Ekaterina V. Kourbatova

Emergence of Community-Acquired Methicillin-Resistant Staphylococcus aureus USA 300 Clone as the Predominant Cause of Skin and Soft-Tissue Infections

Context In community outbreaks of methicillin-resistant Staphylococcus aureus (MRSA), 2 clones predominate in the United States: USA 300 and USA 400. Little is known about these infections in the nonoutbreak setting. Contribution This study evaluated nonoutbreak community-acquired S. aureus skin and soft-tissue infections in patients in a large urban setting. Almost three quarters of the soft-tissue infections were caused by MRSA, and these were predominantly the USA 300 type. No MRSA USA 300 isolate was resistant to trimethoprimsulfamethoxazole or vancomycin, while most were resistant to erythromycin in addition to -lactams. Implications Antibiotic choice for serious nonoutbreak community-acquired skin and soft-tissue infection should consider high rates of MRSA in some communities. The Editors Methicillin-resistant Staphylococcus aureus (MRSA) infections have usually been associated with exposure to health care settings, but they have recently been recognized in persons without traditional risk factors. These infections have been called community-acquired or community-associated MRSA (1). Most cases have been associated with skin and soft-tissue infection and have been reported among selected populations, including correctional facility inmates, homosexual men, and sports teams (2-5). Molecular typing studies in the United States and Australia have demonstrated that most community-acquired MRSA infections are caused by one of several clones or pulsed-field types (6, 7). In the United States, 2 clones, designated as USA 300 and USA 400 by the Centers for Disease Control and Prevention (CDC), have been identified as the primary types that cause community-acquired MRSA infections (6). The outbreaks of MRSA skin and soft-tissue infections observed in correctional facilities and among athletes have been associated with the USA 300 pulsed-field type, while outbreaks associated with severe and fatal disease in children, as well as skin and soft-tissue infections in Native American populations, have been associated with the USA 400 pulsed-field type (6). The community-acquired MRSA clones have frequently been associated with the PantonValentine leukocidin virulence factor and the presence of staphylococcal chromosome cassette mec (SCCmec) type IV allele (1, 6-9). In contrast, hospital-acquired or health careassociated MRSA strains usually lack genes for PantonValentine leukocidin and are associated with other SCCmec alleles (for example, SCCmec type II) (1, 6, 7). In addition to PantonValentine leukocidin and SCCmec type IV, the community-acquired MRSA USA 300 and USA 400 genotypes have usually demonstrated resistance to -lactams and erythromycin while retaining susceptibility to clindamycin, trimethoprimsulfamethoxazole, and fluoroquinolones, whereas health careassociated genotypes are often multidrug-resistant (1, 6). Although increasingly reported as a cause of outbreaks of skin and soft-tissue infection, the proportion of S. aureus skin and soft-tissue infections caused by community-acquired MRSA in nonoutbreak settings remains poorly defined. We sought to determine the proportion of infections caused by community-acquired MRSA, the clinical characteristics associated with community-acquired MRSA, and the molecular epidemiology of community-acquired MRSA among persons with community-onset S. aureus skin and soft-tissue infection who were receiving care at a large hospital and its affiliated clinics in urban Atlanta, Georgia. Methods Laboratory Surveillance for Community-Onset S. aureus Skin and Soft-Tissue Infection We conducted active, prospective laboratory surveillance from 1 August 2003 to 15 November 2003 to identify S. aureus isolates of patients with skin and soft-tissue infections at the Grady Health System. The Grady Health System includes Grady Memorial Hospital, a 1000-bed public inner-city hospital, and its affiliated outpatient clinics. We limited surveillance to S. aureus isolates that were obtained from patients with a community-onset skin and soft-tissue infection (isolates designated either as an exudate or a body fluid culture). We defined community-onset S. aureus by positive test results from cultures that were obtained within 72 hours of admission or at an outpatient visit. An investigator classified community-onset S. aureus before we performed molecular typing studies or before we reviewed antimicrobial susceptibility results other than methicillin susceptibility. We identified S. aureus and tested antimicrobial susceptibility for all isolates in the Grady Memorial Hospital Clinical Microbiology Laboratory in accordance with the National Committee for Clinical Laboratory Standards (10). Study Sample and Data Collection The Emory University Institutional Review Board and the Grady Research Oversight Committee approved the study. Grady Memorial Hospital provides medical care for a primarily medically