Karen Roye-Green

Microbial isolates from patients in an intensive care unit, and associated risk factors

A retrospective one-year analysis of blood, sputum and urine samples taken from all patients admitted for more than 48 hours to the Intensive Care Unit at the University Hospital of the West Indies (UHWI) was undertaken. Positive trapped sputum cultures were found in 50% of patients, positive blood cultures in 32.7% and positive urine cultures in 23.1%. Gram-negative organisms predominated especially Pseudomonas aeruginosa (41.3%) and Acinetobacter spp (33.5%). Coagulase-negative staphylococcus (20%) and streptococcus group D (18.7%) were the most common gram-positive organisms. The Acinetobacter spp showed marked resistance to most antibiotics except for meropenem (82.7% susceptibility) while P. aeruginosa was most susceptible to ceftazidime (84.4%) and amikacin (89.1%). Both the coagulase-negative staphylococcus and streptococcus group D were relatively sensitive to amoxycillin/clavulanate (80.6% and 79.3% respectively). There was a high incidence of yeast found in sputum (27.1%) and urine (16.8%). Mechanical ventilation was a significant risk factor for developing a positive sputum culture (p = 0.01), this effect being particularly prominent in those ventilated for > 5 days. Central venous pressure lines significantly increased the risk of a positive blood culture (p = 0.005). This increase was seen particularly in those with CVP lines for > 7 days. Other risk factors for developing positive cultures included preadmission infection, antibiotic use just prior to ICU admission, increasing APACHE II score and increasing age.

Asymptomatic bacteriuria in sickle cell disease: a cross-sectional study

BackgroundIt is known that there is significant morbidity associated with urinary tract infection and with renal dysfunction in sickle cell disease (SCD). However, it is not known if there are potential adverse outcomes associated with asymptomatic bacteriuria (ASB) infections in sickle cell disease if left untreated. This study was undertaken to determine the prevalence of ASB, in a cohort of patients with SCD.MethodsThis is a cross-sectional study of patients in the Jamaican Sickle Cell Cohort. Aseptically collected mid-stream urine (MSU) samples were obtained from 266 patients for urinalysis, culture and sensitivity analysis. Proteinuria was measured by urine dipsticks. Individuals with abnormal urine culture results had repeat urine culture. Serum creatinine was measured and steady state haematology and uric acid concentrations were obtained from clinical records. This was completed at a primary care health clinic dedicated to sickle cell diseases in Kingston, Jamaica. There were 133 males and 133 females in the sample studied. The mean age (mean ± sd) of participants was 26.6 ± 2.5 years. The main outcome measures were the culture of ≥ 105 colony forming units of a urinary tract pathogen per milliliter of urine from a MSU specimen on a single occasion (probable ASB) or on consecutive occasions (confirmed ASB).ResultsOf the 266 urines collected, 234 were sterile and 29 had significant bacteriuria yielding a prevalence of probable ASB of 10.9% (29/266). Fourteen patients had confirmed ASB (prevalence 5.3%) of which 13 had pyuria. Controlling for genotype, females were 14.7 times more likely to have confirmed ASB compared to males (95%CI 1.8 to 121.0). The number of recorded visits for symptomatic UTI was increased by a factor of 2.5 (95% CI 1.4 to 4.5, p < 0.005) but serum creatinine, uric acid and haematology values were not different in patients with confirmed ASB compared with those with sterile urine. There was no association with history of gram negative sepsis.ConclusionASB is a significant problem in individuals with SCD and may be the source of pathogens in UTI. However, further research is needed to determine the clinical significance of ASB in SCD.

Molecular epidemiology of multidrug resistant extended spectrum beta-lactamase producing Klebsiella pneumoniae at a Jamaican hospital, 2000-2004.

BackgroundThe accurate identification of a pathogen beyond the species level is critical in epidemiological studies and investigations of nosocomial outbreaks of infection. The clonal relatedness of 66 multidrug resistant (MDR) strains of extended spectrum beta-lactamase (ESBL) producing K. pneumoniae isolated from clinical specimens from hospitalized patients at a Jamaican hospital during a 5 year period were determined by pulsed field gel electrophoresis (PFGE).ResultsA total 10 different ESBL producing K. pneumoniae genotypes designated Clones I-X were found. The most frequently occurring strains belonged to Clones I (21/66, 32%), II (15/66, 26%), III (13/66, 20%) and IV (8/66, 12%) which accounted for 86% (57/66) of ESBL producing K. pneumoniae strains over the 5 year period. The remaining 9 (14%) cases of ESBL producing K. pneumoniae were due to strains of Clones V-X. The 4 predominant clones persisted for several years in the hospital.ConclusionsThe clonal and temporal distribution of the MDR ESBL producing K. pneumoniae strains among clinical service areas did not suggest outbreaks of the organism during the period of study. Instead the molecular epidemiology of ESBL producing K. pneumoniae at this hospital was more representative of an endemic persistence of clones of the organism with limited dissemination from patient to patient. Further studies to investigate the factors which determine the emergence and persistence of MDR ESBL producing K. pneumoniae in Jamaican hospitals and their impact on clinical and economic outcomes at such institutions would be useful.

