Long-term intensive care unit outbreak of carbapenemase-producing organisms associated with contaminated sink drains

BACKGROUND

Between 2018 and 2022, a Belgian tertiary care hospital faced a growing issue with acquiring carbapenemase-producing organisms (CPO), mainly VIM-producing P. aeruginosa (PA-VIM) and NDM-producing Enterobacterales (CPE-NDM) among hospitalized patients in the adult intensive care unit (ICU).

AIM

To investigate this ICU long-term CPO outbreak involving multiple species and a persistent environmental reservoir.

METHODS

Active case finding, environmental sampling, whole-genome sequencing (WGS) analysis of patient and environmental strains, and implemented control strategies were described in this study.

FINDINGS

From 2018 to 2022, 37 patients became colonized or infected with PA-VIM and/or CPE-NDM during their ICU stay. WGS confirmed the epidemiological link between clinical and environmental strains collected from the sink drains with clonal strain dissemination and horizontal gene transfer mediated by plasmid conjugation and/or transposon jumps. Environmental disinfection by quaternary ammonium-based disinfectant and replacement of contaminated equipment failed to eradicate environmental sources. Interestingly, efflux pump genes conferring resistance to quaternary ammonium compounds were widespread in the isolates. As removing sinks was not feasible, a combination of a foaming product degrading the biofilm and foaming disinfectant based on peracetic acid and hydrogen peroxide has been evaluated and has so far prevented recolonization of the proximal sink drain by CPO.

CONCLUSION

The persistence in the hospital environment of antibiotic- and disinfectant-resistant bacteria with the ability to transfer mobile genetic elements poses a serious threat to ICU patients with a risk of shifting towards an endemicity scenario. Innovative strategies are needed to address persistent environmental reservoirs and prevent CPO transmission.

Are C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) predictive markers of successful two-stage prosthetic joint infection management?

The treatment of prosthetic joint infections (PJI) regularly involves a two-stage surgical strategy. The second stage is generally performed when the surgeon estimates that the infection is under control based on either the treatment length or clinical and biological data. We have raised the question whether standardization of C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) values could be either indicative of infection control or predictive of infection recurrence. This was an analytical retrospective and monocentric cross-sectional observational study. The CRP and NLR values were recorded prior to the second-stage surgery in a sample of 100 patients who underwent a two-stage revision arthroplasty following a PJI, and these values were correlated with the absence of infectious recurrence within a 2-year follow-up. The statistical analysis consisted of evaluating the diagnostic validity of each marker, first individually, and then in combination. CRP was shown associated with a 68% sensitivity, 40% specificity, 27% positive predictive value (PPV), and 79% negative predictive value (NPV). The ROC curve was 51.1%. The NLR displayed a 12% sensitivity, 89% specificity, 27% PPV, and 75% NPV. The ROC curve was 47.9%. The combination of the two markers did not fundamentally improve the statistical results, with only a 43% concordance of the two markers, 27% sensitivity, 84% specificity, 37% PPV, and 77% NPV. Measuring CRP and NLR values, either individually or in combination, before the second-stage revision arthroplasty did not turn out to be predictive of either infection recurrence or cure within two years of follow-up. Therefore, an absolute test is still lacking, which would enable us to predict without failure the absence of control or the control of a PJI before or after second-stage revision. Level of evidence: Level III, retrospective cross-sectional study.

Fungal pneumonia in kidney transplant recipients

Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.

Clinical characteristics and humoral immune response in healthcare workers with COVID-19 in a teaching hospital in Belgium

Background

Healthcare workers (HCWs) are at high risk of acquiring COVID-19 and could play a role in nosocomial transmission. Since 4^th February 2020, Belgian Health authorities reported more than 90,568 cases, of which 8.3% were HCWs. Data on clinical characteristics, sources of infection and humoral immune response of HCWs with COVID-19 remain scarce.

Aim

To analyse the clinical characteristics, humoral immune response, sources of contamination, and outcomes among HCWs with COVID-19.

