Bloodstream infections in internal medicine

Surveillance and Prediction of Risk Factors for Central Line-Associated Bloodstream Infections in Saudi Arabia

BACKGROUND

Although central line-associated bloodstream infection (CLABSI) is the most common type of healthcare-associated infection among patients with inserted devices, few studies have comprehensively evaluated the related risk factors.

OBJECTIVE

This retrospective study analyzed the risk factors, predictors, causative organisms, and impact of CLABSI on clinical outcomes mortality, and length of stay (LOS) in older adults.

METHODS

We included 36 patients diagnosed with CLABSI according to the Centers for Disease Control and Prevention criteria at King Abdulaziz University Hospital during 2013-2014 cases and 375 control patients controls. Risk factors were evaluated using a multivariate logistic regression analysis.

RESULTS

Cases and controls did not differ significantly in age or sex distribution. However, cases had a significantly longer LOS than controls 78 vs. 19 days, p < 0.001. One-third of 12/36 CLABSI cases were admitted to the medical intensive care unit (MICU). Most had renal disease, acute coronary syndrome, and used steroids. Additionally, 34 cases (94.4%) and 2 cases (5.6%) presented with primary and secondary infections, respectively, and hypotension was the most prevalent symptom (12/36). The internal jugular vein was the most common insertion site, and the nasogastric tube and mechanical ventilator were the most common insertion devices. Seven cases died, and three deaths were attributed to bloodstream infection (BSI). The most common cause of blood infection was Staphylococcus epidermidis, followed by Klebsiella pneumoniae.

CONCLUSIONS

The present study reveals age, LOS, total parenteral nutrition/partial parenteral nutrition (TPN/PPN), and transplantation as the independent risk factors/predictors of CLABSI.

Fever at Time of Leukemia Diagnosis in Children: Predictor of Bloodstream Infection or Catheter Removal?

PURPOSE

To assess the incidence of fever at diagnosis in children with leukemia and determine if fever at diagnosis is a predictor of bloodstream infection (BSI) or central venous access device (CVAD) removal due to infection either within the first 30 days or between 30 and 90 days after CVAD insertion.

MATERIALS AND METHODS

One hundred fifty-one patients with acute leukemia (July 1, 2018, to December 31, 2020) who underwent a CVAD insertion within 2 weeks of diagnosis were included. Patient data included demographic characteristics, fever at diagnosis, CVAD type, antibiotics before and/or on the day of CVAD insertion, BSI incidence, BSI rates per 1,000 catheter days, and need for catheter removal after CVAD insertion within 30 days and between 30 and 90 days.

RESULTS

Patients with fever at diagnosis had a significantly higher incidence of BSI within the first 30 days after CVAD insertion (17/23) than that among patients without fever (6/23) (P = .046) at diagnosis. No statistically significant difference was observed in the incidence of BSI between 30 and 90 days after CVAD insertion between patients with fever (5/11) and those without fever at diagnosis (6/11) (P = .519). Fever at diagnosis was not a predictor of CVAD removal within 30 days (9 patients required CVAD removal; 7/9 had fever and 2/9 had no fever) (P = .181) or between 30 and 90 days (4 patients required CVAD removal; 1/4 had fever and 3/4 had no fever at diagnosis) (P = .343) after insertion.

CONCLUSIONS

Fever at diagnosis in patients with leukemia is not a predictor of CVAD removal due to infection.

