Evaluation of a modified cleaning procedure in the prevention of carbapenem-resistant Acinetobacter baumannii clonal spread in a burn intensive care unit using a high-sensitivity luminometer

BACKGROUND

Enhanced environmental cleaning practices are among the most accepted measures for controlling the spread of carbapenem-resistant Acinetobacter baumannii (CR-Ab).

AIM

To evaluate the impact of heightened cleaning on an ongoing CR-Ab outbreak in a burn intensive care unit (BICU) of an Italian teaching hospital, where chlorhexidine-60% isopropyl alcohol was applied as a complementary disinfectant on high-touch surfaces.

METHODS

Compliance with the microbial limit proposed for the BICU by AFNOR-NF-S90-351 (20 colony-forming units/100cm²) was assessed by plate count, and compared with the results obtained with intracellular adenosine triphosphate (ATP) detection. Genotyping was performed using pulsed-field gel electrophoresis.

FINDINGS

During the standard cleaning regimen, three out of 23 samples (13%) gave results over the AFNOR limit and five (21.7%) showed unacceptable ATP levels with 100 relative light units/100cm² as the benchmark limit (sensibility 86.4%, specificity 92.2%). Following improvement of the cleaning procedure, only two samples out of 50 (4%) did not satisfy the microbiological criteria and seven (14%) exceeded the ATP limit. In a successive phase, eight of 30 samples collected showed unacceptable results (27%).

CONCLUSIONS

Adding chlorhexidine-60% isopropyl alcohol as complementary disinfectant proved to be effective for reducing environmental microbial contamination, ATP levels and CR-Ab infection/colonization in patients admitted to the BICU. Real-time monitoring by ATP assay was useful for managing the cleaning schedule and reducing hospital infections, although the calculated values must be interpreted as cleanliness indicators rather than risk indicators.

Microbiological Activity and Clinical Efficacy of a Colistin and Rifampin Combination in Multidrug-ResistantPseudomonas aeruginosaInfections

The aim of the study was to assess the microbiological activity and clinical efficacy of colistin and rifampin combination against multidrug-resistant (MDR) Pseudomonas aeruginosa infections. The antimicrobial activity of the colistin/rifampin combination was evaluated using the checkerboard and time-kill curve methods against different MDR P. aeruginosa strains. The combination of rifampin and colistin resulted fully (1 strain) or partially (5 strains) synergistic for 6/7 strains and minimum inhibitory concentrations (MICs) in combination were reduced to easily obtainable therapeutic levels. The time-kill curves showed that the combination was bactericidal against the strains tested. The clinical efficacy of the combination was tested in four patients with difficult-to treat infections (sepsis or pneumonia) caused by MDR P. aeruginosa. All infections were successfully treated. Our microbiological and clinical observations suggest that the addition of rifampin to colistin may result in a synergistic bactericidal combination that may be useful in patients with infections caused by MDR P. aeruginosa which are difficult to cure.

Management of Cardiac Device Infections: A Retrospective Survey of a Non-Surgical Approach Combining Antibiotic Therapy with Transvenous Removal

Pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) have become life-saving therapeutic tools for patients with cardiac arrhythmia. Complications include thrombosis, embolism and infections at a highly variable rate. Surgical removal of the infected device has been perceived as the only way to guarantee a successful outcome and to reduce the high risk of mortality. Recently, a transvenous extraction method has been developed to remove infected intracardiac leads without sternotomy. This survey was designed to evaluate the outcome of an approach combining antibiotic therapy with non-surgical transvenous complete removal for the management of cardiac device infections (CDIs). We reviewed case-histories of 121 patients (105 with PM and 16 with ICD infections). The aim of our retrospective survey was to ascertain that a non-invasive transvenous complete removal of the infected devices is safe and effective when associated with appropriate antibiotic therapy starting 10 days before the procedure and extending to at least three weeks after. The infected devices were successfully removed in all patients with a non-surgical transvenous technique. The infections were most frequently caused by coagulase-negative staphylococci (70%), Staphylococcus aureus (14%), and Gram-negative rods (12%). Polymicrobial infections were documented in 19 patients and represent 16% of all device-related infections. The removal of the devices was done during antibiotic therapy, administered for a median of 26 days (range 23 to 45 days). Neither fatalities nor relapse of infections were recorded in the patient population during the one-year follow-up visits. According to our experience, CDIs can be treated with antibiotic therapy and non-surgical removal of the entire infected device, thus allowing a successful reimplantation. This procedure prevents recurrent infections and operative mortality.