Methods

This retrospective study included 176 HCWs with laboratory-confirmed COVID-19 in a teaching hospital in Belgium. Between 1^st March and 31^st May 2020, all HCWs with symptoms suspected of COVID-19 were tested by reverse transcription polymerase chain reaction on a nasopharyngeal swab. Serological testing was performed between 55 and 137 days after the onset of symptoms.

Findings

Median age was 40.8 years and 75% were female. Median delay between onset of symptoms and diagnosis was 4.39 days. Most frequent symptoms were cough and headache (both 75%). Fever accounted for 68.7%. Most represented professions were nurses (42%). HCWs were mainly infected by patient contact (32.9%); 7.6% required hospitalization and 1.7% were admitted to the intensive care unit. Unfortunately, one HCW died (0.5%). Total antibodies were positive in 109/126 (86.5%).

Conclusions

Clinical presentation of COVID-19 in HCWs does not differ from the general population. However, outcomes were more favourable with a mortality rate lower than that reported in Belgian COVID-19 patients in general (16%). The main source of infection was the hospital setting. Our positive antibodies rate was high but lower than previously reported.

Concordance between superficial swab and deep sampling in post-sternotomy mediastinitis: Single center experience

OBJECTIVES

Deep sampling (DS) is the gold standard for microbiological diagnosis of post-sternotomy mediastinitis (PSM), however superficial swab (SS) are frequently performed in some centers and antibiotherapy initiated base on their results. We analysed the concordance between superficial swab and deep sampling in PSM.

MATERIALS AND METHODS

We analysed retrospectively patients with a PSM between 2010 and 2014 at Saint-Luc University hospital (Belgium). We considered that there was a concordance between SS and DS when the same microorganism was found in the two sampling method in each patient. Patients were stratified in six groups according to microbiology results as Staphylococcus Aureus (SA) sensitive or resistant, coagulase negative Staphylococcus (CoNS), Gram negative bacilli (GNB), other Gram positive bacteria (GPB) and fungi.

RESULTS

Thirty-six patients were included. Twenty-five men (69%) and a mean age of 66 years old. The overall concordance between SS and DS was 57%. SA and GNB showed high concordance (100% and 85.7% respectively). For the other groups the concordance was low. The sensitivity and specificity of SS was 97% and 33% respectively. The PPV and NPV of superficial swab was 96% and 50% respectively.

CONCLUSION

Microbiological results from SS, even with flocked swabs, except for SA and GNB have low concordance with those obtained from deep sampling. Our data confirm that in PSM, deep sampling is the gold standard for microbiological assessment.

Bacterial pneumonia in kidney transplant recipients

Bacterial pathogens are the most frequent cause of pneumonia after transplantation. Early after transplantation, recipients are at higher risk for nosocomial infections. The most commonly encountered pathogens during this period are gram-negative bacilli (Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa …), but gram-positive coccus such as Staphylococcus aureus or Streptococcus pneumoniae and anaerobic bacteria can also be found. Empirical antibiotic therapy should be guided by previous colonisation of the recipient and bacterial resistance pattern in the hospital. Six months after transplantation, pneumonias are mostly due to community-acquired bacteria (S. pneumonia, H. influenza, Mycoplasma, Chlamydia and others). Opportunistic pathogens take advantage of the state of immunosuppression which is usually highest from one to six months after transplantation. During this period, but also occurring many years later in the setting of a chronically depressed immune system, bacterial pathogens with low intrinsic virulence can cause pneumonia. The diagnosis of pneumonia caused by opportunistic pathogens can be challenging. The delay in diagnosis preventing the early instauration of adequate treatment in kidney transplant recipients with a depressed immune system, frequently coupled with co-morbid conditions and a state of frailty, will affect prognosis and outcome, increasing morbidity and mortality. This review will focus on the most common opportunistic bacterial pathogens causing pneumonia in kidney transplant recipients: Legionella, Nocardia, Mycobacterium tuberculosis/nontuberculous, and Rhodococcus. Recognition of their specificities in the setting of immunosuppression will allow early diagnosis, crucial for initiation of effective therapy and successful outcome. Interactions with immunosuppressive therapy should be considered as well as reducing immunosuppression if necessary.