Rising Drug Resistance Among Gram-Negative Pathogens in Bloodstream Infections: A Multicenter Study in Ulanhot, Inner Mongolia (2017-2021)

BACKGROUND Bloodstream infections, which arise when pathogenic microorganisms infiltrate the bloodstream, present a grave health risk. Their potentially lethal nature combined with the ability to severely impair physiological functions underscore the importance of understanding and mitigating such infections. This study aimed to elucidate drug sensitivity profiles and distribution of these pathogens in hospitals in Ulanhot, Inner Mongolia. MATERIAL AND METHODS From 2017 to 2021, we gathered blood culture-positive samples from several hospitals across Ulanhot. Using combined diagnostic techniques, including the instrument method, paper diffusion, and Epsilometer test (E-test), we determined the identity of pathogens and assessed their drug sensitivity. Subsequent data processing with WHONET 5.6 software provided insights into the patterns of microbial distribution and extent of drug resistance. RESULTS Of 2498 pathogenic strains identified, 35.83% were gram-positive, 62.45% were gram-negative, and a smaller fraction of 1.72% were fungi. Escherichia coli and Klebsiella pneumoniae were the primary bacteria, contributing to 35.15% and 15.73% of infections, respectively. Alarmingly, methicillin-resistant strains exhibited pronounced resistance to drugs, notably penicillin G (resistance rates of 80.87% to 100.00%) and erythromycin (resistance rates of 91.16% to 97.28%). Acinetobacter baumannii had a particularly high resistance profile, surpassing Pseudomonas aeruginosa, which exhibited a resistance rate below 30.00%. CONCLUSIONS Ulanhot's primary bloodstream infection agents were gram-negative bacteria, specifically E. coli and K. pneumoniae. The growing drug resistance observed, particularly among strains like A. baumannii, highlights the pressing need for rigorous drug resistance surveillance and the strategic use of antibiotics, ensuring their efficacy is preserved for future medical needs.

T2Bacteria and T2Resistance Assays in Critically Ill Patients with Sepsis or Septic Shock: A Descriptive Experience

The use of rapid molecular tests may anticipate the identification of causative agents and resistance determinants in the blood of critically ill patients with sepsis. From April to December 2021, all intensive care unit patients with sepsis or septic shock who were tested with the T2Bacteria and T2Resistance assays were included in a retrospective, single center study. The primary descriptive endpoints were results of rapid molecular tests and concomitant blood cultures. Overall, 38 combinations of T2Bacteria and T2Resistance tests were performed. One or more causative agent(s) were identified by the T2Bacteria assay in 26% of episodes (10/38), whereas negative and invalid results were obtained in 66% (25/38) and 8% (3/38) of episodes, respectively. The same pathogen detected by the T2Bacteria test grew from blood cultures in 30% of cases (3/10). One or more determinant(s) of resistance were identified by the T2Resistance assay in 11% of episodes (4/38). Changes in therapy based on T2Bacteria and/or T2Resistance results occurred in 21% of episodes (8/38). In conclusion, T2Bacteria/T2Resistance results can influence early treatment decisions in critically ill patients with sepsis or septic shock in real-life practice. Large, controlled studies remain necessary to confirm a favorable impact on patients' outcomes and antimicrobial stewardship interventions.

The Diagnostic Relevance of β-D-Glucan for Candidemia within Internal Medicine Wards

Candidemia diagnosis is based on the combination of clinical, microbiological and laboratory data. We aimed to evaluate performances and accuracy of (1,3)-β-D-glucan (BDG) at various cut-offs in internal medicine patients. An observational retrospective−prospective study was performed. Patients with at least two determinations of BDG and paired, associated blood cultures within ±48 h were considered. A total of 140 patients were included: 26 with Candida spp. blood-stream infections (BSI) and 114 without candidemia. Patients with candidemia were older and had higher BDG values, need of parenteral nutrition, higher colonization by Candida in more than one site, presence of percutaneous gastrostomy and higher Candida or Charlson scores. BDG maintained the best compromise between sensitivity, specificity and optimal negative predictive value was 150 pg/mL. BDG values at cut-off of 150 pg/mL increase the strength of association between BDG and development of candidemia (Odds Ratio—OR 5.58; CI 2.48−12.53 vs. OR 1.06; CI 1.003−1.008). Analyzing BDG > 150 pg/mL along with Candida score > 2 and Charlson score > 4, the strength of the association amongst BDG, clinical scores and development of candidemia is increased. The overall clinical evaluation with the help of scores that consider BDG values > 150 pg/mL, Candida score > 2 and Charlson score > 4 in combination seems to predict better the need of antifungal empiric treatment.

