Kidney Transplantation From Deceased Donors With Bloodstream Infection: A Multicenter Retrospective Study

BACKGROUND

The use of organs from donors with infection is limited because of the possibility of transmission. We aimed to investigate the transmission after deceased donor transplantation with bloodstream infection (BSI).

METHODS

A retrospective study of patients undergoing kidney or pancreas transplantation at five tertiary centers in Korea from January 2009 and November 2019 was performed. We analyzed the outcomes after transplantation from deceased donors with BSI.

RESULTS

Eighty-six recipients received transplantation from 69 donors with BSI. The most common isolated pathogens from donors were Gram-positive bacteria (72.0%), followed by Gram-negative bacteria (22.7%), and fungi (5.3%). Appropriate antimicrobial agents were used in 47.8% of donors before transplantation. Transmission occurred only in 1 of 83 recipients (1.2%) from bacteremic donors and 1 of 6 recipients (16.7%) from fungemic donors. One-year patient and graft survival was 97.5%and 96.3%, respectively. There was no significant difference in graft and patient survival between patients who received organs from infected donors and noninfected donors.

CONCLUSION

Using organs from donors with bacteremia seems to be a safe option with low transmission risk. The overall prognosis of using organs from donors with BSI is favorable.

Federal and State Action Needed to End the Infectious Complications of Illicit Drug Use in the United States: IDSA and HIVMA's Advocacy Agenda

In response to the opioid crisis, IDSA and HIVMA established a working group to drive an evidence- and human rights-based response to illicit drug use and associated infectious diseases. Infectious diseases and HIV physicians have an opportunity to intervene, addressing both conditions. IDSA and HIVMA have developed a policy agenda highlighting evidence-based practices that need further dissemination. This paper reviews (1) programs most relevant to infectious diseases in the 2018 SUPPORT Act; (2) opportunities offered by the "End the HIV Epidemic" initiative; and (3) policy changes necessary to affect the trajectory of the opioid epidemic and associated infections. Issues addressed include leveraging harm reduction tools and improving integrated prevention and treatment services for the infectious diseases and substance use disorder care continuum. By strengthening collaborations between infectious diseases and addiction specialists, including increasing training in substance use disorder treatment among infectious diseases and addiction specialists, we can decrease morbidity and mortality associated with these overlapping epidemics.

Systemic infection facilitates transmission of Pseudomonas aeruginosa in mice

Health care-associated infections such as Pseudomonas aeruginosa bacteremia pose a major clinical risk for hospitalized patients. However, these systemic infections are presumed to be a "dead-end" for P. aeruginosa and to have no impact on transmission. Here, we use a mouse infection model to show that P. aeruginosa can spread from the bloodstream to the gallbladder, where it replicates to extremely high numbers. Bacteria in the gallbladder can then seed the intestines and feces, leading to transmission to uninfected cage-mate mice. Our work shows that the gallbladder is crucial for spread of P. aeruginosa from the bloodstream to the feces during bacteremia, a process that promotes transmission in this experimental system. Further research is needed to test to what extent these findings are relevant to infections in patients.

Incidence and Risk Factors for Systemic Infection in Deceased Donors

BACKGROUND

Organ donation shortage is the primary barrier to all organ transplantations.Infectious disease transmission through transplantation is considered controversial for organ retrieval. Donors with bacteremia and sepsis are considered controversial for organ retrieval due to potential transmission of an infectious agent to the recipient.

METHODS

We retrospectively reviewed the results of bacterial culture of the donor's blood from peripheral venous or central venous catheter, urine, and bronchial aspiration from the organ donation registries of 102 potential donors from the Ministry of Health and Tissue Transplant Coordination Center of Istanbul Region in 2015.

RESULTS

Of the 102 deceased donors included in the analysis, 24 (23.5%) had infection. The most common sites of infection were the bloodstream (41.6%) and the respiratory system (37.5%). The most common isolated pathogens of the bacterial cultures were Gram-positive bacteria (21), Gram-negative microorganisms (14), and Candida (1). The significant risk factor for infection was duration of stay at the intensive care unit (median: 5 day; 25-75%: 3-5 day) (odds ratio, 2.94; 95% confidence interval, 1.06-8.12; P < .05). The presence of infection in the donor accounted for a significant part of the reasons why the organs were not accepted for transplantation (kidneys 9%, liver 4%, heart 6%).

CONCLUSIONS

The study showed that deceased donors with prolonged stays in the intensive care unit have an increased risk for developing nosocomial infections; so there is a need for establishing and enforcing the prevention and control of infection in possible donors.

Investigation of a Cluster of Sequence Type 22 Methicillin-Resistant Staphylococcus aureus Transmission in a Community Setting

BACKGROUND

Whole-genome sequencing (WGS) has typically been used to confirm or refute hospital/ward outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) identified through routine practice. However, appropriately targeted WGS strategies that identify routinely "undetectable" transmission remain the ultimate aim.

METHODS

WGS of MRSA isolates sent to a regional microbiological laboratory was performed as part of a 12-month prospective observational study. Phylogenetic analyses identified a genetically related cluster of E-MRSA15 isolated from patients registered to the same general practice (GP) surgery. This led to an investigation to identify epidemiological links, find additional cases, and determine potential for ongoing transmission.

RESULTS

We identified 15 MRSA-positive individuals with 27 highly related MRSA isolates who were linked to the GP surgery, 2 of whom died with MRSA bacteremia. Of the 13 cases that were further investigated, 11 had attended a leg ulcer/podiatry clinic. Cases lacked epidemiological links to hospitals, suggesting that transmission occurred elsewhere. Environmental and staff screening at the GP surgery did not identify an ongoing source of infection.

