Ak Baronia

Epidemiology of bacterial colonization at intensive care unit admission with emphasis on extended-spectrum β-lactamase- and metallo-β-lactamase-producing Gram-negative bacteria - an Indian experience

An important risk factor for nosocomial infection in an intensive care unit (ICU) is prior colonization. This study was undertaken to determine the spectrum of bacterial colonization and predisposing risk factors in patients being admitted to an ICU in India, with special emphasis on extended-spectrum beta-lactamase (ESBL)- and metallo-beta-lactamase (MBL)-producing Gram-negative bacteria. Nasal, oral and rectal swab samples were collected and processed for isolation of ESBL-producing Gram-negative bacteria and MBL-producing Pseudomonas aeruginosa and Acinetobacter species. Bacterial colonization (of one or more sites) on admission was detected in 51 out of 96 patients included in the study. Non-fermenters, i.e. P. aeruginosa and Acinetobacter baumannii, were the most common colonizers, present in 37 patients, with simultaneous colonization in 12 patients. A total of 16 patients were colonized with MBL-producing members of the family Enterobacteriaceae, out of which 11 isolates (from 5 patients) were also carrying ESBL-encoding genes. As for MBLs, most of our patients have shown colonization with ESBL-producing bacteria. On admission, 47 of 51 patients (92 %) have been colonized by ESBL-producing members of the family Enterobacteriaceae, at one or more of the three anatomical sites. The most common MBL subtype was bla(IMP) (51.56 %), whereas bla(CTX) was the most common gene (84.9 %) identified among ESBL producers. Risk factors for colonization on admission to the ICU were hospitalization for more than 48 h, use of >or=3 groups of antibiotics, co-morbidities and mechanical ventilation for more than 48 h prior to ICU admission. There is an increasing incidence of MBLs and ESBLs in the Indian population. The identified risk factors can be used as a guide for empiric antibiotic therapy targeted to these resistant bacteria.

Prospective comparison of new Japanese Association for Acute Medicine (JAAM) DIC and International Society of Thrombosis and Hemostasis (ISTH) DIC score in critically ill septic patients

INTRODUCTIONnWe prospectively compared the new Japanese Association for Acute Medicine (JAAM) score with the International Society of Thrombosis and Hemostasis (ISTH) score for diagnosis of disseminated intravascular coagulation (DIC) in septic patients admitted in a general critical care intensive care unit.nnnMATERIAL AND METHODnSeptic patients with platelet count of <150 × 10(9)/L were included. Both DIC scores were estimated from day 1 to day 4 along with APACHE II and SOFA scores.nnnRESULTSnOut of the 148 blood samples drawn from 42 patients (28 male & 14 female) the JAAM and ISTH DIC scores had an overall significant agreement (k=0.246, p<0.001) in 83 samples. JAAM score had higher diagnostic rates on all four days. Significant (p ≤ 0.001) day wise variation existed in JAAM and ISTH DIC scores. Correlation between JAAM DIC and ISTH DIC scores on day 1 (r=0.631) & day 4 (r=0.609) was significant (p<0.001). Pneumonia was the predominant cause of sepsis. Twenty seven (64.3%) patients died during their stay in ICU. Amongst DIC patients both severity scores (SOFA/APACHE II) and DIC scores (JAAM/ISTH) did not discriminate between survivors and non-survivors. Health care associated infection (p=0.040), high lactate levels (p=0.020) on day 1 and high procalcitonin levels (p=0.036) were found to have significant discriminating ability between survivors and non-survivors. Significantly shorter length of stay was observed amongst non-survivors (p=0.002).nnnCONCLUSIONSnIn sepsis the JAAM DIC score identified most of the patients diagnosed by the overt ISTH criteria, but failed to discriminate between survivors and non-survivors amongst DIC patients.

