Adherence to 2015 ESC Guidelines for the Treatment of Infective Endocarditis: A Retrospective Multicentre Study (LEIOT Study)

Background: Infective endocarditis (IE) is still a severe disease with elevated morbidity and mortality. Nevertheless, the last European guidelines (GL) date back to 2015, and a recent survey described a diffuse suboptimal adherence to their recommendations. Here, we described a real-life scenario about adherence to IE treatment GL. Methods: This was a retrospective, multicentric, case–control study. All the cases of IE admitted to our wards from 2016 to 2020 were enrolled. Patients were divided into two groups, according to the non-adherence (group A, cases) or adherence (group B, controls) to 2015 ESC guidelines. Only targeted treatments were considered. Groups were compared for demographic, clinical, microbiological, and laboratory data and outcome. As a post hoc analysis, we analysed the characteristics of deviations from the guidelines and how these deviations affected mortality. Results: A total of 246 patients were enrolled, with 128 (52%) in group A and 118 (48%) in group B. Groups were homogeneous except for aetiologies: staphylococcal and blood-culture-negative IE were more frequent in group A, while streptococcal and enterococcal IE were more frequent in group B (p < 0.001). In-hospital mortality was comparable in the two groups. The most frequent causes of deviations from the guidelines were use of daptomycin, in addition to standard treatments and the missing administration of rifampin or gentamycin. Conclusions: Adherence to 2015 ESC guidelines was limited but it did not affect mortality.

Impact of septic episodes caused by Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa in a tertiary hospital: clinical and economic considerations in years 2018-2020

OBJECTIVE

To evaluate incidence, therapy and antibiotic resistance trends in septic episodes caused by three multi-drug resistant bacteria in a tertiary hospital, by also estimating their economic impact.

METHODS

An observational, retrospective-cohort analysis was based on data related to patients admitted to the "SS. Antonio e Biagio e Cesare Arrigo" Hospital in Alessandria (Italy) between 2018 and 2020, that developed sepsis from multi-drug resistant bacteria of the examined species. Data were retrieved from medical records and from the hospital's management department.

RESULTS

Inclusion criteria led to enrolment of 174 patients. A relative increase in A. baumannii cases (p < 0.0001) and an increasing resistance trend for K. pneumoniae (p < 0.0001) were detected in 2020 compared to 2018-2019. Most patients were treated with carbapenems (72.4%), although the use of colistin rose significantly in 2020 (62.5% vs 36%, p = 0.0005). Altogether, these 174 cases caused 3295 additional hospitalisation days (mean 19 days/patient): the consequent expenditure attained ≈ 3 million Euros, 85% of which (≈2.5 million Euros) due to the cost of extra hospital stay. Specific antimicrobial therapy accounted for 11.2% of the total (≈336,000 €).

CONCLUSIONS

Healthcare-related septic episodes cause a considerable burden. Moreover, a trend could be spotted towards higher relative incidence of complex cases recently.

Impact of sepses caused by three Multi-Drug Resistant bacteria in a tertiary hospital in 2018-2020

Background

Healthcare-associated infections represent a major health issue, particularly if caused by multi-drug resistant (MDR) microorganisms, with additional hospitalisation days and relevant costs besides illness and deaths. This study aimed at evaluating the economic impact of healthcare-related sepses caused by three MDR Gram-negative bacteria (Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa) in a tertiary hospital.

Methods

An observational, retrospective-cohort analysis was based on data related to patients admitted to the “SS. Antonio e Biagio e Cesare Arrigo” Hospital in Alessandria (Italy) between 2018 and 2020. Starting from the microbiology laboratory database, the set of patients developing sepses from the examined species was selected, by also checking that the relevant antibiogram provided evidence of resistance to ≥ 2 antimicrobial classes indicated by the European Centre for Disease Prevention and Control. Data were retrieved from patients’ medical records and from the hospital's computer-based application.