CONCLUSIONS

Surveillance in the United Kingdom shows that the proportion of MRSA bacteremias apportioned to hospitals is decreasing, suggesting the need for greater focus on the detection of MRSA outbreaks and transmission in the community. This case study confirms that the typically nosocomial lineage (E-MRSA15) can transmit within community settings. Our study exemplifies the continued importance of WGS in detecting outbreaks, including those which may be missed by routine practice, and suggests that universal WGS of bacteremia isolates may help detect outbreaks in low-surveillance settings.

Limited Dissemination of Extended-Spectrum β-Lactamase- and Plasmid-Encoded AmpC-Producing Escherichia coli from Food and Farm Animals, Sweden

Food is a limited source of these antimicrobial resistance genes for humans.

Extended-spectrum β-lactamase (ESBL)– and plasmid-encoded ampC (pAmpC)–producing Enterobacteriaceae might spread from farm animals to humans through food. However, most studies have been limited in number of isolates tested and areas studied. We examined genetic relatedness of 716 isolates from 4,854 samples collected from humans, farm animals, and foods in Sweden to determine whether foods and farm animals might act as reservoirs and dissemination routes for ESBL/pAmpC-producing Escherichia coli. Results showed that clonal spread to humans appears unlikely. However, we found limited dissemination of genes encoding ESBL/pAmpC and plasmids carrying these genes from foods and farm animals to healthy humans and patients. Poultry and chicken meat might be a reservoir and dissemination route to humans. Although we found no evidence of clonal spread of ESBL/pAmpC-producing E. coli from farm animals or foods to humans, ESBL/pAmpC-producing E. coli with identical genes and plasmids were present in farm animals, foods, and humans.

Current concepts in the prevention of pathogen transmission via blood/plasma-derived products for bleeding disorders

The pathogen safety of blood/plasma-derived products has historically been a subject of significant concern to the medical community. Measures such as donor selection and blood screening have contributed to increase the safety of these products, but pathogen transmission does still occur. Reasons for this include lack of sensitivity/specificity of current screening methods, lack of reliable screening tests for some pathogens (e.g. prions) and the fact that many potentially harmful infectious agents are not routinely screened for. Methods for the purification/inactivation of blood/plasma-derived products have been developed in order to further reduce the residual risk, but low concentrations of pathogens do not necessarily imply a low level of risk for the patient and so the overall challenge of minimising risk remains. This review aims to discuss the variable level of pathogenic risk and describes the current screening methods used to prevent/detect the presence of pathogens in blood/plasma-derived products.

Kingella kingae: carriage, transmission, and disease

Kingella kingae is a common etiology of pediatric bacteremia and the leading agent of osteomyelitis and septic arthritis in children aged 6 to 36 months. This Gram-negative bacterium is carried asymptomatically in the oropharynx and disseminates by close interpersonal contact. The colonized epithelium is the source of bloodstream invasion and dissemination to distant sites, and certain clones show significant association with bacteremia, osteoarthritis, or endocarditis. Kingella kingae produces an RTX (repeat-in-toxin) toxin with broad-spectrum cytotoxicity that probably facilitates mucosal colonization and persistence of the organism in the bloodstream and deep body tissues. With the exception of patients with endocardial involvement, children with K. kingae diseases often show only mild symptoms and signs, necessitating clinical acumen. The isolation of K. kingae on routine solid media is suboptimal, and detection of the bacterium is significantly improved by inoculating exudates into blood culture bottles and the use of PCR-based assays. The organism is generally susceptible to antibiotics that are administered to young patients with joint and bone infections. β-Lactamase production is clonal, and the local prevalence of β-lactamase-producing strains is variable. If adequately and promptly treated, invasive K. kingae infections with no endocardial involvement usually run a benign clinical course.

ESBL-producing Escherichia coli isolated from bloodstream infections--antimicrobial susceptibility, conjugative transfer of resistance genes and phylogenetic origin

BACKGROUND

The prevalence of bloodstream infections (BSIs) due to ESBL-producing Escherichia coli (ESBL-EC) strains has increased dramatically over the past years.

OBJECTIVES

Characterization of ESBL-EC isolates collected from BSIs with regard to their antimicrobial susceptibility and phylogenetic background. The conjugative transfer of resistance determinants to the E. coli reference strain K12 C600 was also investigated.

MATERIAL AND METHODS

A collection of forty-eight ESBL-EC strains recovered from BSIs was subjected to the study. These strains were obtained from the ICU (intensive care unit) of the Medical University Hospital, Wrocław, Poland, during a four-year period (2009-2012). All the isolates were screened for ESBL production by the double disk synergy test (DDST). Transferability of plasmid-mediated resistance genes was performed by the conjugational broth method. Susceptibility to antibiotics and chemotherapeutics of clinical isolates and transconjugants was determined by the agar dilution method. PCR assay was used to detect the blaCTX-M gene in ESBL-EC tested and transconjugants. Affiliation to phylogenetic groups was done by the triplex PCR method.

RESULTS

Conjugational transfer of plasmids responsible for ESBL to a recipient strain was successful for all the ESBL-EC analyzed (donors). The conjugation frequencies ranging from 2.3×10(-7) to 5.2×10(-1) per donor. In vitro susceptibility testing revealed that all the ESBL-EC isolates and their transconjugants were resistant to most of the antimicrobial agents tested with the exception of carbapenems, tigecycline, and β-lactam-clavulanate combinations. Moreover, all the donor strains and their transconjugants were found to contain the blaCTX-M gene. The majority of the isolates analyzed belonged to phylogroups B2 (62.5%) and D (25%), whereas groups B1 and A were less frequently represented (8.3% and 4.2%, respectively).

CONCLUSIONS

The results of the study confirm the need of antibiotic policies and effective infection control measures in hospital settings to minimize BSIs caused by multi-resistant ESBL-producing pathogens.