Metabolic profiling of human lung injury by 1H high-resolution nuclear magnetic resonance spectroscopy of blood serum

Acute respiratory distress syndrome (ARDS) contributes substantially toxa0mortality and morbidity in USA and worldwide. Due to limitations in early diagnostics of ARDS by classical methods, there has been need for discovery of novel methods and biomarkers for its characterization. We present here first high-resolution 1H nuclear magnetic resonance (NMR) metabolic profiling of serum from ARDS patients and non ARDS (NARDS) controls to search for novel biomarkers in blood serum for better diagnostics and prognostics. We have carried out study with serum samples from a total of 45 subjects, which included 26 ARDS patients and 19 NARDS controls. Principal component analysis (PCA) and partial least square discriminant analysis (PLS-DA) were performed on 1H NMR spectra of serum for group discrimination between the two. PCA and PLS-DA on 1H NMR spectra of serum clearly discriminated between NARDS control and ARDS diseased samples. In our study, lipid resonances showed major contribution for this separation in loading plots. In order to highlight role of other small molecular weight metabolites, the analysis was also carried out after removing lipids resonances from NMR spectrum. There was significant increase in concentrations of N-acetylglycoproteins (NAC) (pxa0=xa00.001), acetoacetate (pxa0=xa00.001), lactate (pxa0=xa00.001), creatinine (pxa0=xa00.003), histidine (pxa0=xa00.03), formate (pxa0=xa00.04) and aromatic amino acids serum of ARDS patients. Along with small metabolites, lipids play a very important role in this discrimination and can differentiate between two classes. Our study has given new avenue in the metabolic profiling of lung injuries.

Ventilator-associated pneumonia caused by carbapenem-resistant Enterobacteriaceae carrying multiple metallo-beta-lactamase genes.

CONTEXTnVentilator-associated pneumonia (VAP) is a leading nosocomial infection in the intensive care unit (ICU). Members of Enterobacteriaceae are the most common causative agents and carbapenems are the most commonly used antibiotics. Metallo-beta-lactamase (MBL) production leading to treatment failure may go unnoticed by routine disc diffusion susceptibility testing. Moreover, there is not much information on association of MBL-producing Enterobacteriaceae with ICU-acquired VAP. Therefore, a study was undertaken to find out the association of MBL-producing Enterobacteriaceae with VAP.nnnSETTINGSnThis study was conducted in a large tertiary care hospital of North India with an eight-bed critical care unit.nnnMATERIALS AND METHODSnThe respiratory samples (bronchoalveolar lavage, protected brush catheter specimens and endotracheal or transtracheal aspirates) obtained from VAP patients (during January 2005-December 2006) were processed, isolated bacteria identified and their antibiotic susceptibilities tested as per standard protocols. The isolates of Enterobacteriaceae resistant to carbapenem were subjected to phenotypic and genotypic tests for the detection of MBLs.nnnRESULTSnTwelve of 64 isolates of Enterobacteriaceae were detected as MBL producers, bla(IMP) being the most prevalent gene. Additionally, in three strains, simultaneous coexistence of multiple MBL genes was detected.nnnCONCLUSIONnThe coexistence of multiple MBL genes in Enterobacteriaceae is an alarming situation. As MBL genes are associated with integrons that can be embedded in transposons, which in turn can be accommodated on plasmids thereby resulting in a highly mobile genetic apparatus, the further spread of these genes in different pathogens is likely to occur.

Outcome of mechanical ventilation in patients of Guillain-Barre syndrome: An audit from a tertiary care centre