Multidrug-Resistant Bloodstream Infections in Internal Medicine: Results from a Single-Center Study

OBJECTIVES

Infections due to multidrug-resistant organisms (MDROs) are expanding globally and are associated with higher mortality rates and hospital-related costs. The objectives of this study were to analyze the trends of MDRO bacteremia and antimicrobial resistance rates in Internal Medicine wards of our hospital and to identify the variables associated with these infections.

METHODS

During a 6-year period (July 1, 2011-June 30, 2017), patients with positive blood culture isolates hospitalized in the Internal Medicine wards in the Santa Croce and Carle Hospital in Cuneo, Italy, were assessed. We performed an analysis taking into consideration the time trends and frequencies of MDRO infections, as well as a case-control study to identify clinical-demographic variables associated with MDRO bacteremias.

RESULTS

During the study period a total of 596 blood cultures were performed in 577 patients. The most frequently identified organism was Escherichia coli (33.7%), followed by Staphylococcus aureus (15.6%) and S epidermidis (7.4%). The percentage of resistance to methicillin among S aureus isolates showed a decreasing trend, whereas rates of extended-spectrum β-lactamase-producing Enterobacteriaceae and carbapenemase-producing Klebsiella pneumoniae increased during the study period. Multivariate analysis showed that the nosocomial origin of the infection, hospitalization during the previous 3 months, residence in long-term care facilities, presence of a device, antibiotic exposure during the previous 3 months, and cerebrovascular disease were independently associated with bacteremia by resistant microorganisms.

CONCLUSIONS

Our analysis reveals a concerning microbiological situation in an Internal Medicine setting, in line with other national and regional data. The risk variables for infection by MDRO identified in our study correspond to those reported in the literature, although studies focused on Internal Medicine settings appear to be limited.

Microbial Distribution and Antibiotic Susceptibility of Bloodstream Infections in Different Intensive Care Units

Background: Bloodstream infection (BSI) is an increasing public health concern worldwide, representing a serious infection with significant morbidity and mortality, especially in children and the elderly. The predominant microbial distribution and antibiotic susceptibility were investigated among BSIs in the different intensive care units (ICUs)—pediatric ICU (PICU), surgical ICU (SICU), cardiac ICU (CICU), respiratory ICU (RICU), and geriatric ICU (GICU)—in order to achieve more efficient and appropriate therapies for patients in various ICUs.

Methods: In this retrospective cross-sectional study, the blood specimens were collected from five different ICUs of Peking University First Hospital and comprehensive ICU of Miyun Teaching Hospital (Miyun ICU) before antimicrobial treatment from 2017 to 2020. Microorganism cultures of the blood samples were conducted, and positive cultures were tested for type of pathogens and drug susceptibility.

Results: The prevalence of BSIs was the highest in the Miyun ICU (10.85%), followed by the RICU (9.48%) and the PICU (8.36%). The total prevalence of Gram-positive bacterial strains (especially Staphylococcus spp. and Enterococcus spp.) in the PICU (44.55%), SICU (57.58%), CICU (55.00%), GICU (49.06%), and Miyun ICU (57.58%) was higher than that of Gram-negative bacteria. The major bacterial strain was Acinetobacter baumannii in the PICU (21.82%); Klebsiella pneumoniae in the SICU (12.88%), CICU (30.00%), and RICU (30.39%); Escherichia coli in the GICU (20.75%); and Staphylococcus epidermidis (18.18%) in the Miyun ICU. Staphylococcus hominis of BSIs remained highly susceptible (>70%) to gentamicin, linezolid, daptomycin, teicoplanin, vancomycin, tigecycline, and rifampicin in all the ICUs. Its antibiotic sensitivity to levofloxacin was moderate in the PICU and CICU, but mild (<30%) in the SICU, RICU, and GICU. K. pneumoniae was highly susceptible to doxycycline, minocycline, and tigecycline in all the ICUs except the RICU, and its antibiotic sensitivity to imipenem, meropenem, amikacin, ciprofloxacin, and levofloxacin was high/moderate in the PICU, CICU, GICU, and Miyun ICU, but mild in the SICU and RICU.