The impact and recovery of asteroid 2008 TC(3)

In the absence of a firm link between individual meteorites and their asteroidal parent bodies, asteroids are typically characterized only by their light reflection properties, and grouped accordingly into classes. On 6 October 2008, a small asteroid was discovered with a flat reflectance spectrum in the 554-995 nm wavelength range, and designated 2008 TC(3) (refs 4-6). It subsequently hit the Earth. Because it exploded at 37 km altitude, no macroscopic fragments were expected to survive. Here we report that a dedicated search along the approach trajectory recovered 47 meteorites, fragments of a single body named Almahata Sitta, with a total mass of 3.95 kg. Analysis of one of these meteorites shows it to be an achondrite, a polymict ureilite, anomalous in its class: ultra-fine-grained and porous, with large carbonaceous grains. The combined asteroid and meteorite reflectance spectra identify the asteroid as F class, now firmly linked to dark carbon-rich anomalous ureilites, a material so fragile it was not previously represented in meteorite collections.

The flux of small near-Earth objects colliding with the Earth

Asteroids with diameters smaller than approximately 50-100 m that collide with the Earth usually do not hit the ground as a single body; rather, they detonate in the atmosphere. These small objects can still cause considerable damage, such as occurred near Tunguska, Siberia, in 1908. The flux of small bodies is poorly constrained, however, in part because ground-based observational searches pursue strategies that lead them preferentially to find larger objects. A Tunguska-class event-the energy of which we take to be equivalent to 10 megatons of TNT-was previously estimated to occur every 200-300 years, with the largest annual airburst calculated to be approximately 20 kilotons (kton) TNT equivalent (ref. 4). Here we report satellite records of bolide detonations in the atmosphere over the past 8.5 years. We find that the flux of objects in the 1-10-m size range has the same power-law distribution as bodies with diameters >50 m. From this we estimate that the Earth is hit on average annually by an object with approximately 5 kton equivalent energy, and that Tunguska-like events occur about once every 1,000 years.

Cidofovir for cytomegalovirus infection and disease in allogeneic stem cell transplant recipients. The Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation

A retrospective study was performed to collect information regarding efficacy and toxicity of cidofovir (CDV) in allogeneic stem cell transplant patients. Data were available on 82 patients. The indications for therapy were cytomegalovirus (CMV) disease in 20 patients, primary preemptive therapy in 24 patients, and secondary preemptive therapy in 38 patients. Of the patients, 47 had received previous antiviral therapy with ganciclovir, foscarnet, or both drugs. The dosage of CDV was 1 to 5 mg/kg per week followed by maintenance every other week in some patients. The duration of therapy ranged from 1 to 134 days (median, 22 days). All patients received probenecid and prehydration. Ten of 20 (50%) patients who were treated for CMV disease (9 of 16 with pneumonia) responded to CDV therapy, as did 25 of 38 (66%) patients who had failed or relapsed after previous preemptive therapy and 15 of 24 (62%) patients in whom CDV was used as the primary preemptive therapy. Of the patients, 21 (25.6%) developed renal toxicity that remained after cessation of therapy in 12 patients. Fifteen patients developed other toxicities that were potentially due to CDV or the concomitantly given probenecid. No toxicity was seen in 45 (61.6%) patients. Cidofovir can be considered as second-line therapy in patients with CMV disease failing previous antiviral therapy. However, additional studies are needed before CDV can be recommended for preemptive therapy.

The fall, recovery, orbit, and composition of the Tagish Lake meteorite: a new type of carbonaceous chondrite

The preatmospheric mass of the Tagish Lake meteoroid was about 200,000 kilograms. Its calculated orbit indicates affinity to the Apollo asteroids with a semimajor axis in the middle of the asteroid belt, consistent with a linkage to low-albedo C, D, and P type asteroids. The mineralogy, oxygen isotope, and bulk chemical composition of recovered samples of the Tagish Lake meteorite are intermediate between CM and CI meteorites. These data suggest that the Tagish Lake meteorite may be one of the most primitive solar system materials yet studied.