First description of Bartonella bovis in cattle herds in Israel

Bartonella bovis has been described in beef and dairy cattle worldwide, however the reported prevalence rates are inconsistent, with large variability across studies (0-89%). This study describes the first isolation and characterization of B. bovis among cattle herds in the Middle East. Blood samples from two beef cattle herds (each sampled thrice) and one dairy herd (sampled twice) in Israel were collected during a 16-months period. Overall, 71 of 95 blood samples (75%) grew Bartonella sp., with prevalence of 78% and 59% in beef and dairy cattle, respectively. High level bacteremia (≥100,000 colony forming units/mL) was detected in 25 specimens (26%). Such high-level bacteremia has never been reported in cattle. Two dairy cows and one beef cow remained bacteremic when tested 60 or 120 days apart, respectively, suggesting that cattle may have persistent bacteremia. One third of animals were infested with ticks. Sequence analysis of a gltA fragment of 32 bacterial isolates from 32 animals revealed 100% homology to B. bovis. Species identification was confirmed by sequence analysis of the rpoB gene. Phylogenetic analysis based on the concatenated sequences of gltA and rpoB demonstrated that the isolates described herein form a monophyletic group with B. bovis strains originating from cattle worldwide. Taken together, the high prevalence of bacteremia, including high-level bacteremia, in beef and dairy cattle, the potential to develop prolonged bacteremia, the exposure of cattle to arthropod vectors, and proximity of infected animals to humans, make B. bovis a potential zoonotic agent.

Outbreaks of infections associated with drug diversion by US health care personnel

OBJECTIVE

To summarize available information about outbreaks of infections stemming from drug diversion in US health care settings and describe recommended protocols and public health actions.

PATIENTS AND METHODS

We reviewed records at the Centers for Disease Control and Prevention related to outbreaks of infections from drug diversion by health care personnel in US health care settings from January 1, 2000, through December 31, 2013. Searches of the medical literature published during the same period were also conducted using PubMed. Information compiled included health care setting(s), infection type(s), specialty of the implicated health care professional, implicated medication(s), mechanism(s) of diversion, number of infected patients, number of patients with potential exposure to blood-borne pathogens, and resolution of the investigation.

RESULTS

We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing.

CONCLUSION

These outbreaks revealed gaps in prevention, detection, and response to drug diversion in US health care facilities. Drug diversion is best prevented by health care facilities having strong narcotics security measures and active monitoring systems. Appropriate response includes assessment of harm to patients, consultation with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies.

Low risk of apparent transmission of vancomycin-resistant Enterococci from bacteraemic patients to hospitalized contacts

BACKGROUND

Vancomycin-resistant enterococci (VRE) are primarily opportunistic pathogens with incalculable clinical significance. In addition, the effectiveness of isolation in VRE is often not easily assessed. The goals of this study were to estimate the transmissibility of VRE of patients with VRE bacteraemia to other hospitalized patients and to document reliable epidemiologic data on all VRE cases in a large health care center.

METHODS

A prospective survey on in-patients colonized and/or systemically infected with VRE was conducted at a 2,000-bed tertiary care university hospital in Germany. All roommates of VRE bacteraemia patients were analyzed. Pulsed-field gel electrophoresis was performed to assess clonal relatedness.

RESULTS

16,507 Screening tests were performed on 9,258 patients, of which 560 tested positive for VRE (6.1%). Nineteen patients also suffered from VRE bacteraemia, an incidence of 3.4%. This cohort was multimorbid and had high rates of exposure to external risk factors (eg, previous hospital stay prior to admission, 78.9%). The transmission rate to contacts was low (3.5%). Contact time of negative contacts was significantly lower than that of VRE-positive contacts (19.3 hours vs 72.0 hours, respectively, P < .006).

CONCLUSION

VRE bacteraemia was found exclusively in multimorbid patients, transmission occurred seldom, and average contact time of positive contacts was very high. The risk of transmission of VRE from bacteraemic patients to hospitalized contacts is low.

Anaplasma phagocytophilum infection in American robins and gray catbirds: an assessment of reservoir competence and disease in captive wildlife

Anaplasma phagocytophilum (Dumler et al.) is the bacterial agent of human granulocytic anaplasmosis, an emerging infectious disease. The main vector of A. phagocytophilum in the United States is the blacklegged tick (Ixodes scapularis (Say)) and various small and medium-sized mammals are reservoirs. Previous studies indicate that birds are exposed to A. phagocytophilum; however, because no studies have directly investigated avian susceptibility, reservoir competence, and morbidity for A. phagocytophilum, uncertainty remains as to what role birds could play in its transmission ecology. In a controlled laboratory study, we tested whether two species, the American robin (Turdus migratorius (L.)) and the gray catbird (Dumetella carolinensis (L.)), can become infected with and then transmit A. phagocytophilum to feeding ticks, and whether exposed birds develop disease. Wild caught, seronegative birds (n = 10 per species) were exposed to A. phagocytophilum-infected I. scapularis nymphs (day 0). Transmission was assessed by xenodiagnosis on days 7, 14, 42, and 77; blood was assayed for bacteremia and serology. A. phagocytophilum was detected using quantitative polymerase chain reaction targeting the 16s rRNA gene. One robin infected 2 of 13 larval ticks (15%) on day 7; no other birds were found to infect feeding ticks at any time. Birds did not develop bacteremia, specific antibodies or significant illness because of exposure. Mouse controls became bacteremic, infected feeding ticks, and seroconverted. Our results suggest that these two avian species are unlikely to play a significant role in the maintenance of the agent of human granulocytic anaplasmosis and that avian serosurveys may not be a reliable indicator of A. phagocytophilum exposure.

[Unusual infection--Pasteurella canis bacteremia in a child after exposure to rabbit secretions]

Pasteurella spp. is a natural habitant of the oral flora and digestive tract of various domestic animals. There are several species of Pasteurella which can cause disease in humans. The most common species is Pmultocida, generally associated with an animal bite. The infection that evolves is usually constricted to the area of the bite. Systemic forms of infection are rare and were described in patients with underlying diseases. The authors would like to report on a case of a healthy 21-month-old child diagnosed with Pasteurella canis bacteremia after exposure to rabbit secretions. To our knowledge, this is the first report of bacteremia which was caused by Pasteurella canis.