Results

In years 2018-2020, 174 patients developed septic infections from the examined species, the majority of which (88, i.e. 50.6%) in 2020 only. Altogether, these cases were responsible for 3,295 additional hospitalisation days (median 14 days, mean 19 days), with 901 imaging and 7,365 laboratory exams being reasonably ascribable to the septic episodes. Sepsis-related costs could be estimated in around 3 million Euros, about 85% of which (≈2.5 million Euros) were due to the actual cost of extra hospital stay. Specific antimicrobial therapy accounted for around 11.2% of the total (≈336,000 €).

Conclusions

The results of this study pointed out that MDR sepses were responsible for conspicuous costs, largely grounded on the extra length of hospital stays but also due to the use of highly-expensive new-generation antimicrobials. Further research is needed to explore costs of septic episodes in different contexts.

Key messages

• MDR sepses entailed high costs (around 3 million Euros in three years only in a single hospital), due to extra length of hospital stays and use of highly-expensive new-generation antimicrobials.

• In order to provide wider-scale estimates of the economic impact of sepses, further research is needed to explore costs of septic episodes in different sanitary systems and contexts.

Durability of Dolutegravir-Based Regimens: A 5-Year Prospective Observational Study

This study evaluates the frequency and causes of dolutegravir (DTG) discontinuation along 5 years of follow-up, in both antiretroviral treatment (ART)-naive and experienced people living with HIV (PLWH). This is a prospective multi-center cohort study enrolling PLWH on DTG from July 2014 until November 2020. DTG-durability was investigated using the Kaplan-Meier survival curve. The Cox proportional-hazards model was used for estimating the hazard ratio (HR) of DTG discontinuation for any cause, and for adverse events (AEs). Nine hundred sixty-three PLWH were included, 25.3% were women and 28.0% were ART-naive. Discontinuations for any causes were 10.1 [95% confidence interval (95% CI) 8.9-11.5] per 100 person-years, similar in most regimens, with the apparent exception of tenofovir alafenamide/emtricitabine+DTG (p < 0.0001). In the multivariable Cox regression model, non-Caucasian ethnicity, age ≥50 years, and lower estimated glomerular filtration rate (eGFR) were associated with a higher probability of DTG interruption. The incidence rate of virological failure was 0.4 (95% CI 0.2-0.7) per 100 person-years, while the estimated discontinuation rate for AEs was 4.0 (3.2-4.9) per 100 person-years. Thirty-four DTG interruptions were due to grade ≥3 events (10 central nervous system, 6 hypersensitivity, 3 renal, 3 myalgia/asthenia, 3 abdominal pain, 2 gastrointestinal, and 7 other events). People with lower body mass index, age ≥50 years, and lower eGFR were at higher risk of AEs, while dual combinations were protective (HR 0.41 compared with abacavir/lamivudine/DTG, 95% CI 0.22-0.77). In this prospective observational study, we found high DTG durability and a low rate of virological failures. Dual therapies seemed protective toward AEs and might be considered, when feasible, a suitable option to minimize drug interactions and improve tolerability.

Factors Associated With Weight Gain in People Treated With Dolutegravir

Background

An unexpected excess in weight gain has recently been reported in the course of dolutegravir (DTG) treatment. The aim of the present study was to investigate whether weight gain differs among different DTG-containing regimens.

Methods

Adult naïve and experienced people with HIV (PWH) initiating DTG-based antiretroviral therapy (ART) between July 2014 and December 2019 in the Surveillance Cohort Long-Term Toxicity Antiretrovirals (SCOLTA) prospective cohort were included. We used an adjusted general linear model to compare weight change among backbone groups and a Cox proportional hazard regression model to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for weight increases >10% from baseline.