Fatal thoracic empyema involving Campylobacter rectus: A case report

We report the case of a 69-year-old man admitted for septic shock secondary to necrotic pneumoniae complicated by thoracic empyema of fatal issue. Microbiological examination of pleural liquid revealed a mixed anaerobic flora involving Campylobacter rectus and Actinomyces meyeri. Campylobacter rectus is an infrequent anaerobic pathogen of oral origin To our knowledge, this is the first case report of fatal C. rectus - associated thoracic empyema, and only the second reported case in which identification was successfully performed by MALDI-TOF MS.

Difficult to treat osteoarticulars infections : Focus on Mycobacterial and Fungal infection

Bone and joint infections are rare but often devastating. While bacteria are most commonly encountered organisms, mycobacteria and fungi are less frequent. Management of the latter is often more complex, especially in the presence of foreign material. We will increasingly be faced with mycobacterial and fungal bone infections, as medical conditions and newer therapeutics lead to more immunosuppression. In this article, we will review osteomyelitis, septic arthritis and peri-prosthetic joint infections related to mycobacteria and fungi.

First Robinsoniella peoriensis aortic cross homograft mycotic pseudoaneurysm: A case report and review of the literature

Mycotic aortic aneurysm is a rare and challenging complication of aortic homografts caused by an infection and is associated with high morbidity and mortality. We report the first case of an aortic cross homograft mycotic pseudoaneurysm caused by Robinsoniella peoriensis in a 70-year-old man. Our patient underwent surgery for a recurrence of aortic cross mycotic pseudoaneurysm at the level of the aortic homograft he had had 7 years before. A clot-removal of the pseudoaneurysm was surgically carried out and the homograft was completely removed. Anaerobic culture from tissue samples yielded pure growth of a spore-forming Gram-positive rod, identified later as Robinsoniella peoriensis by 16S rRNA gene sequencing. The patient was then discharged with oral clindamycin according to the in vitro susceptibility testing. Identification of R. peoriensis might be challenging in clinical laboratories with no access to molecular methods.

First case of a dog bite wound infection caused by Streptococcus minor in human

We report the first case of human infection caused by Streptococcus minor in a 51-year-old immunocompetent woman admitted for dog bite injuries. At present, the role of Streptococcus minor in bite wound infections is unknown. Further studies on virulence factors are needed to elucidate its pathogenicity mechanisms.

Clinical features and outcome of typhoid fever and invasive non-typhoidal salmonellosis in a tertiary hospital in Belgium: analysis and review of the literature

OBJECTIVES

Typhoid fever (TF) occurs rarely in industrialized countries because of advances in health care and improvement of drinking water. Conversely, non-typhoid salmonellosis (NTS) remains widespread, because of food contamination or asymptomatic carriage. Non-typhoid salmonellosis can be severe when becoming invasive non-typhoid salmonellosis (iNTS). Although established prognostic indicators of the two pathologies are different, direct comparisons between iNTS and TF in the literature remain scarce. The purpose of this study was to analyse and compare demographic, clinical features and outcome of hospitalized patients with TF and iNTS.

METHODS

Demographic, clinical features and outcome were retrospectively analysed in a series of patients hospitalized between 2007 and 2012.

RESULTS

A total of 33 patients were enrolled, including 13 with established TF and 20 with iNTS. No differences between TF and iNTS patients were observed in incidence of fever, abdominal cramps, diarrhoea, headache, nausea and vomiting and duration of antibiotic therapy (≤ 7 days in both groups). Although the clinical outcome of TF patients was identical to that of iNTS patients, including incidence of complications, length of hospitalization and mortality (1/13 (7.7%) vs 2/20 (10%), P = 0.43), comorbidities were less frequent in the TF group than in the iNTS group (2/13 vs 15/20, P = 0.003).

CONCLUSION

The clinical profile and outcome of TF patients are similar to those with iNTS. Although comorbidities are more often associated with iNTS, the results of our study suggest that clinical management of these two diseases should remain similar.