Background: About a third of patients with Guillain-Barre Syndrome (GBS) presents with acute respiratory failure requiring invasive mechanical ventilation. We studied the outcome of patients with GBS. Material and Methods: A retrospective data extraction was done on clinical records of 103 patients with diagnosis of GBS admitted in intensive care unit (ICU) over a period of 7 years. All patients requiring ICU admission and mechanical ventilation for more than 48 h were included in the study. Demographic profile, clinical characteristics, treatment given, duration of mechanical ventilation, ICU acquired infections, incidence of pressure sores, and length of ICU stay was noted. Results: Eighty six patients fulfilled the inclusion criteria. The mean age of patients was 32.4 (± 18.12) years. Mean duration of ICU stay was 28.9 (± 26.99) days. Majority (82%) of our patients were male. The most common co-morbidities were diabetes mellitus and hypertension. Axonal neuropathy was the most common (76%) lesion. Autonomic dysfunction was present in 35% of patients. Fifty two percent of patients received immunoglobulin therapy while 64% of required mechanical ventilation for more than 14 days. Tracheostomy was performed in 85% of patients. Ventilator associated pneumonia (VAP) was seen in 33% of patients, blood stream infection in 11% and urinary tract infection in 7%. Forty percent of patients developed bed sore grade 1-2. Seven (8.3%) patients died perhaps due to complications including VAP and sepsis. Conclusions: GBS has a good outcome despite prolonged mechanical ventilation and ICU stay.

Epidemiology of central line-associated bloodstream infections at a tertiary care centre in northern India

1. Shakil S, Khan AU. Detection of CTX-M-15-producing and carbapenem-resistant Acinetobacter baumannii strains from urine from an Indian hospital. J Chemother 2010;22:324e327. 2. Seki LM, Pereira PS, Conceição MS, et al. Molecular epidemiology of CTX-M producing Enterobacteriaceae isolated from bloodstream infections in Rio de Janeiro, Brazil: emergence of CTX-M-15. Braz J Infect Dis 2013;17:640e646. 3. Potron A, Munoz-Price LS, Nordmann P, Cleary T, Poirel L. Genetic features of CTX-M-15-producing Acinetobacter baumannii from Haiti. Antimicrob Agents Chemother 2011;55:5946e5948. 4. Silbert S, Pfaller MA, Hollis RJ, Barth AL, Sader HS. Evaluation of three molecular typing techniques for nonfermentative Gramnegative bacilli. Infect Control Hosp Epidemiol 2004;25: 847e851. 5. Monstein HJ, Ostholm-Balkhed A, Nilsson MV, Nilsson M, Dornbusch K, Nilsson LE. Multiplex PCR amplification assay for the detection of blaSHV, blaTEM and blaCTX-M genes in Enterobacteriaceae. APMIS 2007;115:1400e1408. 6. Woodford N, Ellington MJ, Coelho JM, et al. Multiplex PCR for genes encoding prevalent OXA carbapenemases in Acinetobacter spp. Int J Antimicrob Agents 2006;27:351e353. 7. Poirel L, Walsh TR, Cuvillier V, Nordmann P. Multiplex PCR for detection of acquired carbapenemase genes. Diagn Microbiol Infect Dis 2011;70:119e123. 8. Shahcheraghi F, Nikbin VS, Feizabadi MM. Prevalence of ESBL genes among multidrug-resistant isolates of Pseudomonas aeruginosa isolated from patients in Tehran. Microb Drug Resist 2009;15:37e39. 9. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twentieth informational supplement. CLSI M100-S25. Wayne, PA: Clinical and Laboratory Standards Institute; 2015.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

ObjectivenTo evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.nnnDesignnThis prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.nnnSettingnWe conducted this study over a period of 16 months at a tertiary care referral medical center.nnnParticipantsnAll patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.nnnIntervention and main outcome measuresnPatient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.nnnResultsnThere were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.nnnConclusionsnOur results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses chart for site inspection and alerts in all shifts are some measures planned at our center.

Invasive candidiasis in non neutropenic critically ill - need for region-specific management guidelines

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

External validation of risk prediction scores for invasive candidiasis in a medical/surgical intensive care unit: An observational study

Background: The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. Methods: We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostroskys clinical prediction rule (CPR). Patients characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Results: Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%–47%, along with negative predictive values (NPVs) in the range of 84%–96% in the subgroup analysis. Conclusion: Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.

Comparison between sustained low-efficiencydialysis (SLED) and continuous renal replacement therapy (CRRT) in patients of septic shock: a randomized controlled trial.

Acute Kidney Injury is common in patients of septic shock. There is sparse data comparing SLED and CRRT in septic shock patients.