Conclusion: The current study demonstrated the distribution of prevalent microorganisms, and their antimicrobial susceptibility exhibited a high divergence among BSIs in different ICUs from a tertiary hospital and an outer suburban hospital in Beijing. Therefore, different antibiotic therapies for various wards and distinct age groups (especially between pediatric and elderly patients) should be considered to control the emergence and spread of highly antibiotic-resistant infections.

Inflammasome-mediated GSDMD activation facilitates escape of Candida albicans from macrophages

Candida albicans is the most common cause of fungal sepsis. Inhibition of inflammasome activity confers resistance to polymicrobial and LPS-induced sepsis; however, inflammasome signaling appears to protect against C. albicans infection, so inflammasome inhibitors are not clinically useful for candidiasis. Here we show disruption of GSDMD, a known inflammasome target and key pyroptotic cell death mediator, paradoxically alleviates candidiasis, improving outcomes and survival of Candida-infected mice. Mechanistically, C. albicans hijacked the canonical inflammasome-GSDMD axis-mediated pyroptosis to promote their escape from macrophages, deploying hyphae and candidalysin, a pore-forming toxin expressed by hyphae. GSDMD inhibition alleviated candidiasis by preventing C. albicans escape from macrophages while maintaining inflammasome-dependent but GSDMD-independent IL-1β production for anti-fungal host defenses. This study demonstrates key functions for GSDMD in Candida's escape from host immunity in vitro and in vivo and suggests that GSDMD may be a potential therapeutic target in C. albicans-induced sepsis.

The role of new antimicrobials for Gram-negative infections in daily clinical practice

PURPOSE OF REVIEW

To discuss a possible clinical reasoning for treating resistant Gram-negative bacteria (GNB) infections in daily clinical practice, as well as developing a research agenda for the field.

RECENT FINDINGS

Novel agents, both belonging to β-lactams and to other classes of antimicrobials, have recently become available, likely replacing polymyxins or polymyxin-based combination regimens as the preferred choices for the first-line treatment of severe resistant GNB infections in the near future.

SUMMARY

The peculiar characteristics of novel agents for severe resistant GNB infections have abruptly made the structure of previous therapeutic algorithms somewhat obsolete, in view of the differential activity of most of them against different classes of carbapenemases. Furthermore, other agents showing activity against resistant GNB are in late phase of clinical development. Optimizing the use of novel agents in order both to guarantee the best available treatment to patients and to delay the emergence and spread of resistance is an important task that cannot be postponed, especially considering the unavailability of well tolerated and fully efficacious options for treating resistant GNB infections that we faced in the last 15 years.

Innovative therapies for acute bacterial skin and skin-structure infections (ABSSSI) caused by methicillin-resistant Staphylococcus aureus: advances in phase I and II trials

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) is among the most frequent causative agents of acute bacterial skin and skin-structure infections (ABSSSI) and has been associated with increased risks of invasive disease and of treatment failure.

AREAS COVERED

In this review, we focus on those novel anti-MRSA agents currently in phase I or II of clinical development that may enrich the armamentarium against ABSSSI caused by MRSA in the future.

EXPERT OPINION

Promising agents belonging to either old or novel antibiotic classes are currently in early phases of clinical development and may become available in the future for the effective treatment of ABSSSI caused by MRSA. In particular, the future availability of agents belonging to novel classes will be important for guaranteeing an effective treatment and for allowing outpatient treatment/early discharge, with a consequent reduced impact on healthcare resources. However, this does not mean that we can relax our efforts directed toward improving the responsible use of already available agents. Indeed, preserving their activity in the long term is crucial for optimizing the use of healthcare resources.