Enterococcal glycopeptide resistance at an Italian teaching hospital

Two thousand one hundred and thirteen strains of enterococci isolated at Pisa General Hospital in 1998 were analysed retrospectively to determine their glycopeptide resistance. Of all the microorganisms isolated in this period, 14.7% were enterococci (1405 Enterococcus faecalis, 19 Enterococcus faecium, six Enterococcus avium and 683 Enterococcus spp.). Two hundred and thirty (10.8%) of these enterococci were resistant or demonstrated reduced susceptibility to vancomycin and/or teicoplanin. The highest rate of resistance was found in outpatient enterococcal strains isolated from the urogenital tract. The frequency of enterococcal glycopeptide resistance at Pisa Hospital is higher than that reported from other areas of Italy.

Cytogenetic and myelodysplastic alterations after autologous hemopoietic stem cell transplantation

Secondary myelodysplastic syndrome/acute myelogenous leukemia (MDS/AML) are today considered a primary complication of autologous hematopoietic stem cell transplantation. In our Center, 83 autografted patients underwent bone marrow (BM) biopsy and cytogenetic analysis at fixed intervals. Twelve patients developed non-clonal cytogenetic abnormalities and 10 patients clonal abnormalities, five of whom (three - 7, one - 5 and one t(9;11)) developed secondary MDS/AML. MDS was also diagnosed in two patients with a normal karyotype. In brief, seven patients (three males, four females; median age 36 years) developed MDS/AML 12-48 months (median 14) after autografting. The FAB diagnosis was AML-M2 in one, chronic myelomonocytic leukemia in two and refractory anemia with excess of blasts in transformation in four cases. Two patients presented a BM biopsy picture of MDS with fibrosis; none of them experienced leukemic transformation. Four MDS patients died, three of leukemic transformation and one of BM insufficiency; the two remaining patients are still living and untransformed. Our data underline the leukemogenic role of previous treatments, even if it is not possible to exclude that underlying disease and/or conditioning therapy may be involved.

Moderate zinc and vitamin A deficiency in breast milk of mothers from East-Jakarta

OBJECTIVE

To gain information about the micronutrient status of urban, middle-income, breast-feeding mothers in relation to zinc and selected fat-soluble vitamins in plasma and breast milk and to assess possible interaction between the measured micronutrients.

DESIGN

Cross-sectional study.

SUBJECTS

91 mothers and their infants living in middle-income areas of Jakarta, Indonesia.

RESULTS

None of the measured anthropometric data of the mothers (e.g. BMI: 22.0+/-3.1 kg/m2) and their infants (birth weight: 3.2+/-0.5 kg) gave any indication of undernutrition. The mean concentrations in blood were 124+/-18 g/l for hemoglobin, 385+/-111 microg/l for retinol, 34+/-23 microg/l for alpha-carotene, 104+/-72 microg/l for beta-carotene, 7.7+/-3.3 mg/l for alpha-tocopherol, 0.57+/-0.23 mg/l for gamma-tocopherol, 855+/-242 microg/l for zinc, and the median concentration of lycopene was 29 microg/l. The median breast milk concentrations were 420 microg/l for retinol, 7.8 microg/l for beta-carotene, and 2.7 mg/l for zinc. With increased duration of lactation, vitamin A and zinc concentrations significantly decreased in breast milk whereas plasma zinc concentration increased. Plasma alpha- and beta-carotene were positively correlated (P < 0.0001) with each other and with plasma lycopene. Breast milk beta-carotene was positively correlated with breast milk retinol and with plasma beta-carotene (P < 0.0001). There was no correlation between zinc and vitamin A in either breast milk or plasma. Forty per cent of the mothers were anemic, 29.1% had a low plasma zinc concentration, and 23.7% had a moderately low plasma vitamin A concentration. Breast milk from 70% of the women had a low concentration of vitamin A and that from 66% had a low concentration of zinc.