Nocardia prosthetic knee infection successfully treated by one-stage exchange: case report and review

A 64-year-old man with a history of sarcoidosis on corticosteroids and azathioprine was admitted to our hospital with complaints of worsening left knee pain and swelling for the past 3 weeks. His past medical history is also significant for severe osteoarthritis requiring a cemented total left knee arthroplasty 1 year ago. Diagnostic investigation during his hospital admission eventually led to the diagnosis of Nocardia nova knee prosthetic joint infection in the setting of a disseminated nocardiosis. He was successful treated by one-stage complete hardware exchange in conjunction with an adapted antibiotic therapy regimen (meropenem and doxycycline followed by ceftriaxone and doxycycline). Two years later, his recovery was deemed excellent.

Emergence and dissemination of multi-resistant Gram negative Enterobacteriaceae: lessons to be learnt from local and national surveillance programs in Belgium

Infections caused by multi drug resistant bacteria (MDRB) constitutes an international health care problem. Since the year 2000, a longitudinal surveillance programme (LSP) and two multicentric surveys (100 hospitals, 826 isolates) were performed to monitor the emergence of MDRB in Belgium. The implementation of a LSP detected the emergence and spread of new types of ESBLs (CTX-M), mostly among community associated E. coli in the setting of a university hospital several years before the large spread and recognition in Belgium of a pathogenic E. coli CTX-M-15 (B2-O25:H4-ST131) pandemic clone (found in extra-intestinal virulent strains). This finding supports the progressive increase in Belgium of systemic infections including UTI caused by MDRB with limited therapeutical options. The real burden of the problem remains however, difficult to estimate in the absence of any surveillance network in Belgium to monitor the epidemiology of antimicrobial resistance in the community. The current Belgian national recommendations for the detection, surveillance, prevention and control of epidemics by ESBL-producing organisms and possibly other MDRBs (eg: Carbapenemase producing Enterobacteriaceae [CPE]) must be updated taking into accounts these new elements. A global coordinated network for antimicrobial surveillance resistance gathering experts (e.g: public health epidemiologists, representative of the national reference centres of antimicrobial resistance, field experts in infection control, infectious disease specialists, other clinicians and general practitioners) must be urgently implemented, including the longitudinal analysis of resistance in different ecosystems (human, animal, water and food).

Early infection of hip joint prosthesis by Clostridium difficile in an HIV-1 infected patient

Anaerobes are less frequently described as causative pathogen of prosthetic joint infection (PJI). We report the first case of early PJI after hip arthroplasty due to Clostridium difficile in a diabetic and HIV-1 infected patient with bacteremia. Our patient was successfully treated through surgical debridement and prosthesis retention combined with targeted antibiotic therapy.

Pneumococcal septic arthritis in adults: clinical analysis and review

BACKGROUND

Septic arthritis (SA) is a rheumatological emergency that can lead to rapid joint destruction and irreversible loss of function. The most common pathogen causing SA is Staphylococcus aureus which is responsible for 37-65% of cases. Streptococcus pneumoniae is traditionally described as an uncommon cause of SA of a native joint. The objective of our study was to analyse clinical characteristics, treatment, and outcome of all cases of pneumococcal septic arthritis treated in our institution, and to compare them with other series published in the literature.

MATERIALS AND METHODS

We conducted a retrospective study of pneumococcal SA identified among all cases of SA diagnosed in a teaching hospital of one thousand beds between 2004 and 2009. Diagnosis was based on culture of joint liquid or by the presence of pneumococcal bacteraemia and purulent (more than 50 000/mm(3) white blood cells with more than 90% neutrophils) joint fluid aspiration.

RESULTS

Among 266 cases of SA, nine patients (3·3%) were diagnosed as having pneumococcal SA. The median age was 75 years. The main affected joint was the knee (7/9). No patient had more than one joint involved. Four patients suffered from concomitant pneumonia. Joint culture and blood cultures were positive in 7/9 and 5/9, respectively. Median (range) length of stay was 18 days (3-47 days). One patient with associated pneumococcal bacteraemia died 19 days after admission. Seven patients recovered completely.