Incorporation of rapid diagnostic tests to improve time to antimicrobial therapy for gram-positive bacteremia and candidemia

Purpose

Even with rapid diagnostic technology to swiftly identify infectious organisms, prompt response is needed to translate results into appropriate actions. The purpose of this study was to determine if the introduction of real-time pharmacist response to positive rapid diagnostic test results would decrease time to antimicrobial therapy for gram-positive bacteremia and candidemia in a community hospital setting.

Methods

A quasi-experimental study was conducted in 2 community hospitals. The study comprised 2 cohorts of adult patients who tested positive for gram-positive bacteremia involving Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, or Candida species. The preintervention cohort consisted of patients admitted from November 2017 through May 2018. The intervention cohort consisted of patients admitted from July 2018 through January 2019, after the intervention went live. The primary outcomes were time to optimal antimicrobial therapy and time to effective antimicrobial therapy.

Results

A total of 140 patients were included in the preintervention group, with 124 patients included in the intervention group. The mean (SD) time to effective therapy decreased from 13.9 (21.6) hours in the preintervention group to 8.6 (12.5) hours in the intervention group (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.89-1.48; P = 0.29). The mean (SD) time to optimal therapy significantly decreased from 53.7 (57.7) hours in the preintervention group to 38.4 (31.5) hours in the intervention group (HR, 1.73; 95% CI, 1.33-2.26; P &lt; 0.001).

Conclusion

The introduction of real-time pharmacist response to positive rapid diagnostic test results led to a significant decrease in time to optimal antimicrobial therapy but did not significantly affect time to effective therapy. The results showed that the allocation of limited resources of a community hospital to such a stewardship program is justifiable.

First bloodstream infection caused by Prevotella copri in a heart failure elderly patient with Prevotella-dominated gut microbiota: a case report

Background

Bloodstream infection (BSI) is a constant threat for hospitalized patients, and elderly patients are particularly susceptible to BSI caused by anaerobic bacteria. Changes in the gut microbiota composition may lead to pathogen overgrowth and translocation into the bloodstream. Consequently, domination of specific taxa in the intestinal bacterial community seems to be associated with a higher risk of bacteremia in some patient populations.

Case presentation

Here, we report the case of a 90-year-old heart failure (HF) patient who was admitted to the hospital for an acute state of cardiac decompensation. Twenty days after admission, he was febrile to 38.2 °C whereas his white blood count and C-reactive protein increased to 6190 cells/μL and 31.2 mg/L, respectively. Of the patient’s blood culture (BC) bottle pairs collected under the suspicion of infection, the anaerobic bottle yielded an organism that was later identified as Prevotella copri. Concomitantly, the patient’s fecal sample was obtained for the intestinal microbiota characterization by sequencing the V3/V4/V6 regions of the bacterial 16S rRNA gene. The analysis revealed highest relative abundances of Bacteroidales (34.1%), Prevotellaceae (19.0%), Prevotella (15.2%), and P. copri (6.1%) taxa, indicating that the patient’s gut microbiota was dominated by Prevotella organisms. The patient was successfully treated with metronidazole, and was discharged to a long-term care facility at 35 days of admission.

Conclusions

We provide the first evidence for a clinically significant BSI caused by P. copri and its relationship to a Prevotella-rich gut microbiota in the HF patient setting. When strengthening the pathogenicity of P. copri, the present case suggests that the gut may be a source of BSI caused by the rare anaerobic organism. Future studies are necessary to assess the role of the gut microbiota profiling for precise identification and targeted treatment of patients at high risk of BSI.