Results

A total of 713 participants, 25.3% women and 91% Caucasian, were included. Of these, 195 (27.4%) started DTG as their first ART regimen, whereas 518 (72.6%) were ART-experienced. DTG was associated with abacavir/lamivudine in 326 participants, tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in 148, boosted protease inhibitors in 60, rilpivirine in 45, lamivudine in 75, and tenofovir alafenamide (TAF)/FTC in 59. At 6 and 12 months, weight gain was highest among PWH on TDF/FTC+DTG and TAF/FTC+DTG. Baseline CD4 <200 cells/mm³ (HR, 1.84; 95% CI, 1.15 to 2.96), being ART-naïve (HR, 2.24; 95% CI, 1.24 to 4.18), and treatment with TDF/FTC+DTG (HR, 1.92; 95% CI, 1.23 to 2.98) or TAF/FTC+DTG (HR, 3.80; 95% CI, 1.75 to 8.23) were associated with weight gain >10% from baseline. Higher weight (HR, 0.97 by 1 kg; 95% CI, 0.96 to 0.99) and female gender (HR, 0.54; 95% CI, 0.33 to 0.88) were protective against weight gain.

Conclusions

Naïve PWH with lower CD4 counts and those on TAF/FTC or TDF/FTC backbones were at higher risk of weight increase in the course of DTG-based ART.

Example of antimicrobial stewardship program in a community hospital in Italy

BACKGROUND

Inappropriate use of antibiotics has caused the emergence of resistant strains of bacteria. The hospital of Alessandria, Italy, implemented an antimicrobial stewardship (AS) pilot program between 2013 and 2015 in the intensive care units (ICUs) and internal medicine departments of Casale Monferrato and Tortona. We aimed to describe the project, results at the end of the intervention, and its strengths and weaknesses.

METHODS

The protocol, designed by the local infection control committee, included three consecutive steps: local guidelines for empirical antibiotic therapy and list of prescription antibiotics with justification, monitoring of antibiotic consumption and antimicrobial resistance trend, and peer-to-peer audit sessions in the wards.

RESULTS

One thousand and eighty-five observations were made, corresponding to 850 patients admitted to the ICUs (16.7%) and internal medicine departments (83.3%). Appropriate antibiotic prescriptions increased by 6.4% between 2013 and 2015. The greatest improvement in appropriate prescriptions was observed for glycopeptides and fluoroquinolones (+17.4% and +16.2%, respectively). We reported 305 inappropriate prescriptions, with the most frequent errors being absence of an infectious process (33.3%), inadequate combination therapy (12.8%), and absence of microbiological investigations (8.5%). A reduced incidence of methicillin-resistant Staphylococcusaureus (MRSA) was also observed (p<0.0037).

CONCLUSIONS

Antimicrobial stewardship programs contribute to improving antibiotic prescription and can be implemented in small community hospitals. Narrower interventions, focused on a single disease or single antibiotic should be encouraged.

Use of colistin in adult patients: A cross-sectional study

OBJECTIVES

The aim of this study was to assess colistin use in a country endemic for multidrug-resistant Gram-negative bacteria (MDR-GNB).

METHODS

Colistin prescription patterns were evaluated in 22 Italian centres. Factors associated with use of colistin in combination with other anti-MDR-GNB agents were also assessed.

RESULTS

A total of 221 adults receiving colistin were included in the study. Their median age was 64 years (interquartile range 52-73 years) and 134 (61%) were male. Colistin was mostly administered intravenously (203/221; 92%) and mainly for targeted therapy (168/221; 76%). The most frequent indications for colistin therapy were bloodstream infection and lower respiratory tract infection. Intravenous colistin was administered in combination with at least another anti-MDR-GNB agent in 80% of cases (163/203). A loading dose of 9 MU of colistimethate was administered in 79% of patients receiving i.v. colistin and adequate maintenance doses in 85%. In multivariable analysis, empirical therapy [odds ratio (OR) = 3.25, 95% confidence interval (CI) 1.24-8.53;P = 0.017] and targeted therapy for carbapenem-resistant Enterobacterales infection (OR = 4.76, 95% CI 1.69-13.43; P = 0.003) were associated with use of colistin in combination with other agents, whilst chronic renal failure (OR = 0.39, 95% CI 0.17-0.88; P =  0.024) was associated with use of colistin monotherapy.