CONCLUSIONS

Streptococcus pneumoniae is now being increasingly recognized as a common agent of SA. This organism is frequently associated with pneumococcal pneumonia or bacteraemia, particularly in patients with advanced age and comorbidities. Direct inoculation of joint fluid into blood culture medium BACTEC system increases the probability of microbiological diagnosis. The prognosis is usually favourable if the disease is promptly recognized and treated (antibiotic therapy combined with joint drainage).

Capnocytophaga species and perinatal infections: case report and review of the literature

Capnocytophaga species are part of the normal human oral bacterial flora.They are recognized as opportunistic pathogens leading to various extra-oral infections including septicemia, osteomyelitis, abscesses and keratitis and they have been rarely reported as a cause of chorioamionitis and neonatal infection. We here report the first two cases of chorioamionitis produced by Capnocytophaga sputigena and the recently described C. leadbetteri in Belgium. Both isolates were correctly identified at the genus level, in the first 24 hours of incubation by MALDI-TOF.

Trends in production of extended-spectrum beta-lactamases among Enterobacteriaceae of clinical interest: results of a nationwide survey in Belgian hospitals

OBJECTIVES

to assess the frequency and diversity of extended-spectrum β-lactamases (ESBLs) in Enterobacteriaceae isolates in Belgium.

METHODS

during 2006 and 2008, non-duplicate clinical isolates of Enterobacteriaceae resistant to ceftazidime and/or cefotaxime were collected in 100 Belgian hospitals. ESBL production was confirmed by phenotypic and genotypic tests. MICs of 13 antimicrobial agents were determined by Etest. ESBL-encoding genes were identified by PCR sequencing and the bla(CTX-M) environment was characterized by PCR mapping. Selected isolates were genotyped by PFGE, multilocus sequence typing analysis and phylogenetic grouping by PCR.

RESULTS

overall, 733 isolates were confirmed as ESBL producers. Carbapenems and temocillin were active against ≥ 95% of all tested isolates. Co-resistance to co-trimoxazole and to ciprofloxacin was found in almost 70% and 80% of the strains, respectively. Overall, Escherichia coli (49%), Enterobacter aerogenes (32%) and Klebsiella pneumoniae (9%) represented the most prevalent species. Isolates harboured predominantly TEM-24 (30.7%), CTX-M-15 (24.2%) and TEM-52 (12.1%). Compared with 2006, the proportion of CTX-M-type enzymes increased significantly in 2008 (54% versus 23%; P < 10(-6)), mostly linked to a rising proportion of CTX-M-15-producing E. coli. TEM-24 decreased (19% in 2008 versus 43% in 2006; P < 10(-6)) during the same period, while the prevalence of TEM-52 remained unchanged (10% in 2008 versus 14% in 2006; not significant). Over 80% of the CTX-M-15-producing E. coli isolates clustered into a single PFGE type and phylogroup B2, corresponding to the sequence type (ST) 131 clone. Intra- and inter-species gene dissemination (CTX-M-15, CTX-M-2 and CTX-M-9) and wide epidemic spread of the CTX-M-15-producing E. coli ST131 clone in several Belgian hospitals were observed.

CONCLUSIONS

the rapid emergence of multiresistant CTX-M-15-producing E. coli isolates is of major concern and highlights the need for further surveillance in Belgium.

First case of bacteremia caused by Moellerella wisconsensis: case report and a review of the literature

Moellerella wisconsensis, a member of the Enterobacteriaceae family, is rarely isolated in clinical specimens. We report here a case of M. wisconsensis infection in a 46-year-old cirrhotic patient with acute cholecystitis. This is the first reported case of a M. wisconsensis infection in Belgium and the first reported case of human bacteremia caused by this bacterium. Our case report is followed by a review of the literature.

Intensive care unit outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae controlled by cohorting patients and reinforcing infection control measures

OBJECTIVE

To describe an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in the intensive care units (ICUs) of a hospital and the impact of routine and reinforced infection control measures on interrupting nosocomial transmission.

DESIGN

Outbreak report.

SETTING

A 31-bed intensive care department (composed of 4 ICUs) in a university hospital in Belgium.