CONCLUSIONS

Multi-micronutrient intervention should be considered to provide a sufficient supply of zinc and vitamin A for growth of exclusively breast-fed infants.

G-CSF after autologous hemopoietic stem cell transplantation in malignant lymphoma

Forty-eight autografted patients were studied after treatment with granulocyte-colony stimulating factor (G-CSF) and were compared with a historical series of 24 patients autografted with bone marrow (BM) without G-CSF. When the patients were divided on the basis of G-CSF administration, type of lymphoma and the source of hemopoietic stem cells, no significant difference was found in the median number of infused BM cells, duration of febrile episodes, platelet and hemoglobin recovery, or in the number of transfusions. The patients receiving peripheral blood (PB) + G-CSF had significantly shorter median durations of antibiotic therapy, hospital stay and polymorphonucleate (PMN) recovery. When the Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL) cases were considered separately, a significant difference between those receiving and those not receiving G-CSF was observed only in the HD group. The advantage offered by PB + G-CSF over BM + G-CSF was far more evident in the NHL group than in HD. It can be concluded that G-CSF improves the outcome of BM transplant in HD, and that the use of PB + G-CSF adds a further advantage; conversely, in NHL, PB + G-CSF is strikingly superior to BM + G-CSF, but the addition of G-CSF adds little advantage.

Haematopoietic abnormalities after autologous stem cell transplantation in lymphoma patients

Haematopoietic reconstitution after autologous stem cell transplantation (ASCT) was evaluated at different times in 26 lymphoma patients. All of the patients showed a significant decrease in the number of both committed (CFU-C) and more primitive progenitor cells (LTC-IC). The expansion of bone marrow progenitor cells in a 'stroma-free' long-term liquid culture system supplemented with SCF, IL-3, IL-6 and GM-CSF from 19 transplanted patients was significantly reduced compared to normal controls. The stromal cell compartment, evaluated by means of a CFU-F assay, was also greatly reduced. The number of haematopoietic and stromal cell progenitors was, nevertheless, very similar to their pre-transplant values. Bone marrow histology, which was evaluated at different times after transplant, showed an increase in reticulin fibres, the dilatation of parenchymal sinusoids and some morphological evidence of trilineage dysplasia in 11 patients; however, the same abnormalities were seen in the majority of pre-transplant samples. No cytogenetic abnormalities were observed in 15 patients before transplant, but four subsequently developed persistent clonal karyotypic alterations and five showed non-clonal abnormalities that generally disappeared over time. Our data suggest that both the stromal and the haematopoietic compartments are somehow damaged after ASCT for lymphoma; however, these defects generally pre-exist the transplant conditioning regimen and seem to become less pronounced over time.

Autologous bone marrow transplantation in advanced Hodgkin's disease

Autologous bone marrow transplantation (ABMT) has been proposed as an alternative treatment of resistant/refractory Hodgkin's disease (HD). Thirty-seven patients in various phases of HD underwent autografting in our Center: fourteen received a CBV conditioning regimen, the others BCNU or VP16 followed by cyclophosphamide and TBI. Three patients died before engraftment, 28 (75.67%) achieved CR and 6 showed persistent disease. As of March 1996, 18 patients had died and 13 were in continuous CR. The median event-free survival (EFS) and 3-year EFS chances were respectively 9 months and 31.3% in the series as a whole, 14 months and 40% in primary resistant disease, 9 months and 28.4% in responsive relapse, and 3 months and 22.2% in resistant relapse. As many of these patients had failed to respond to third-line therapies, their EFS figures are primarily attributable to the therapeutic efficacy of ABMT. Furthermore, since the EFS curves are better in patients seemingly characterized by a lower chance of chemoresistance, our data favour the use of ABMT in the earlier phases of HD.