Molecular and Physiological Study of Candida albicans by Quantitative Proteome Analysis

Candida albicans is one of the major pathogens that cause the serious infectious condition known as candidiasis. C. albicans was investigated by proteome analysis to systematically examine its virulence factors and to promote the development of novel pharmaceuticals against candidiasis. Here, we review quantitative time-course proteomics data related to C. albicans adaptation to fetal bovine serum, which were obtained using a nano-liquid chromatography/tandem mass spectrometry system equipped with a long monolithic silica capillary column. It was revealed that C. albicans induced proteins involved in iron acquisition, detoxification of oxidative species, energy production, and pleiotropic stress tolerance. Native interactions of C. albicans with macrophages were also investigated with the same proteome-analysis system. Simultaneous analysis of C. albicans and macrophages without isolating individual living cells revealed an attractive strategy for studying the survival of C. albicans. Although those data were obtained by performing proteome analyses, the molecular physiology of C. albicans is discussed and trials related to pharmaceutical applications are also examined.

Epidemiology and microbiology of Gram-positive bloodstream infections in a tertiary-care hospital in Beijing, China: a 6-year retrospective study

Background

Gram-positive bacterial bloodstream infections (BSIs) are serious diseases associated with high morbidity and mortality. The following study examines the incidence, clinical characteristics and microbiological features, drug resistance situations and mortality associated with Gram-positive BSIs at a large Chinese tertiary-care hospital in Beijing, China.

Methods

A retrospective cohort study of patients with Gram-positive BSIs was performed between January 1, 2011, and June 31, 2017, at the Chinese People^’s Liberation Army General Hospital. The patients’ data were collected and included in the reviewing electronic medical records.

Results

A total of 6887 episodes of Gram-positive BSIs occurred among 4275 patients over 6 years, and there were 3438 significant BSI episodes 69% of these cases were healthcare-associated, while 31% were community-associated. The overall incidence of Gram-positive BSIs fluctuated from 7.26 to 4.63 episodes per 1000 admissions over 6 years. Malignancy was the most common comorbidity and indwelling central intravenous catheter was the most common predisposing factor for BSI. Staphylococci were the major pathogen (65.5%), followed by Enterococcus spp:(17.5%), Streptococcus spp.(7.1%) and other bacterial pathogens (9.9%). The resistance rates of Staphylococci and E.faecium to penicillins were more than 90%. the vancomycin-resistant isolates were E. faecium (4.1%) and staphylococcus epidermidis (0.13%); and only E.faecalis and E.faecium showed resistance to linezolid (3.8% and 3.1%). Between 2011 and 2017, the overall mortality of Gram-positive BSIs decreased from 6.27 to 4.75% (X² = 0.912, p = 0.892). Neverthess, the mortality in the ICU decreased from 60.46 to 47.82%, while in the general ward it increased from 39.54 to 52.18%.

Conclusions

The morbidity and mortality of Gram-positive BSIs have showed downward trends. Vancomycin and linezolid are still consider the best treatment for patients with Gram-positive BSIs.

Curcumin-loaded graphene oxide flakes as an effective antibacterial system against methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for serious hospital infections worldwide and represents a global public health problem. Curcumin, the major constituent of turmeric, is effective against MRSA but only at cytotoxic concentrations or in combination with antibiotics. The major issue in curcumin-based therapies is the poor solubility of this hydrophobic compound and the cytotoxicity at high doses. In this paper, we describe the efficacy of a composite nanoparticle made of curcumin (CU) and graphene oxide (GO), hereafter GOCU, in MRSA infection treatment. GO is a nanomaterial with a large surface area and high drug-loading capacity. GO has also antibacterial properties due mainly to a mechanical cutting of the bacterial membranes. For this physical mechanism of action, microorganisms are unlikely to develop resistance against this nanomaterial. In this work, we report the capacity of GO to support and stabilize curcumin molecules in a water environment and we demonstrate the efficacy of GOCU against MRSA at a concentration below 2 µg ml-1. Further, GOCU displays low toxicity on fibroblasts cells and avoids haemolysis of red blood cells. Our results indicate that GOCU is a promising nanomaterial against antibiotic-resistant MRSA.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