[Analysis of nosocomial pediatric bacteremias at a general hospital between 1990 and 2006. The impact of attending the intravascular therapy]

INTRODUCTION

The administration of parenteral infusates is a frequent intervention that is considered innocuous; moreover, the risk of this procedure which offers a direct access to the bloodstream is minimized.

OBJECTIVE

To evaluate the epidemiology of nosocomial pediatric bacteremias after implementing a control program.

METHODS

Analysis of pediatric bacteremias was made in 3 periods: 1) 1990-1992, prior to establishing strategies to avoid contamination of parenteral infusions; 2) 1996, the phase after establishing these strategies; and 3) 2005-2006, the recent situation in the hospital.

RESULTS

The proportion of gram-negative rods isolated in blood cultures dropped from 82.9 to 35.1% (p = 0.004) during the 17-year study period. There was no significant difference in the proportion of gram-negative rods isolated from intravascular catheters. The proportion of contaminated parenteral infusions dropped from 22.2% to 0.4% (p < 0.001).

DISCUSSION

The strategies established to avoid the contamination of parenteral infusions were associated with a reduction in the proportion of gram-negative rods in blood cultures, although the proportion is still higher than that in developed countries, probably related to catheter contamination. We suggest establishing similar strategies in other hospitals from developing countries.

Investigations of Enterococcus faecalis-induced bacteraemia in brown layer pullets through different inoculation routes in relation to the production of arthritis

In the present aerosol experiment, assessment of the respiratory tract of 1-day-old birds as a natural route of infection for induction of Enterococcus faecalis bacteraemia and arthritis was performed. Second, the severity and type of arthritis produced through intramuscular infection in two different inoculation sites (musculus pectoralis versus musculus gastrocnemius) was studied. Third, the resulting bacteraemia was assessed qualitatively and quantitatively in relation to the occurrence of arthritis. Exposure of 1-day-old brown layer pullets to aerosolized E. faecalis with an estimated uptake of 10(4) to 10(5) colony forming units per chick resulted in bacteraemia; however, joint lesions were not induced. In contrast, 3/10 birds inoculated intratracheally with 10(8) colony forming units developed both bacteraemia and arthritis. This suggests the occurrence of a dose effect and a role for the respiratory tract as a natural infection route in young chickens. In both intramuscularly inoculated groups the incidence of arthritis was 10/10 birds and 9/10 birds, respectively. Birds inoculated in the m. pectoralis developed symmetric polyarthritis, which harmonizes with haematogenous colonization of joints. In contrast, m. gastrocnemius-inoculated chicks mostly had asymmetric (poly)arthritis of the injected leg and varus deformation of the contralateral leg, suggesting predominantly local spread. The qualitative and quantitative results of bacteriology of blood samples show that arthritis develops in those groups with the highest number of bacteraemic birds and the highest median bacterial colony forming units per millilitre of blood during the first 24 to 36 h after treatment.

A novel rapid and effective donor arm disinfection method

BACKGROUND

The aim of the study was to derive a donor arm disinfection technique that was rapid, but with a disinfection efficacy equivalent to a previous "best-practice" technique. This method consisted of a two-stage procedure with an initial application of 70% isopropyl alcohol and then 2% tincture of iodine (IATI). The total time for the IATI method was 2 minutes in duration. A rapid technique (1 min in duration) was needed to obviate potential problems due to increased donor waiting time, had the IATI method been implemented at blood donation sessions.

STUDY DESIGN AND METHODS

A direct swabbing and plating technique was used to enumerate bacteria present before and after disinfection. In total, seven methods were evaluated.

RESULTS

The chlorhexidine/alcohol applicator (CAA) disinfection device containing 1.5 mL of 2% chlorhexidine gluconate and 70% isopropyl alcohol (99.91% reduction; confidence limits, 99.55%, 99.98%) was shown to have equivalent disinfection efficacy as the IATI method (99.89% reduction; confidence limits, 99.36%, 99.98%; p = 0.86). Procedural time for the 1.5-mL CAA method was 1 minute thereby avoiding potential problems of increased donor waiting time, inherent in the IATI 2-minute procedure at blood donation sessions.

CONCLUSIONS

The 1.5-mL CAA disinfection method offers blood services a rapid and effective donor arm disinfection procedure. In 2006, the 1.5-mL CAA procedure was implemented throughout the entire English blood service for all donations.

Skin disinfection methods: prospective evaluation and postimplementation results

BACKGROUND

Optimal skin disinfection ensures blood safety. In this study, efficacies of the two-step skin disinfection methods used at Canadian Blood Services (CBS) and two one-step methods produced by different manufacturers were compared.

STUDY DESIGN AND METHODS

In each of the three phases of the study, two methods were compared by disinfection of the antecubital fossae of study subjects. The two-step methods were compared in Phase I: Method A (isopropyl alcohol scrub and iodine tincture ampule) and Method B (isopropyl alcohol and chlorhexidine scrub and isopropyl alcohol and chlorhexidine ampule). In Phases II and III, Method B was compared to two different one-step swab sticks containing isopropyl alcohol and chlorhexidine (Methods C and D). Contact plates were applied on each of the subjects before and after disinfection and incubated at 37 degrees C for 24 hours followed by colony counting.

RESULTS

In 99% of the subjects, colonies per plate were reduced from approximately 60 to less than 10 after disinfection using any method. Method B was superior to Method A (p < 0.05) but was not significantly different from Methods C and D. Method D was implemented for skin disinfection at CBS with no significant effects on blood product contamination. Skin reactions increased from approximately 0.02% to approximately 0.62% after implementation, which were subsequently reduced to approximately 0.04%.

CONCLUSION

In this study, isopropyl alcohol and chlorhexidine disinfectants were more efficacious than isopropyl alcohol and iodine. There was no difference in efficacy between one-step and two-step procedures or between methods of application. A one-step chlorhexidine and isopropyl alcohol kit has been successfully implemented at CBS.