CONCLUSION

Colistin remains an important option for severe MDR-GNB infections when other treatments are not available. Despite inherent difficulties in optimising its use owing to peculiar pharmacokinetic/pharmacodynamic characteristics, colistin was mostly used appropriately in a country endemic for MDR-GNB.

Epidemiological evaluation of Leishmania infantum zoonotic transmission risk in the recently established endemic area of Northwestern Italy

Leishmania infantum infection had been expanding into new areas due to changes in vector and host biology. Zoonotic visceral leishmaniasis has become endemic in previously unsuitable areas as vectors find favourable climatic conditions and an increasing number of reservoir dogs are moved between traditionally and new endemic areas. Monitoring vector and disease expansion in areas of recent colonization is needed to understand transmission mechanisms and patterns of disease establishment. Here, we studied the infection status of 815 human blood donors and of 803 sympatric dogs from five, newly endemic, areas in Northwestern Italy. In autochthonous dogs, the seroprevalence of anti-L. infantum antibodies, recorded by Western blot, reached 42.22%, while in humans, the seroprevalence was of 16.81%. No significant correlation between the infection status of dogs and that of their human owners was found, but L. infantum infection was recorded in the different study areas with significant levels of diversity. Restriction fragment length polymorphism showed a high genetic variability of the circulating strains and gave useful insights on patterns of disease establishment into a naïve area.

Dogs' parasite and zoonotic risk: from old to new "emergencies" in the North-West of Italy

Toxocariasis due to soil contamination from dog and cat faeces has been long described and represents one of the zoonotic risk linked with pets presence in human settlements. Soil samples were collected from private backyards and school playgrounds in Turin and tested for the presence of Toxocara spp. eggs. Samples from dogs and cats living in the same area were also analysed and our results seem to indicate a decrease in soil contamination respect to a survey carried out in 1985. Considering that recently new foci of Canine Leishmaniosis and the presence of competent sand fly vectors have also been reported in the North-West of Italy, a survey was carried out on dogs and humans living in Asti province. To assess the risk of local Leishmania infantum transmission between dog and humans, samples were also analysed by Restriction Fragment Length Polymorphism (PCR-RFLP). Our results have shown that more than 10% of autochthonous dogs and human being living in this previously non-endemic area have been infected by L. infantum. The identity of PCR-RFLP patterns from 3 human clinical cases and from the dogs of one of them allows us to confirm the autochthonous origin of these cases.

Adrenal location of the echinococcus. Considerations on a clinical case

Adrenal location of a hydatic cyst is a clinical occurrence of exceptional rarity, especially in its primitive form and it could be evaluated, on the operative and autoptic comparison, not to exceed overall 0.5% of all the possible locations. Moreover, among all the cystic formations of the adrenal glands, parasitic ones are only 7%. Our observation of a case of adrenal hydatidosis, initially suspected as hepatic mass, was casually discovered by means of abdominal ultrasonography and later confirmed with the operation. This work contributes to the knowledge of this pathology, emphasizing diagnostic difficulties, and, considering the exiguous literature, helping us in supplying real indications to the surgical treatment.

[Extrahepatic gastrinoma. Report of a clinical case]

Gastrinoma is a rare neoplasia producing gastrina, the hormone responsible of the clinic manifestations related to Zollinger-Ellison syndrome. The localization of gastrinoma is pancreatic or extrapancreatic (usually in Stabile and Passaro triangle). We present a case report concerning an extra-pancreatic gastrinoma not localized in this area and included in a lymph node. This is an extremely infrequent localization (2.4%). There are two different opinions about this localization. Some authors think that this is always a secondary lesion of a small primary neoplasia usually asymptomatic. Other authors think that there are primary lymph nodal gastrinomas that could be safely removed with excision of lymph node. The infrequent localisation of this case induced us to report this experience in order to contribute to the comprehension of this pathology.