Impact of a mixed educational and semi-restrictive antimicrobial stewardship project in a large teaching hospital in Northern Italy

BACKGROUND

The overuse of antimicrobials favors the dissemination of antimicrobial resistance, as well as invasive fungal diseases and Clostridium difficile infections (CDI). In this study, we assessed the impact of a mixed educational and semi-restrictive antimicrobial stewardship (AMS) project in a large teaching hospital in Italy.

METHODS

The AMS project was conducted from May 2014 to April 2016. It consisted of two initiatives in two consecutive periods: (1) educational activities; (2) semi-restrictive control of antimicrobial prescribing through a computerized software. The primary endpoint was consumption of antibacterials and antifungals. Secondary endpoints were incidence of CDI, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI, and Candida BSI.

RESULTS

During the study period, a statistically significant reduction in consumption was observed for antibacterials (-1.45 defined daily doses (DDD)/1000 patient-days monthly, 95% confidence intervals [CI] -2.38 to -0.52, p 0.004), mainly driven by reductions in the use of fluoroquinolones, third/fourth generation cephalosporins, and carbapenems. No decrease in consumption of antifungals was observed (-0.04 DDD/1000 patient-days monthly, 95% CI -0.34 to +0.25, p 0.750). A statistically significant trend towards reduction was observed for incidence of CRKP BSI (incidence rate ratio 0.96, 95% CI 0.92-0.99, p 0.013). No statistically significant variations in trends were observed for CDI, MRSA BSI, and Candida BSI.

CONCLUSIONS

The mixed AMS project was effective in reducing the use of major antibacterials and the incidence of CRKP BSI. Further research is needed to assess the extent of long-term benefits of semi-restrictive approaches.

Epidemiology, management, and outcome of carbapenem-resistant Klebsiella pneumoniae bloodstream infections in hospitals within the same endemic metropolitan area

In the last decade, carbapenem-resistant Klebsiella pneumoniae (CR-Kp) has become endemic in several countries, including Italy. In the present study, we assessed the differences in epidemiology, management, and mortality of CR-Kp bloodstream infection (BSI) in the three main adult acute-care hospitals of the metropolitan area of Genoa, Italy. From January 2013 to December 2014, all patients with CR-Kp BSI were identified through the computerized microbiology laboratory databases of the three hospitals. The primary endpoints of the study were incidence and characteristics of CR-Kp BSI in hospitals within the same endemic metropolitan area. Secondary endpoints were characteristics of CR-Kp BSI in hospitals with and without internal infectious diseases consultants (IDCs) and 15-day mortality. During the study period, the incidence of healthcare-associated CR-Kp BSI in the entire study population was 1.35 episodes per 10,000 patient-days, with substantial differences between the three hospitals. Patients admitted to the two hospital with internal IDCs were more likely to receive post-susceptibility test combined therapy including carbapenems (77% vs. 26%, p<0.001), adequate post-susceptibility test therapies (86% vs. 52%, p<0.001), and post-susceptibility therapies prescribed by an infectious diseases specialist (84% vs. 14%, p<0.001). Overall, the crude 15-days mortality was 26%. In the final multivariable model, only septic shock at BSI presentation was unfavorably and independently associated with 15-days mortality (odds ratio [OR] 6.7, 95% confidence intervals [CI] 2.6-17.6, p<0.001), while a protective effect was observed for post-susceptibility test combined therapies including a carbapenem (OR 0.11, 95% CI 0.03-0.43, p=0.002). Mortality of CR-Kp remains high. Differences in the incidence of CR-Kp BSI were detected between acute-care centers within the same endemic metropolitan area. Efforts should be made to improve the collaboration and coordination between centers, to prevent further diffusion of CR-Kp.