Almond oil implicated in a Staphylococcus capitis outbreak in a neonatal intensive care unit

OBJECTIVE

To develop an effective outbreak-control strategy by identifying the source and modes of transmission of Staphylococcus capitis in a 60-bed neonatal intensive care unit (NICU).

STUDY DESIGN

We conducted a study among neonates hospitalized during the outbreak (June 2000 through November 2003). All cases of S. capitis colonization or infection detected by clinical samples during the outbreak were included. The molecular analysis of the isolated was assessed by pulsed-field electrophoresis. We reported the description of the outbreak and the measures taken during this investigation.

RESULT

Thirty-three patients were colonized or infected by S. capitis. Mean gestational age was 28.5+/-4.4 weeks of gestation, mean birth weight was 1068+/-637.3 g and the mean length of hospital stay was 77.9+/-35.9 days. We observed that positive S. capitis cultures were over-represented in six beds of the NICU. Because S. capitis is known to thrive in lipid media, we cultured samples from the almond oil bottles assigned to these beds. S. capitis strain recovered from one of the almond oil sample was genetically identical to the strain recovered from the cases.

CONCLUSION

Almond oil is an unusual reservoir infection. Control policy allowed prompt institution of measures that were successful in ending the outbreak.

Migration and transmission of blood-borne infections among injection drug users: understanding the epidemiologic bridge

Migration is one of many social factors contributing to the spread of HIV and other blood-borne or sexually transmitted infections (STI). Bringing together large numbers of people from diverse settings, the process of migration moves infected individuals to diverse geographic locations. Injection drug users (IDU) are a relatively mobile group, often moving between cities, smaller communities, and across international borders for reasons of work, security, or access to narcotics. This mobility indicates the potential for IDU who engage in risky behavior outside their home areas to transmit HIV infection to other IDU, their sex partners, and others in the population. The objectives of this review are to examine: (1) the influence of drug trafficking and the spread of drug use on the diffusion of HIV, (2) the influence of migration on drug use and HIV-related risk behaviors among migrants, and (3) the mobility patterns of IDU and its role in the spread of HIV. We also discuss the potential policy implications of addressing prevention and care issues in mobile drug using populations.

Diagnosis of intravascular catheter infection

PURPOSE OF REVIEW

To review the distinction between catheter-related and catheter-associated infections and to report the recent advances in the methods used for their diagnosis.

RECENT FINDINGS

The distinction between device-associated and device-related infections affects the effective benchmarking of the rates of both types of infection. Numerous microbiological methods have been described to diagnose these infections. Studies comparing the performance of microbiological methods that avoid the removal of the intravascular device have recently suggested that they may be effective in daily life.

SUMMARY

The present review summarizes recent advances in the methods currently available to diagnose intravascular catheter-related infections and their performance at the bedside.

A cluster of hemodialysis-related bacteremia linked to artificial fingernails

We examined a cluster of 5 hemodialysis patients who contracted gram-negative bacteremia. A nurse who used an artificial fingernail to open a vial of heparin that was mixed to make a flush solution had a culture of an artificial fingernail specimen positive for Serratia marcescens. The typing of the S. marcescens strains isolated from the 5 patients and the nurse showed them to be identical. This finding provides strong support for policies prohibiting artificial nails for healthcare workers in all hemodialysis units.

Internal jugular venous catheter-related bacteremia according to central and posterior accesses

BACKGROUND

Although there are many studies about central venous catheter-related infection, we have not found any analysis of the incidence of internal jugular venous catheter-related bacteremia associated with different accesses.

OBJECTIVE

The objective of this study was to test whether the position of the internal jugular venous catheter, central or posterior, influences the incidence of bacteremia.

DESIGN

A cohort study.

SETTING

A 12-bed polyvalent medical-surgical intensive care unit (ICU).

PATIENTS

Patients admitted to ICU between 1 May 2000 and 30 April 2004 who received one or more internal jugular venous catheters.

MEASUREMENTS AND RESULTS

A total of 1,483 patients were admitted to the polyvalent ICU, of whom 1,311 underwent central venous catheterization. A total of 547 patients received 684 internal jugular venous catheters, 169 by posterior and 515 by central access. There were no significant differences between central and posterior access patients in sex, age, APACHE II (14.1 +/- 5.0 vs. 13.9 +/- 5.2, p = 0.40), diagnosis, order of catheter insertion, use of mechanical ventilation, use of antimicrobials, use of total parenteral nutrition or use of pulmonary artery catheter. We found a higher incidence of internal jugular venous catheter-related bacteremia with central (4.8 per 1000 catheter-day) than with posterior (1.2 per 1000 catheter-day) access (odds ratio 3.9; 95% confidence interval 1.1-infinite; p = 0.03).

CONCLUSION

Posterior access has a lower incidence of internal jugular venous catheter-related bacteremia than central access in non-severely ill patients (according to the low APACHE II score values of the study patients).

Outbreak of legionellosis suspected to be related to a whirlpool spa display, September 2006, Lorquin, France

Twelve cases of legionellosis in the small town of Lorquin, district of Moselle, northeast France, were identified by the local health authority in charge of legionellosis surveillance in September 2006.

Transfer of Borrelia Burgdorferi s.s. Infection via Blood Transfusion in a Murine Model

Without antibiotic treatment, the Lyme-disease-causing bacterium, Borrelia burgdorferi can be cultured from the peripheral blood of human patients nearly 6 wk post-tick bite. To determine if Lyme disease spirochetes can be transmitted from a spirochetemic donor mouse to a naive recipient during blood transfusion, blood taken from immunocompetent infected mice was transfused into either immunodeficient (SCID) mice, inbred immunocompetent animals (C3H/HeJ), or outbred mice. Nine of 19 (47.7%) immunodeficient mice, 7 of 15 (46.8%) inbred immunocompetent mice, and 6 of 10 (60.0%) outbred mice became infected with B. burgdorferi after transfusion. Our results indicate that it is possible to acquire B. burgdoferi infection via transfused blood in a mouse model of Lyme borreliosis.