INTERVENTION

After routine infection control measures (based on biweekly surveillance cultures and contact precautions) failed to interrupt a 2-month outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures were implemented. The frequency of surveillance cultures was increased to daily sampling. Colonized patients were moved to a dedicated 6-bed ICU, where they received cohorted care with the support of additional nurses. Two beds were closed to new admissions in the intensive care department. Meetings between the ICU and infection control teams were held every day. Postdischarge disinfection of rooms was enforced. Broad-spectrum antibiotic use was discouraged.

RESULTS

Compared with a baseline rate of 0.44 cases per 1,000 patient-days for nosocomial transmission, the incidence peaked at 11.57 cases per 1,000 patient-days (October and November 2005; rate ratio for peak vs baseline, 25.46). The outbreak involved 30 patients, of whom 9 developed an infection. Bacterial genotyping disclosed that the outbreak was polyclonal, with 1 predominant genotype. Reinforced infection control measures lasted for 50 days. After the implementation of these measures, the incidence fell to 0.08 cases per 1,000 patient-days (rate ratio for after the outbreak vs during the outbreak, 0.11).

CONCLUSION

These data indicate that, in an intensive care department in which routine screening and contact precautions failed to prevent and interrupt an outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures controlled the outbreak without major disruption of medical care.

[The threat of antibiotic resistance: origin, impact and public health perspectives]

Bacterial resistance to antibiotics is as old as the living planet, i.e. over 3 billion years ago when bacterial life emerged together with its biological warfare weapons, the antibiotics. Bacteria can readily develop a diverse array of antibiotic resistance mechanisms, including selection of mutants which produce modified low-affinity drug targets, exhibit reduced drug permeability or increased drug efflux. Another pathway is through acquisition of mobile genetic determinants of drug inactivating enzymes, target protection or bypass mechanisms. Antibiotic resistance has accelerated and spread across the community of human and animal bacteria following massive use of antibiotics for over half-a century in human and veterinary medicine and agriculture. Today, the increasing prevalence of resistance among many bacterial pathogens is no longer counter-balanced by the launching of innovative and active antibiotics. This imbalanced "arms race" undermines the escalating use of broad-spectrum antibiotics and increases the risk of therapeutic failure, drug side effets and excess costs of care. The accumulation of antibiotic resistance genes and their epidemic dissemination is fuelled by the selective pressure associated with excess and inappropriate use of antibiotics combined with insufficient infection prevention and control measures. Confronting this threat effectively requires new strategies to be implemented globally, nationally, and locally across all healthcare and agricultural sectors.

In vitro activity of temocillin against prevalent extended-spectrum beta-lactamases producing Enterobacteriaceae from Belgian intensive care units

Temocillin is a narrow spectrum penicillin with high stability to most beta-lactamases including AmpC types and extended-spectrum types (ESBLs). We have analysed its in vitro activity against 652 clinical isolates of Enterobacteriaceae prospectively collected from patients hospitalised in intensive care units at seven different university hospitals in Belgium in 2005. Strains were screened for ESBL production using cefotaxime and ceftazidime screen agar plates and by double ESBL E-tests. The MIC of temocillin and of five comparators was determined using the E-test method. ESBLs were characterized at one central laboratory by isoelectric focusing, PCR for bla genes of the SHV, TEM, and CTX-M families, and by DNA sequencing. The prevalence of ESBL-producing Enterobacteriaceae averaged 11.8% and ranged between 3.0 and 29% in the different hospitals. Meropenem exhibited the highest in vitro activity overall (mode MIC 0.064 microg; MIC(90); 0.19 microg/ml), whereas ceftazidime (MIC(90) > 256 microg/ml) and ciprofloxacin (MIC(90) > 32 microg/ml) scored the worst. Temocillin was active against more than 90% of the isolates including most AmpC- and ESBL-producing isolates. These data indicate the well preserved activity of temocillin over the years against Enterobacteriaceae and show the wide variation in prevalence of ESBL-producing Enterobacteriaceae isolates in Belgian intensive care units. Prospective clinical studies are, however, needed to validate the usefulness of temocillin in the treatment of microbiologically documented infections caused by ESBL- and/or AmpC- overproducing nosocomial Enterobacteriaceae pathogens.