indigent inner-city population, approximately 80% of whom are African American, residing within inner-city Atlanta (Fulton County and DeKalb County). The hospital serves as a teaching hospital for both Emory University School of Medicine and Morehouse School of Medicine. The referral pattern for the hospital and its affiliated clinics is primarily patient self-referral on the basis of place of residence (that is, residence within DeKalb or Fulton Counties) or indigent status, with some patients referred for tertiary academic medical care. We retrospectively reviewed computerized medical and laboratory records to document patient demographic characteristics, HIV status, presence of end-stage renal disease, hospitalization within the previous 12 months, and any history of MRSA infection or colonization. The reviewer completed the abstraction process blinded to the molecular typing results of MRSA isolates. We documented the need for hospitalization for managing the S. aureus skin and soft-tissue infection. We obtained S. aureus antimicrobial susceptibility profiles from the hospitals microbiology laboratory, and we categorized infections as due to either methicillin-susceptible S. aureus (MSSA) or MRSA. We reviewed computerized pharmacy records to document the antimicrobial agent therapy that was used to treat the patients skin and soft-tissue infection. We considered antimicrobial agent therapy to be adequate if the prescribed antimicrobial agent had in vitro activity against the isolated S. aureus strain. Molecular Typing and Genetic Analyses We performed pulsed-field gel electrophoresis (PFGE) using SmaI as a restriction endonuclease on all available MRSA isolates, as described by Bannerman and colleagues (11). We digitized gels and saved them as an image for analysis with BioNumerics software (Applied Maths, Sint-Martens-Latem, Belgium). We performed cluster analysis by using the unweighted pair-group method based on Dice coefficients. We defined pulsed-field type clusters by using a similarity coefficient of at least 80% and the criteria of Tenover and colleagues (12). By using the nomenclature outlined by McDougal and colleagues (6), we categorized MRSA isolates into 1 of 8 lineages: USA 100 through USA 800. For some isolates, we determined SCCmec type by using polymerase chain reaction (PCR)typing of the mec gene complex as described by Okuma and colleagues (7). Similarly, we assessed the presence of PantonValentine leukocidin genes in selected MRSA isolates by using PCR as previously described by Lina and colleagues (13). Classification of Community-Onset S. aureus Skin and Soft-Tissue Infections We classified community-onset S. aureus skin and soft-tissue infections into 3 groups on the basis of either molecular typing results (pulsed-field type) of MRSA isolates or antimicrobial susceptibility pattern in cases in which the MRSA isolate was not available for PFGE. The 3 groups were 1) the community-acquired MRSA USA 300/USA 400 group, 2) the other MRSA group, and 3) the MSSA group. The community-acquired MRSA USA 300/USA 400 group was defined by MRSA skin and soft-tissue infections caused by a MRSA isolate that either demonstrated a USA 300 or USA 400 pulsed-field type (6) or had an antimicrobial susceptibility profile demonstrating resistance only to -lactams and erythromycin while retaining susceptibility to clindamycin, levofloxacin, trimethoprimsulfamethoxazole, and vancomycin. The other MRSA group was defined by MRSA skin and soft-tissue infections caused by a MRSA isolate that either demonstrated a pulsed-field type other than USA 300 or USA 400 (for example, USA 100, USA 500, or USA 800 [which have all been described as health careassociated pulsed-field types]) or had an antimicrobial susceptibility profile demonstrating resistance to -lactams, erythromycin, and at least 1 additional antibiotic. We defined the MSSA group by skin and soft-tissue infections caused by MSSA. Statistical Analysis We performed data management and statistical analyses by using Microsoft Excel 2000 software (Microsoft Corp., Redmond, Washington) and SAS software, version 8.2 (SAS Institute, Cary, North Carolina). We assessed risk factors for community-acquired MRSA skin and soft-tissue infection in 2 separate analyses. Our first analysis compared the community-acquired MRSA USA 300/USA 400 group with the MSSA group, and our second analysis compared the community-acquired MRSA USA 300/USA 400 group with the other MRSA group. In addition, we repeated each analysis using data that were limited to those skin and soft-tissue infections in which a MRSA isolate was available for PFGE to account for any potential misclassification bias introduced when skin and soft-tissue infections were classified according to antimicrobial susceptibility profile. We initially identified potential risk factors for community-acquired MRSA skin and soft-tissue infection by univariate analysis. We calculated prevalence ratios and the corresponding 95% CIs. Multivariable log-binomial regression models included variables that were

Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureus USA300 Genotype as a Major Cause of Health Care—Associated Blood Stream Infections

BACKGROUND Whether community-associated methicillin-resistant Staphylococcus aureus (MRSA) genotypes (e.g., USA300) are a major cause of bloodstream infections (BSIs) and health care-associated infections has been poorly defined. METHODS Consecutive MRSA isolates recovered from patients with BSIs were prospectively collected at an urban public hospital. Molecular typing studies were performed. Prevalence and risk factors for the MRSA USA300 genotype were assessed. RESULTS One hundred thirty-two cases of MRSA BSI were documented over 7.5 months in 2004 (incidence, 6.79 per 1000 admissions); 116 isolates were available for genotyping. Characteristics of the 116 evaluable cases included: a mean age 47 years; 62% were male, 82% were African American, and 22% were HIV seropositive. The crude in-hospital mortality rate was 22%. In 107 cases (92%), there was contact with a health care facility within the year prior to infection, and a nosocomial infection (defined as positive blood culture results obtained >48 h after admission) occurred in 49 cases (42%). PFGE demonstrated that 39 (34%) of the 116 isolates were the MRSA USA300 genotype; 34 (29%) were USA100; 42 (36%) were USA500; and 1 (1%) was USA800. MRSA USA300 accounted for 28% of health care-associated BSIs and 20% of nosocomial MRSA BSIs. In multivariate analysis, isolation of the USA300 genotype was associated with injectiondrug use (OR, 3.67; 95% CI, 1.10-12.28) and skin and soft tissue infection (OR, 4.26; 95% CI, 1.08-16.84). Patients who resided in long-term care facilities (OR, 0.09; 95% CI, 0.01-0.82) and those who were treated with antimicrobials in the prior year were less likely to have MRSA USA300 genotype recovered (OR, 0.10; 95% CI, 0.02-0.49). CONCLUSIONS MRSA USA300 genotype, the predominant cause of community-associated MRSA infections in our area (Atlanta, GA), has now emerged as a significant cause of health care-associated and nosocomial BSI. MRSA USA300 as a nosocomial pathogen presents new challenges to infection control programs.

Risk Factors for Colonization with Methicillin-Resistant Staphylococcus aureus (MRSA) in Patients Admitted to an Urban Hospital: Emergence of Community-Associated MRSA Nasal Carriage

BACKGROUND Surveillance cultures performed at hospital admission have been recommended to identify patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) but require substantial resources. We determined the prevalence of and risk factors for MRSA colonization at the time of hospital admission among patients cared for at a public urban hospital. METHODS Anterior nares cultures were obtained within 48 h after admission during a 1-month period. A case-control study and molecular typing studies were performed. RESULTS A total of 53 (7.3%) of 726 patients had a nares culture positive for MRSA, and 119 (16.4%) had a nares culture that was positive for methicillin-susceptible S. aureus. In multivariate analysis, risk factors for MRSA colonization included antibiotic use within 3 months before admission (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.2-5.0), hospitalization during the past 12 months (OR, 4.0; 95% CI, 2.0-8.2), diagnosis of skin or soft-tissue infection at admission (OR, 3.4; 95% CI, 1.5-7.9), and HIV infection. A total of 47 (89%) of 53 case patients colonized with MRSA had at least 1 of these independent risk factors, in contrast to 343 (51%) of 673 control patients (OR, 7.5; 95% CI, 3.2 -17.9). Molecular typing demonstrated that 16 (30%) of 53 MRSA nares isolates (2.2% of the 726 isolates) belonged to the USA300 community-associated MRSA (CA-MRSA) genotype. CONCLUSION The prevalence of MRSA colonization at the time of patient admission was high (>7%). Limiting surveillance cultures to patients with >or=1 of the identified risk factors may allow for targeted screening. The emergence of CA-MRSA colonization represents a new, unrecognized reservoir of MRSA within hospitals, potentially increasing the risk for horizontal transmission.

Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial.

BACKGROUND Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited. OBJECTIVE To determine the impact of an AUT on antimicrobial use at a teaching hospital. DESIGN Randomized controlled intervention trial. SETTING A 953-bed, public, university-affiliated, urban teaching hospital. PATIENTS Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams. INTERVENTION Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period. MEASUREMENTS Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage. RESULTS A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantly more likely to prescribe end antimicrobial usage appropriately, compared with control teams. CONCLUSIONS A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use. Trial registration. ClinicalTrials.gov identifier: NCT00552838.

Etiology of Neonatal Blood Stream Infections in Tbilisi, Republic of Georgia

BACKGROUND Neonatal blood stream infections (BSI) are a major cause of morbidity and mortality in developing countries. It is crucial to continuously monitor the local epidemiology of neonatal BSI to detect any changes in patterns of infection and susceptibility to various antibiotics. OBJECTIVES To examine the etiology of BSI in two neonatal intensive care units (NICUs) in the Republic of Georgia, a resource-poor country, and to determine antibiotic susceptibility of the isolated organisms. METHODS A cross-sectional study of all septic infants was conducted in the NICUs of two pediatric hospitals in Tbilisi between September 2003 and September 2004. RESULTS A total of 200 infants with clinical signs of sepsis were admitted to two NICUs. Of these, 126 (63%) had confirmed bacteremia. The mortality rate was 34%. A total of 98 (78%) of 126 recovered isolates were Gram-negative organisms and 28 (22%) were Gram-positive. Klebsiella pneumoniae was the most common pathogen, accounting for 36 (29%) of 126 isolates, followed by Enterobacter cloacae accounting for 19 (15%) and Staphylococcus aureus accounting for 15 (12%). The Gram-negative organisms showed a high degree of resistance to commonly used antibiotics such as ampicillin and amoxicillin/clavulanate, and comparatively low resistance to amikacin, ciprofloxacin, carbapenems, and gentamicin; 40% of S. aureus isolates were methicillin-resistant (MRSA). In multivariate analysis only umbilical discharge was a significant risk factor for having a positive blood culture at admission to NICU (prevalence ratio = 2.25, 95% confidence interval 1.82-2.77). CONCLUSIONS Neonatal BSI was mainly caused by Gram-negative organisms, which are developing resistance to commonly used antibiotics. Understanding the local epidemiology of neonatal BSI can lead to the development of better medical practices, especially more appropriate choices for empiric antibiotic therapy, and may contribute to improvement of infection control practices.

High Prevalence of Multidrug-Resistant Tuberculosis in Georgia

BACKGROUND Tuberculosis (TB) has emerged as a serious public health problem in the country of Georgia. However, little or no data exist on rates and risk factors for drug-resistant TB, including multidrug-resistant (MDR)-TB, in Georgia. OBJECTIVE To assess the prevalence and risk factors for drug-resistant TB. METHODS A cross-sectional prospective survey of patients with suspected pulmonary TB was carried out at four sentinel sites (Tbilisi, Zugdidi, Kutaisi, and Batumi) in Georgia between January 1, 2001 and December 31, 2004. RESULTS Among 1422 patients with suspected pulmonary TB, 996 (70.0%) were culture positive; 931/996 (93.5%) had drug susceptibility testing performed. Overall, 64.0% of patients (48.3% of new and 85.3% of retreatment cases) had positive cultures for Mycobacterium tuberculosis resistant to >or=1 first-line antituberculosis drugs. The overall prevalence of MDR-TB was 28.1% (10.5% of newly diagnosed patients and 53.1% of retreatment cases). In multivariate analysis, risk factors for MDR-TB included: being a retreatment case (prevalence ratio (PR)=5.28, 95% CI 3.95-7.07), history of injection drug use (PR=1.59, 95% CI 1.21-2.09), and female gender (PR=1.36, 95% CI 1.12-1.65). CONCLUSIONS MDR-TB has emerged as a serious public health problem in Georgia and will greatly impact TB control strategies.

Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus (MRSA) among Patients Admitted to Adult Intensive Care Units: The STAR * ICU Trial

BACKGROUND The multicenter, cluster-randomized Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial was performed in 18 U.S. adult intensive care units (ICUs). It evaluated the effectiveness of infection control strategies to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA) colonization and/or infection. Our study objective was to examine the molecular epidemiology of MRSA and assess the prevalence and risk factors for community acquired (CA)-MRSA genotype nasal carriage at the time of ICU admission. METHODS Selected MRSA isolates were subjected to molecular typing using pulsed-field gel electrophoresis. RESULTS Of 5,512 ICU patient admissions in the STAR*ICU trial during the intervention period, 626 (11%) had a nares sample culture result that was positive for MRSA. A total of 210 (34%) of 626 available isolates were selected for molecular typing by weighted random sampling. Of 210 patients, 123 (59%) were male; mean age was 63 years. Molecular typing revealed that 147 isolates (70%) were the USA100 clone, 26 (12%) were USA300, 12 (6%) were USA500, 8 (4%) were USA800, and 17 (8%) were other MRSA genotypes. In a multivariate analysis, patients who were colonized with a CA-MRSA genotype (USA300, USA400, or USA1000) were less likely to have been hospitalized during the previous 12 months (PR [prevalence ratio], 0.39 [95% confidence interval (CI), 0.21-0.73]) and were less likely to be older (PR, 0.97 [95% CI, 0.95-0.98] per year) compared with patients who were colonized with a healthcare-associated (HA)-MRSA genotype. CONCLUSION CA-MRSA genotypes have emerged as a cause of MRSA nares colonization among patients admitted to adult ICUs in the United States. During the study period (2006), the predominant site of CA-MRSA genotype acquisition appeared to be in the community.

Treatment interruptions and duration associated with default among new patients with tuberculosis in six regions of Russia

OBJECTIVE To determine the frequency and length of treatment interruptions among new pulmonary tuberculosis (TB) patients and to evaluate the duration of interruption associated with default in the tuberculosis services of six Russian regions. METHODS This was a retrospective study of all adult patients with new pulmonary TB enrolled for treatment from April 1 to September 30, 2003. Data from patients with treatment outcomes of default (n=84), failure (n=130), death (n=113), and success (n=1444) were analyzed. RESULTS The default rate was 4.6%. Treatment interruptions were frequent: 63% of patients who defaulted and 36% of those successfully treated had interruptions of treatment during the intensive phase, and 30% of those who defaulted and 45% of those with a successful outcome had interrupted treatment during the continuation phase. The length of treatment interruptions was 1-125 days during the intensive phase and 1-127 days during the continuation phase among patients with outcomes other than default. Patients with treatment gaps of 2-8 weeks during the intensive phase included 15.5% of defaulters, 13.9% of those with an outcome of failure, and 4.4% of those with treatment success. The integrated probability of default was >or=50% in those patients who missed at least 2-3 consecutive days of treatment during the intensive phase and at least one day during the continuation phase. CONCLUSION Treatment interruptions were frequent in TB patients in the six Russian regions. Interventions to improve treatment adherence in patients are necessary. Social support and incentive programs should be universally available for all patients from the start of the continuation phase of treatment, during the intensive phase for patients considered to be at risk for default, and for those patients who have missed at least 2-3 days of treatment during the intensive phase. Directly observed therapy (DOT) at home could be a recommendation for some patients.