Genotypic analysis of Acinetobacter bloodstream infection isolates in a Turkish university hospital

Acinetobacter baumannii is a significant pathogen of bloodstream infections in hospital patients that frequently causes single clone outbreaks. We aimed to evaluate the genetic relatedness and antimicrobial susceptibility of Acinetobacter spp. bloodstream isolates, in order to obtain insight into their cross-transmission. This prospective study was conducted at the Erciyes University Hospital. During a 1-y period, all patients with nosocomial BSI caused by Acinetobacter spp. were included in the study. All data with regard to the patients, underlying diseases and risk factors for BSI and the severity of disease were collected. Blood culture isolates of Acinetobacter spp. were identified according to their morphology and biochemical reactions. The antimicrobial susceptibility was determined using the Kirby-Bauer disk diffusion test according to the NCCLS; the genetic relatedness of isolates was determined by RAPD-PCR analysis and pulsed-field gel electrophoresis (PFGE). 41 patients acquired a nosocomial bloodstream infection caused by A. baumanii during this period. 88% of these infections (36 of 41) occurred while the patients were treated in the intensive care unit. Nearly 80% of the isolates belonged to 3 genotypes, suggesting cross-transmission in ICU settings where infection control practices are poor. All Acinetobacter isolates were multidrug-resistant and the crude mortality of patients infected with A. baumanii was 80.5%. We concluded that the genetic relatedness of Acinetobacter spp. causing BSI was very high, indicating cross-transmission within the ICU setting. Essential components of an infection control programme to prevent nosocomial transmission of A. baumannii are early detection of colonized patients, followed by strict attention to standard precautions and contact isolation.

Psychrobacter bacteraemia in a cirrhotic patient after the consumption of raw geoduck clam

Psychrobacter species rarely cause infections in human. We reported herein a 62-year-old cirrhotic patient who presented with fever and diarrhoea after the consumption of raw geoduck clam. Blood culture grew Psychrobacter phenylpyruvicus which was sensitive to most anti-microbial agents. The patient responded promptly to intravenous antibiotics. This is the first report of human infection with this unusual organism which illustrates the potential health hazards of eating raw geoduck clam in patients with advanced liver disease.

L'isolement septique des patients colonisés–infectés par Acinetobacter baumannii est-il totalement superflu, utile ou indispensable ?

Until 2001, the infection control department of the Besançon university hospital (France) recommended isolation precautions for all patients colonized-infected by Acinetobacter baumannii (Ab) whatever the antibiotic susceptibility of the strain. These systematic isolation procedures were given up at the beginning of 2002 since the number of colonized-infected patients remained stable from 1998 to 2001.

OBJECTIVE

The aim of this study was to evaluate the impact of this decision on the risk of Ab infection.

METHOD

Incidence rates of colonization-infections that were observed during years 2002 and 2003 were compared with expected incidence rate, based on data from 1998-2001 period. Infection control practices and antibiotics consumption were evaluated for each ward of hospitalisation. Genotyping made it possible to determine diversity of clones inside each unit and the whole hospital.

RESULTS

The expected incidence per 1000 patients-days was 0.22 in comparison with observed data in 2002, 0.34 (CI(95%) [0.28-0.42]), and in 2003, 0.53 (CI(95%) [0.45-0.63]). The expected number of Ab bloodstream infections, about two per year compared with the observed numbers in 2002 and 2003 respectively seven and 17. The number of unit with more than three cases per year increased from seven in 1999 to 18 in 2003. Antibiotics consumption did not change significantly.

CONCLUSION

Genotyping results show the importance of cross-transmission in these units. Finally, observed results suggest that some measures of isolation precautions in addition to standard precautions are needed to prevent outbreaks of Ab.

Experimental Infection Models of Ticks of theRhipicephalus sanguineusGroup withRickettsia conorii

Rhipicephalus sanguineus group ticks collected on dogs in Thailand were maintained in the laboratory over several generations to test methods to infect these ticks with Rickettsia conorii, the agent of Mediterranean spotted fever. Three methods were tested: (1) infection of adults and nymphs through artificially induced bacteremic rabbit, (2) capillary feeding of solution containing 5 x 10(3) and 5 x 10(5)pfu/mL of R. conorii to adult female ticks, and (3) immersion of engorged nymphs which were "one leg-cut," "two leg-cut," or "cuticle cut" in solution containing R. conorii. The most efficient method to infect adult ticks with R. conorii was infection of ticks through the bacteremic rabbit (71.4%). The best method to infect nymphs with R. conorii was immersion of "one leg-cut" engorged nymphs in solution containing R. conorii (30%). Interestingly, a high mortality of the ticks infected with R. conorii was observed regardless of the method used. The harmful effect of R. conorii on Rh. sanguineus group ticks from Thailand is discussed including the role of the geographic origin of the ticks and the difficulties to identify ticks within this group to the species level.

Nosocomial spread of a Staphylococcus hominis subsp. novobiosepticus strain causing sepsis in a neonatal intensive care unit

From 2002 to 2003, 32 isolates of Staphylococcus hominis subsp. novobiosepticus (SHN) were recovered from 21 patients, 18 of whom were neonates, with 13 considered to have late-onset SHN sepsis. All isolates from neonates had an indistinguishable pulsed-field gel electrophoresis pattern. Our data support SHN as an important nosocomial pathogen in neonates.

Cannula-associated Staphylococcus aureus bacteraemia: outcome in relation to treatment

BACKGROUND

Despite the frequency of cannula-associated Staphylococcus aureus bacteraemia (CASAB) there is uncertainty regarding the duration of treatment required.

AIM

To determine the relationship between the duration and type of treatment for CASAB and subsequent relapse with deep-seated S. aureus infection.