Emergence and dissemination of multidrug resistant clones of Pseudomonas aeruginosa producing VIM-2 metallo-beta-lactamase in Belgium

Emergence of carbapenem-hydrolysing metallo-beta-lactamase (MBL) in Pseudomonas aeruginosa has been described worldwide. Infection with MBL-producing strains represents a therapeutic problem due to their resistance to all beta-lactams except monobactams. Several types of MBL enzymes have been identified in P. aeruginosa among which the VIM-type enzymes appear as the most prevalent in Europe with more than 12 allelic variants.

Successful treatment of septic shock due to pan-resistant Acinetobacter baumannii using combined antimicrobial therapy including tigecycline

Reported here is the case of a patient with septic shock due to multidrug-resistant Acinetobacter baumannii, which developed after complicated acute pancreatitis with intra-abdominal abscess. Treatment with colistin methanesulphonate and high doses of meropenem were initiated, but since shock persisted, tigecycline was added to the regimen, resulting in successful resolution of the infection.

Potential risk factors for infection with Candida spp. in critically ill patients

The incidence, risk factors and prognostic factors for candidal infection were determined in a prospective study of 280 infected patients. Thirty-one (11%) patients were infected with Candida spp., sub-divided into 18 (58%) with C. albicans, and 13 (42%) with non-albicans spp. (six C. glabrata, three C. parapsilosis, and one each of C. krusei, C. tropicalis, C. guilliermondii and C. lusitaniae). Infection with Candida spp. was always associated with concurrent bacterial infection. By univariate logistic regression analysis, the degree of morbidity and the duration of mechanical ventilation were independent predictive factors for death, but infection with Candida spp., was not. Factors associated with Candida spp. infection were the degree of morbidity, intensive care unit length of stay, alterations of immune response, and the number of medical devices involved. By multivariate logistic regression analysis, the only independent risk factor for candidal infection was intensive care unit length of stay.

Management of long-term catheter-related Brevibacterium bacteraemia

Brevibacterium has been reported as a rare cause of implanted-device infection. In two cases of recurrent Brevibacterium casei bacteraemia associated with infection of surgically implanted intravascular devices, relapse occurred 2 and 5 months, respectively, after completion of therapy with vancomycin via the infected catheter. A second intravenous antibiotic therapy course by the antibiotic-lock technique led to bacteriological cure in one patient. Molecular typing results demonstrated that the recurrent bacteraemia was caused by the same strain. Implanted-device removal may be necessary, in addition to appropriate antibiotics, for successful management of such infections.

Haemophilus parainfluenzae : an Underdiagnosed Pathogen of Biliary Tract Infections?

Presented here is a case of monobacterial peritonitis complicating cholecystitis and caused by an uncommon agent of gastrointestinal infections, Haemophilus parainfluenzae. The pathogenic role of this organism in digestive infections, particularly in those of the biliary tract, has been reported increasingly though sporadically. Indeed, it has been shown to be a coloniser of the gastrointestinal tract, and a recent hypothesis of an ascending route of infection to the biliary tract has been postulated to partly explain its pathogenicity. More frequent identification of Haemophilus parainfluenzae as a causal agent of biliary tract infection would probably be obtained through the use of specific culture media, since its potential implication has been demonstrated.

[The microbiology department]

From the outset, the Department of Microbiology of Erasme Hospital has striven to offer to clinical teams a full range of high performance tests for diagnosis and therapeutic monitoring of bacterial, viral, fungal and parasitic infections, including opportunistic infections. Furthermore, the laboratory has developed and made available cutting edge tools for the epidemiologic surveillance and outbreak investigation in support to the hospital infection control and antibiotic resistance control programmes. Research and development programmes have led to technological innovation in the fields of molecular virologic diagnosis, notably for HIV and herpes viruses, rapid bacterial identification, detection of resistance genes and epidemiological typing. Research in collaboration with clinical teams has focused on congenital infections, HIV infection, opportunistic infections and prevention of nosocomial infection. The Department acts as national reference laboratory for a number of infectious diseases and co-ordinates or actively participates to several European multicentre studies and epidemiologic surveillance networks.