Unrelated mismatched cord blood transplantation in an adult with secondary AML

Umbilical cord blood (CB) has been widely used for related and unrelated transplants in pediatric patients. We present the case of an adult with secondary AML who received an unrelated, one-antigen mismatched CB transplant due to the lack of a matched donor. The patient was a 26-year-old female (35 kg/bw) who had received an autologous bone marrow transplant for Hodgkin's disease in April 1994 and, 6 months later, developed secondary MDS (RAEB, 46, XX, -7, +mar), which slowly evolved into acute myelogenous leukemia. In May 1995, she was transplanted with a 165 ml CB unit containing a total of 1.6 x 10(9) nucleated cells, 11 x 10(6) CD34+ cells and 7.2 x 10(5) CFU-GM. GVHD prophylaxis consisted of standard CsA and methotrexate. Myeloid engraftment occurred on day +28 (PMN > 500) and full donor chimerism was confirmed twice (on days +33 and +56) by means of cytogenetics and DNA microsatellite analysis. Erythroid and megakaryocytic engraftment was documented by immunohistochemical analysis of a bone marrow biopsy on day +40, showing the presence of erythroblastic islands and isolated CD61+ immature cells. The patient did not develop GVHD but died on day +56 from idiopathic interstitial pneumonia and multiorgan failure. To our knowledge, this is one of the first case reports of unrelated mismatched CB transplantation in an adult.

Efficacy of different prophylactic antifungal regimens in bone marrow transplantation

BACKGROUND

Fungal infections still represent a major clinical problem in neutropenic patients; the recent availability of active imidazole derivatives, particularly fluconazole and itraconazole, has increased interest in prophylaxis.

MATERIALS AND METHODS

Fifty-nine consecutive bone marrow transplant (BMT) recipients were randomized to receive either itraconazole 400 mg/day or fluconazole 300 mg/day as oral antimycotic prophylaxis during the pancytopenic phase; they were retrospectively compared with a historical control group of 30 patients who had received fluconazole 50 mg/day. Every febrile episode was treated with the same empirical antibiotic combination; amphotericin-B was added after 4-5 days in the case of persistent fever. Proven or suspected mycotic infections and the empirical use of amphotericin-B were considered as failures of prophylaxis.

RESULTS

There were no differences in the number of febrile episodes in the three groups. Five patient died of bacterial sepsis: two in the fluconazole 300, two in the itraconazole and one in the fluconazole 50 group. The addition of amphotericin-B was required in 12, 16 and 11 cases, respectively, in the three groups. There were four documented fungal infections in the intraconazole and one in both fluconazole groups; three suspected fungal infections were observed in the fluconazole 300 group and two in both the itraconazole and the fluconazole 50 group. None of the differences were statistically significant.

CONCLUSIONS

The present results indicate that high-dose fluconazole and itraconazole are equivalent; neither of them was superior to low-dose fluconazole, which is regarded as being devoid of prophylactic activity against systemic mycoses.

Single-institution results of autologous bone marrow transplantation in acute myeloid leukemia

BACKGROUND

Current results of autologous bone marrow transplantation (ABMT) suggest that this procedure may prolong disease-free survival (DFS) in patients with acute myeloid leukemia (AML).

MATERIALS AND METHODS

Over the last ten years, 29 AML patients received unpurged autologous bone marrow (BM) after a conditioning regimen including Ara-C (3 g/m2/12h, days -9, -8), CTX (60 mg/kg/day, days -6, -5) and TBI (3.33 Gy/day, days -3 through -1). In 21 patients, ABMT was performed as late intensification after first CR. Eight more relapsing patients were autografted after the achievement of second CR.

RESULTS

Three patients died from transplant-related complications. In the remaining patients, mean times to WBC and platelet recovery were, respectively, 23 days (range 13-55) and 55 days (range 22-790). Follow-up for censored patients ranged from 1 to 120 months. Relapse occurred in 7 patients (5 in first and 2 in second CR). Overall 5-year DFS and event-free survival (EFS) chances were, respectively, 67.3% and 60%, with no statistically significant differences between first (DFS = 67.3%, EFS = 60.3%) and second CR (DFS = 68.6%, EFS = 60%).

DISCUSSION

Apart from obvious selection biases, our study suggests that outcome in first CR AML patients is improved by ABMT. Long-term DFS and EFS are clearly better than when conventional post-remission chemotherapies are used. The greater antileukemic potential of ABMT is further underlined by the results in patients autografted in second CR, when conventional chemotherapy is almost never curative.