METHODS

We prospectively studied 276 patients with CASAB. Patients were followed for at least 8 weeks after completion of antibiotic treatment. Initial and subsequent isolates of S. aureus were compared using molecular methods to determine strain similarity.

RESULTS

Initial mortality was 9% (26 of 276) and a complicating focus of infection presented during initial treatment in 6% (15 of 250) of the survivors. There were nine relapses of deep-seated infection from the strain causing the original infection. Relapses were equally common following peripheral CASAB and central CASAB. There was no relationship between the duration of treatment and the rate of relapse of deep-seated infection (P = 0.24). This observation held true regardless of whether the duration of treatment was analysed as < or = 7 versus > or = 8, < or =10 versus > or =11, or < or=14 versus > or =15 days (P = 0.62, 0.87 and 0.16, respectively).

CONCLUSION

Episodes of peripheral CASAB pose an equal risk of relapse to central cannula-related episodes. Although further studies are needed to determine the optimal treatment of CASAB, our study strongly suggests that more than 14 days treatment is excessive for most patients who respond promptly to cannula removal and antibiotic treatment.

Clinical significance of bacteriologic screening in platelet concentrates

BACKGROUND

Despite routine bacterial screening with a bacterial culturing system (BacT/ALERT, bioMerieux) of platelet (PLT) concentrates, two cases of life-threatening sepsis attributed to transfused PLT products contaminated with Bacillus cereus were reported to the regional hemovigilance office in the southwest region of the Netherlands. These reports necessitated a retrospective evaluation of the currently applied bacteriologic screening program.

STUDY DESIGN AND METHODS

Bacteriologic screening of all PLT concentrates on production was introduced in October 2001. Aliquots (5-10 mL) of pooled PLT concentrates in additive solution were taken for cultures with the BacT/ALERT system 14 to 24 hours after donation. The total culturing period was 7 days and in case of positive signals, identification cultures were taken from the culture bottles. The results of the bacterial screening, identification, and clinical significance of possibly contaminated pooled PLT concentrates were evaluated retrospectively over a 2-year period.

RESULTS

In this period, a total of 28,104 pooled PLT concentrates were produced. Positive bacterial screening was found in 0.72 percent (n = 203). Of these, in 184 pooled PLT concentrates bacteria were cultured and identified, and in the remaining 19 (9.4%) identification cultures were negative. Before a positive screening was found, 113 PLT concentrates had already been transfused without the occurrence of clinical significant transfusion reactions.

CONCLUSION

Bacterial contamination of pooled PLT concentrates was not related to clinically significant transfusion reactions. Despite negative screening for bacterial contamination, life-threatening transfusion-transmitted infections by contaminated PLT products can still occur. Other strategies should be applied to guarantee a higher degree of bacteriologic safety.

Diagnosing meningococcemia as a cause of sepsis

OBJECTIVE

In 2004, a consensus meeting of critical care and infectious disease experts was organized to review and make recommendations on current definitions of infections, sepsis, and organ failure for neonates and children and for the predisposing conditions leading to these diseases. Among the infections leading to sepsis, meningococcemia is so distinguishable that a separate article on its diagnosis and management was thought to be warranted.

DESIGN AND METHODS

The process included a modified Delphi method, a consensus conference, subsequent smaller meetings of subgroups and key individuals, and electronic-based discussion among subgroups. A systematic review of the literature was undertaken.

CONCLUSIONS

Early recognition and treatment of likely meningococcal sepsis has led to decreased mortality. Since the start of vaccination against serogroup C, the prevalence of this disease has decreased. Not only the possible presence of a meningococcal sepsis is important, but also the assessment of the shock state and the severity of disease and the possible presence of meningoencephalitis. There are also a number of genetic predispositions determining the severity of disease. The only three randomized trials in this disease have led to the conclusion that mortality is not a stable end point. Improvement in organ function, morbidity (including amputations), and functional outcome are better outcome measures.

Neonatal Group B Streptococcus Sepsis After Negative Screen in a Patient Taking Oral Antibiotics

BACKGROUND

Group B streptococcus (GBS) is a leading cause of serious neonatal infection. Neonatal morbidity and mortality can be reduced by appropriate prenatal screening and intrapartum chemoprophylaxis.

CASE

A 20-year-old primigravida was treated with oral antibiotics at 35 weeks for a recurrent urinary tract infection. Her GBS screen following the antibiotic treatment showed a negative culture. The patient, therefore, did not receive intravenous antibiotics during her induction of labor for mild preeclampsia. The infant developed early onset neonatal GBS pneumonia and sepsis.

CONCLUSION

Oral antibiotics can cause a temporary negative culture in a GBS-colonized patient. Relying on a negative culture for management may not be appropriate in a patient treated with oral antibiotics. Additional studies are necessary to elucidate the effects of oral antibiotics on GBS.

Escherichia coli: a growing problem in early onset neonatal sepsis

AIMS

To review the demographic characteristics, antecedents and outcome for early neonatal Escherichia coli sepsis. Secondary aims were to identify antenatal antibiotic use and to review the antimicrobial susceptibility.

METHODS

A retrospective chart review was performed for all infants with a positive culture for E. coli from either blood or CSF samples obtained between January 1998 and October 2002.

RESULTS

Nineteen liveborn infants with early onset sepsis and one stillborn baby with a positive maternal blood culture for E. coli were identified. Pregnancy complications included multiple pregnancy in five (25%), preterm rupture of membranes 10 (50%) and maternal urinary tract infection in five (25%). Eighteen of the cases were born preterm and two at term. The mortality was 8/20 (40%), and for nine cases with developmental outcome data available, 67% were within normal limits and 33% were abnormal. Of the 20 E. coli isolates 11 (55%) were resistant to amoxycillin and 1 (5%) was resistant to gentamicin.