Staphylococcus aureus pneumonia and dengue virus co-infection and review of implications of coinfection.

Dengue fever is an important public health problem in Jamaica and has various serious manifestations, which if not identified and treated at the appropriate time can lead to dire consequences. Bacterial co-infections have been seen in clinical practice but may be thought of as simply coincidental. This review highlights the importance of bacteria in exacerbating dengue infections and the importance of looking for co-infection in patients with certain clinical manifestations. It also provides the reader with a scientific understanding of the immune pathogenesis of dengue and bacterial co-infections.

Antiphospholipid and other autoantibodies in a cohort of habitual aborters and healthy multiparous women in Jamaica.

Blood samples from 50 women who had had recurrent spontaneous abortions and 135 healthy multiparous women were investigated for anticardiolipin (aCL) antibodies and anti-β 2 Glycoprotein 1 (anti-β 2 GP1 ) dependent aCL antibodies by enzyme-linked immunosorbent assays (ELISA), lupus anticoagulant activity was measured by activated partial thromboplastin time, antinuclear antibodies, rheumatoid factors and thyroid antibodies using standard techniques. Serological tests for syphilis were performed on all sera and thyroid function was evaluated. There was no significant difference in the prevalence of autoantibodies in habitual aborters and control subjects (60% and 44%, respectively). Habitual aborters differed from controls only in the prevalence of positive aCL antibody tests (15/50, 30% vs. 15/135, 1 1%; χ 2 = 8.5, P = 0.01); medium/high concentrations of aCL antibodies (9/50, 18% vs. 9/135, 7%; χ 2 4.3, P = 0.05); aCL antibodies of the IgM isotype (8/50, 16% vs. 7/135, 5%; χ 2 = 4.5, P = 0.05) and anti-β 2― GPI antibodies (7/50, 14% vs. 3/135, 2%; χ 2 = 6.1, P = 0.05). We recommend aCL antibody screening in habitual aborters and the performance of the anti-β 2 GP1 antibody tests to identify those most at risk.

Abiotrophia defectiva endocarditis

A previously healthy 27-year-old Jamaican man presented to the University Hospital of the West Indies with recurrent joint pain, remitting and relapsing fever, and shortness of breath. He was subsequently found to have Abiotrophia defectiva endocarditis. This was the first time this organism had been isolated at our institution. Despite culture directed antibiotics, his clinical course was quite severe with mitral regurgitation and congestive cardiac failure requiring mitral valve replacement. He recovered well postoperatively and is currently being followed at our outpatient cardiology clinic. This report highlights the severe presentation and often poor outcome associated with A. defectiva endocarditis and stresses that the outcome may be improved by early and appropriate surgical intervention.

Autoimmune hepatitis in a Jamaican cohort spanning 40 years.

BACKGROUND The prevalence and characteristics of autoimmune hepatitis (AIH) in black populations are not well documented. OBJECTIVES To describe the clinical and laboratory features of AIH in patients presenting at a Jamaican hospital, 1969-2009. METHODS A retrospective review of hospital records was done and patients were classified by the revised international scoring system. RESULTS Fifty patients satisfied criteria for diagnosis of AIH type-1 and most presented late at hospital. Almost one third of cases presented with chronic liver disease (32%) while 8% presented with fulminant hepatic failure and 2% with acute liver disease. Jaundice (92%) was the most common presenting feature. Other associated autoimmune diseases (10%) systemic lupus erythematosus and insulin dependent diabetes mellitus, were found. All patients (100%) had abnormal liver biochemical tests, 81% had hypergammaglobulinaemia and 82% AIH associated autoantibodies. The prevalence of autoantibodies increased with age (P=0.05). Liver biopsy, performed in 33 cases, showed chronic hepatitis (45%), cirrhosis (24%) chronic hepatitis with bridging necrosis (15%), chronic hepatitis with rosetting (6%) and nonspecific findings (10%). Patients were treated with prednisone with or without azathioprine. Relapse occurred in 4% and death 6%. CONCLUSION Autoimmune hepatitis is rare in Jamaicans and prognosis is similar to that reported in developed countries.