=0.004), resulting in peculiar etiologic and epidemiological profiles. The factors that influence the outcome of AIDS patients who develop bacteremia are sometimes avoidable or known during the first days after admission. Therefore, knowledge about these factors could improve the prognosis of bloodstream infections in this population. Electronic Publication     

Prevalence and risk factors for quinolone resistance among Escherichia coli strains isolated from males with community febrile urinary tract infection

The purpose of this study was to evaluate the prevalence and clinical risk factors for quinolone resistance (QR) in E. coli strains from males with febrile urinary tract infection (FUTI). An ambispective cross-sectional study was performed in which we evaluated 153 males with a community FUTI caused by E. coli. Among the 153 FUTI episodes, 101 (66%) were due to quinolone susceptible E. coli strains while 52 (34%) were caused by QR E. coli strains. In the univariate analysis QR was associated with older age, higher Charlson scores, dementia, past UTI, urinary tract abnormalities, previous antibiotic use, particularly with fluoroquinolones (FQ), a healthcare-associated (HA)-UTI (HA-UTI) and to four of the components included in the definition of HA-UTI: hospital admission, nursing home residence, indwelling urethral catheter and invasive urinary instrumentation. In the multivariate analysis, HA-UTI (OR 3.82, 95% CI 1.3–11.24; P 0.015) and use of antimicrobials in the previous month (OR 5.82, 95% CI 2.3–14.88; P < 0.001) mainly with FQ (OR 13.97, 95% CI 2.73–71.53; P 0.002) were associated with QR. To have a HA-UTI and a previous use of FQ in the preceding month were strong risk factors for QR E. coli, and thus empirical antimicrobial treatment with quinolones should be avoided in these patients.     

Plasma TNF-α and IL-10 Level-Based Prognostic Model Predicts Outcome of Patients with Diffuse Large B-Cell Lymphoma in Different Risk Groups Defined by the International Prognostic Index

Tumor necrosis factor (TNF)-α and interleukin (IL)-10 are key cytokines involved in lymphoma development. Their pretreatment plasma levels were reported to influence the clinical course of non-Hodgkin’s lymphoma. In this study the impact of combined elevation of TNF-α and IL-10 on disease features and outcome of patients with diffuse large B-cell lymphoma (DLBCL) were investigated. Plasma TNF-α and IL-10 levels were determined at the time of diagnosis in a group of 106 DLBCL patients uniformly treated with anthracycline-based regimens. Three risk groups depending on the pretreatment levels of the cytokines were identified: low-, intermediate-, and high-risk groups. In univariate analysis, the cytokine intermediate- and high-risk groups were associated with lower probability of achieving a complete remission (odds ratio [OR] = 0.2, 95% confidence interval [CI] 0.06–0.6, p = 0.006 and OR = 0.05, 95% CI 0.01–0.2, p < 0.0001, respectively) and shorter progression-free survival (PFS) (OR = 4.4, 95% CI 1.9–10.2, p < 0.001 and OR = 9.7, 95% CI 4.1–23.0, p < 0.0001, respectively) and overall survival (OS) (OR = 4.2, 95% CI 1.7–10.1, p = 0.002 and OR = 11.2, 95% CI 4.4–28.4, p < 0.0001, respectively) in comparison with the cytokine low-risk group. In multivariate analysis, the cytokine intermediate- and high-risk groups also correlated with shorter PFS (relative risk [RR] = 4.5, 95% CI 1.9–10.9, p = 0.001 and RR = 5.8, 95% CI 2.2–15.3, p < 0.0001, respectively) and OS (RR = 4.6, 95% CI 1.8–12.0, p = 0.001 and RR = 7.5, 95% CI 2.7–20.9, p < 0.0001, respectively) regardless of the International Prognostic Index (IPI) scoring system. The TNF-α and IL-10 level-based index may work as an additional model to the IPI for predicting the survival of DLBCL patients. This model may help to identify patients in a given IPI risk group for whom more accurate and risk-adapted treatment could be advised.     

Risk factors and pathogens involved in early ventilator-acquired pneumonia in patients with severe subarachnoid hemorrhage

Ventilator-acquired pneumonia (VAP) is a common burden in intensive care unit (ICU) patients, but, to date, specific data are not available in patients with severe aneurysmal subarachnoid hemorrhage (SAH). A single neuro-ICU retrospective analysis of 193 patients with SAH requiring mechanical ventilation (MV) ≥48 h admitted from January 2005 to May 2010 was undertaken. The diagnosis of early VAP was prospectively upheld during a multidisciplinary staff meeting, according to the American Thoracic Society (ATS) 2005 guidelines with a threshold of 7 days after the onset of MV. Patients had a median age of 53 (44–62) years and 70 (36 %) were male. The median Glasgow coma scale (GCS) score before MV was 9 (5–14). 142 (74 %) patients had a World Federation of Neurosurgeons (WFNS) score?≥III. Aneurysm was secured with an endovascular coiling procedure in 162 (84 %) patients. 81 (48.7 %) patients declared an early VAP. On multivariate analysis, male sex (odds ratio [OR] 2.26, 95 % confidence interval [CI] [1.14–4.46]), use of mannitol before day 7 (OR 3.03, 95 % CI [1.54–5.95]), and achieving enteral nutrition ≥20 kcal kg^?1 day^?1 after day 7 (OR 2.91, 95 % CI [1.27–6.67]) remained independent risk factors of VAP. The main pathogens involved were methicillin-susceptible Staphylococcus aureus (MSSA) (34.9 %), Haemophilus influenzae (28.1 %), Streptococcus pneumoniae (15.5 %), and Enterobacteriaceae (10.7 %). Early VAP was associated with a longer duration of MV and ICU stay, but not with an excess of mortality. Early VAP bears significant morbidity in patients with severe SAH. Pathogens involved in early VAP are susceptible to antibiotics. Among modifiable risk factors of VAP, early enteral nutrition could be an easy and effective target.     

Short- and long-term outcome of HIV-infected patients admitted to the intensive care unit

The purpose of this investigation was to analyse the impact of the availability of highly active antiretroviral therapy (HAART) on the long-term outcome of human immunodeficiency virus (HIV)-infected patients admitted to the intensive care unit (ICU). A retrospective cohort study of HIV-infected patients admitted to the ICU was undertaken. Outcomes in the pre-HAART era (1990–June 1996), early- (July 1996–2002), and recent-HAART (2003–2008) periods and total HAART era (July 1996–2008) were analysed and compared with those reported of the general population. A total of 127 ICU admissions were included. The 1-year mortality decreased from 71% in the pre-HAART era to 50% in the recent-HAART period (p = 0.06). The 5-year mortality decreased from 87% in the pre-HAART era to 59% in the early-HAART period (p = 0.005). Independent predictors of 1-year mortality in the HAART era were age (odds ratio [OR] = 1.16 [95% confidence interval [CI] = 1.06–1.27]), APACHE II score > 20 (6.04 [1.25–29.22]) and mechanical ventilation (40.01 [3.01–532.65]). The 5-year survival after hospitalisation was 80% and in the range of the reported survival of non-HIV-infected patients (83.7%). Predictors of 1-year mortality for HIV patients admitted to the ICU in the HAART era were all non-HIV-related. Short- and long-term outcome has improved since the introduction of HAART and is comparable to the outcome data in non-HIV-infected ICU patients.