CONCLUSIONS

Infants with early onset E. coli sepsis had a poor outcome with high mortality and a third of the survivors manifesting neurodevelopmental impairment. Although amoxycillin resistance is common, there is a low prevalence of gentamicin resistance in local isolates.

Bacterial contamination of blood components

Blood for transfusion is a potential source of infection by a variety of known and unknown transmissible agents. Over the last 20 years, astounding reductions in the risk of viral infection via allogeneic blood have been achieved. As a result of this success, bacterial contamination of blood products has emerged as the greatest residual source of transfusion-transmitted disease. This paper summarizes the current status of detection, prevention, and elimination of bacteria in blood products for transfusion.

A cluster of nosocomial Klebsiella oxytoca bloodstream infections in a university hospital

BACKGROUND

On February 19, 2003, four patients (patients 1-4) in the neurology ward underwent cranial magnetic resonance angiography (MRA) and developed fever within 1 hour afterward. Klebsiella oxytoca was isolated from blood cultures of patients 1 through 3.

OBJECTIVE

To identify the source of this cluster of nosocomial K. oxytoca bloodstream infections.

DESIGN

Outbreak investigation.

SETTING

A 1,000-bed university hospital.

METHODS

The infection control team reviewed patient charts and interviewed nursing staff about the preparation and administration of parenteral fluids. The procedure of cranial MRA was observed. Arbitrarily primed polymerase chain reaction (AP-PCR) was performed to show the clonal relationship among these three strains.

RESULTS

AP-PCR revealed that three K. oxytoca isolates had the same molecular profile. Cranial MRA was found to be the only common source among these patients. During MRA, before injection of the contrast medium, normal saline solution was infused to check the functioning of the intravenous catheter. Use of the solution for multiple patients was routine, but the access diaphragm of the bottle was not cleansed. The bottle of normal saline solution used on February 19 had already been discarded and the culture sample taken from the solution on the day of observation was sterile.

CONCLUSIONS

We speculate that normal saline solution became contaminated during manipulation and that successive uses might have been responsible for this cluster. Poor aseptic techniques employed during successive uses appear to be the most likely route of contamination. Use of parenteral solutions for multiple patients was discontinued.

Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae hospital acquired bacteremia. Risk factors and clinical outcome

OBJECTIVE

To study the risk factors and clinical outcome in patients having extended-spectrum beta-lactamase producing (ESBL) Klebsiella pneumoniae (K. pneumoniae) hospital acquired bacteremia.

METHODS

The study was conducted at 500 bedded King Fahad Hospital and Tertiary Care Center, Al-Hofuf, Al-Hasa, Eastern Province of Saudi Arabia. Retrospectively infection control and microbiology records of patients having hospital acquired K. pneumoniae bacteremia during July 2001 to July 2003 were reviewed. Data on age, gender, location, onset of bacteremia, hospital stay after onset of bacteremia, prior antibiotic therapy, comorbid conditions and clinical outcome were recorded.

RESULTS

During 2 years of study period 26 patients developed hospital acquired K. pneumoniae bacteremia, out of them 10 patients had bacteremia due to ESBL producing strains. Extended-spectrum beta-lactamase producing K. pneumoniae bacteremia was significantly higher among patients of less than 65 years of age (p=0.004). Klebsiella pneumoniae bacteremia was more common (12/26, 46.1%) among diabetic patients and 8/12 had ESBL K. pneumoniae bacteremia. (p=0.02). Invasive devices (urinary and vascular catheters) were more commonly observed among patients having ESBL K.pneumoniae bacteremia (p=0.004, 0.001). Significantly higher number (9/10) of patients with ESBL K.pneumoniae bacteremia received prior third generation cephalosporins (p=0.001). Extended-spectrum beta-lactamase K. pneumoniae hospital acquired bacteremia had significantly longer hospital stay and higher mortality (p=0.0001).

CONCLUSION

Elderly age, diabetes, invasive devices and prior third generation cephalosporin therapy are the major risk factors for hospital acquired ESBL K.pneumoniae bacteremia, leading to significantly higher mortality and prolonged hospitalization. Infection control measures should be aggressively followed to prevent such infections among these high risk patients.

Inactivation of Gram-negative and Gram-positive bacteria in red cell concentrates using INACTINE PEN110 chemistry

BACKGROUND AND OBJECTIVES

The risk of transfusion-transmitted bacterial infections as a result of the presence of bacteria in blood is one of the major concerns in transfusion medicine. The purpose of this study was to investigate whether bacteria inoculated into red blood cell concentrates can be inactivated by the INACTINE PEN110 pathogen-reduction process. Four bacterial species were chosen for the study: anaerobic Gram-positive Clostridium perfringens and Propionibacterium acnes, known to be transfusion-transmitted; and two Gram-negative species, Acinetobacter johnsonii and Acinetobacter lwoffii, recently reported to be a common cause of transfusion-associated infections in Europe.

MATERIALS AND METHODS

Identical units of leucoreduced red cell concentrates were inoculated with A. johnsonii, A. lwoffii, C. perfringens, or P. acnes. The 4 degrees C control units were put on storage immediately after receiving the spike. The test units were subjected to PEN110 treatment and then stored. The bacterial titre in all units was monitored during a 6-week storage period.

RESULTS

The PEN110 inactivation of all tested bacterial strains was time- and titre-dependent. For A. johnsonii and A. lwoffii, no viable bacteria were detected in the units spiked with up to 10(4) colony-forming units (CFU)/ml and treated with PEN110. For red cell units spiked with 10(4)-10(5) CFU/ml of C. perfringens and P. acnes, no viable bacteria were detected in the units treated with PEN110. In control units, there was a gradual decrease in A. johnsonii, A. lwoffii and C. perfringens titres during cold storage, while P. acnes titres remained stable.

CONCLUSIONS

The PEN110 pathogen-reduction process was demonstrated to inactivate high titres of A. johnsonii, A. lwoffii, C. perfringens and P. acnes in red cell concentrates.