Brief Report: Risk Factors for Pneumococcal Vaccine Refusal in Adults

AbstractBACKGROUND: Invasive pneumococcal disease is a significant cause of morbidity and mortality in the United States. Despite availability of an effective vaccine, many patients refuse vaccination. OBJECTIVE: To investigate patient characteristics and features of the patient-provider relationship associated with pneumococcal vaccine refusal. DESIGN: Case-control study using chart review. PATIENTS: Five hundred adults from the medical clinics of a 1,000-bed inner-city teaching hospital. MEASUREMENTS AND MAIN RESULTS: Independent risk factors for pneumococcal vaccine refusal included patient-provider gender discordance (odds ratio (OR)=2.09, 95% confidence interval (CI) 1.07 to 4.09); a visit to a not-usual provider at the time of vaccine offering (OR=2.26, 95% CI 1.13 to 4.49); never having received influenza vacination (OR=7.44, 95% CI 3.76 to 14.76); prior pneumococcal vaccine refusals (OR=3.45, 95% CI 1.60 to 7.43); and a history of ever having refused health maintenance tests (OR=2.86, 95% CI 1.40 to 5.84). CONCLUSIONS: We have identified both patient factors and factors related to the patient-provider relationship that are risk factors for pneumococcal vaccine refusal. By identifying patients at risk for pneumococcal vaccine refusal, efforts to increase vaccination rates can be better targeted.

Hospital acquired blood-stream infections among intensive care unit (ICU) Patients in Tbilisi, Georgia

Since gaining independence in 1991, the ex-Soviet republic of Georgia has suffered severe socio-economic deterioration and civil unrest that has significantly affected the healthcare system [1–3]. For example, blood cultures are rarely used in the standardized care of febrile patients due to: lack of inhospital laboratory facilities, expense of specimen processing, and in the current reimbursement system, cultures are considered non-essential for patient care. Instead, with a lack of microbial susceptibility data, patients are treated empirically with broad spectrum antibiotics. Infection control practices are also underdeveloped and contribute to the risk of antibiotic resistance. The purpose of this study was to determine the microbial spectrum of blood stream infections (BSI) among febrile patients admitted to the intensive care unit (ICU) and the emergency room (ER) at a major, general hospital in Tbilisi. In August 2007, febrile patients admitted to the ICU and the ER of this referral hospital, underwent blood culture testing. Isolates from blood cultures were identified using Analytical Profile Index identification testing, and antibiotic susceptibilities were performed using both ATB testing and disk diffusion methods. A total of 19 febrile patients (14 ICU patients and 5 ER patients) had blood cultures performed. Study patients aged from 20 to 79 (mean 46.5 years); 14 (74%) of 19 patients were male. All patients had recorded temperature C38.0 C. All patients, including those treated in the ER, had received antibiotics prior to the collection of blood culture samples. Trauma was the most common reason for admission to the ICU (9 of 14, 64%) with average pre-culture length of stay of 9 days, and in patients with positive isolates, 14 days. All the ICU patients had a history of central venous catheters. Cultures from all 5 ER patients were sterile. Cultures from 4 of 14 (29%) ICU patients were positive. Two separate bacteria (coagulase negative Staphylococcus [CNS] and Aeromonas hydrophila) were isolated in the same culture from one patient; the CNS was considered to be a contaminant. Isolates from 3 other patients were gram-negative bacteria: Burkholderia cepacia, Klebsiella pneumonia, and Pseudomonas aeruginosa. Both Aeromonas and Pseudomonas isolates were resistant to all antibiotics tested. The Pseudomonas demonstrated intermediate sensitivity to carbapenems alone. The Burkholderia isolate was susceptible to ciprofloxacin, carbapenems, and most aminoglycosides and intermediate to several penicillins. The Klebsiella isolate was susceptible to carbapenems, piperacillin/tazobactam, and ticarcillin/clavulanic acid but resistant to all additional antibiotics. The lack of culture driven antimicrobial therapy and few infection control practices is largely responsible for the resistant gram negative BSI in this study. There is a paucity of data in the medical literature on hospital acquired infections in the former Soviet states. A recent observational study of postoperative infection rates revealed that 17% of operations in Georgia were complicated by infections [4]. Next steps to further evaluate the scope of this problem include more surveillance of hospital acquired infections, C. E. Low (&) K. Walker Department of Internal Medicine, Emory University School of Medicine, Atlanta, USA e-mail: celow@emory.edu