P. Pecile

Zygomycosis in Italy: a Survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

Abstract The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in italy during the european Confederation of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin b (L- AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Molecular epidemiological investigation of an outbreak of Pseudomonas aeruginosa infection in an SCT unit

From May to October 2006, six severe Pseudomonas aeruginosa infections were diagnosed in patients undergoing SCT in the SCT unit of the Careggi hospital (Florence, Italy). Four of the infected patients were treated consecutively in the same room (room N). On the hypothesis of a possible environmental source of infection, samples were collected from different sites that had potential for cross-contamination throughout the SCT unit, including the electrolytic chloroxidant disinfectant used for hand washing (Irgasan) and the disinfectant used for facilities cleaning. Four of the environmental samples were positive for P. aeruginosa: three Irgansan soap samples and a tap swab sample from the staff cleaning and dressing room. The AFLP (amplified fragment length polymorphism) typing method employed to evaluate strain clonality showed that the isolates from the patients who had shared the same room and an isolate from Irgasan soap had a significant molecular similarity (dice index higher than 0.93). After adequate control measures, no subsequent environmental sample proved positive for P. aeruginosa. These data strongly support the hypothesis of the clonal origin of the infective strains and suggest an environmental source of infection. The AFLP method was fast enough to allow a ‘real-time’ monitoring of the outbreak, permitting additional preventive measures.

Antifungal susceptibility of invasive yeast isolates in Italy: the GISIA3 study in critically ill patients

BackgroundYeasts are a common cause of invasive fungal infections in critically ill patients. Antifungal susceptibility testing results of clinically significant fungal strains are of interest to physicians, enabling them to adopt appropriate strategies for empiric and prophylactic therapies. We investigated the antifungal susceptibility of yeasts isolated over a 2-year period from hospitalised patients with invasive yeast infections.Methods638 yeasts were isolated from the blood, central venous catheters and sterile fluids of 578 patients on general and surgical intensive care units and surgical wards. Etest strips and Sensititre panels were used to test the susceptibility of the isolates to amphotericin B, anidulafungin, caspofungin, fluconazole, itraconazole, posaconazole and voriconazole in 13 laboratories centres (LC) and two co-ordinating centres (CC). The Clinical and Laboratory Standards Institute (CLSI) reference broth microdilution method was used at the CCs for comparison.ResultsEtest and Sensititre (LC/CC) MIC90 values were, respectively: amphotericin B 0.5/0.38, 1/1 mg/L; anidulafungin 2/1.5 and 1/1 mg/L; caspofungin 1/0.75 and 0.5/0.5 mg/L; fluconazole 12/8 and 16/16 mg/L; itraconazole 1/1.5, 0.5/0.5 mg/L; posaconazole 0.5 mg/L and voriconazole 0.25 mg/L for all. The overall MIC90 values were influenced by the reduced susceptibility of Candida parapsilosis isolates to echinocandins and a reduced or lack of susceptibility of Candida glabrata and Candida krusei to azoles, in particular fluconazole and itraconazole. Comparison of the LC and CC results showed good Essential Agreement (90.3% for Etest and 92.9% for Sensititre), and even higher Categorical Agreement (93.9% for Etest and 96% for Sensititre); differences were observed according to the species, method, and antifungal drug. No cross-resistance between echinocandins and triazoles was detected.ConclusionsOur data confirm the different antifungal susceptibility patterns among species, and highlight the need to perform antifungal susceptibility testing of clinically relevant yeasts. With the exception of a few species (e.g. C. glabrata for azoles and C. parapsilosis for echinocandins), the findings of our study suggest that two of the most widely used commercial methods (Etest and Sensititre) provide valid and reproducible results.

Molecular analysis of population structure and antibiotic resistance of Klebsiella isolates from a three-year surveillance program in Florence hospitals, Italy

We report the results of a three-year surveillance program of Klebsiella spp. in six hospitals in Florence (Italy). A total of 172 Klebsiella isolates were identified and typed by AFLP: 122 were K. pneumoniae and 50 were K. oxytoca. Most K. pneumoniae (80%) and K. oxytoca (93%) showed unrelated AFLP profiles. Beside this heterogeneous population structure, we found five small epidemic clonal groups of K. pneumoniae. Four of these groups were involved in outbreak events, three of which occurred in neonatal ICUs. The fifth clonal group spread in three different wards of two hospitals. Only one non-epidemic clonal group of K. oxytoca was detected. The frequencies of isolates with multiple antibiotic resistances increased with time; at the end of the study period, most K. pneumoniae were resistant to all the antibiotics tested. A PCR analysis of seven ertapenem resistant isolates was unable to detect any of the major genes known to underlie carbapenem resistance in K. pneumoniae.

Management of Fever in Neutropenic Patients with Acute Leukemia: Current Role of Ceftazidime Plus Amikacin as Empiric Therapy

Abstract To evaluate the current role of ceftazidime plus amikacin as empiric therapy in the management of fever in neutropenic patients with acute leukemia, we examined 172 febrile episodes in 106 patients enrolled during 1996-98. The overall success rate (survival of neutropenia, both with and without protocol modification) was 90%: 39% without modification and 51% with modification. We documented a significant difference in documented infections (DI) and fever of undetermined origin (FUO): success without modification was lower in DI and higher in FUO. Failure (death due to documented or presumed infection) was recorded in 10% of all episodes. Episodes with severe neutropenia were treated in 48% of cases without modification and in 41% with modification. No significant difference was observed in the status of underlying disease. 33% of Gram-negative bacteria responsible for bloodstream infections were resistant to ceftazidime, of which 21% were multiresistant strains. We conclude that initial chemotherapy with ceftazidime plus amikacin remains a reasonable option for treating febrile and prolonged neutropenia, although patients with DI are likely to require additional or modified treatment. The emergence of resistant strains is an increasingly important issue.

Predominance of the fimH30 Subclone Among Multidrug-Resistant Escherichia coli Strains Belonging to Sequence Type 131 in Italy

TO THE EDITOR—We read with interest the article by Johnson et al, which demonstrates that, in extraintestinal pathogenic Escherichia coli (ExPEC), fluoroquinolone (FQ) resistance is currently associated with the rapid expansion of a single dominant multidrug-resistant (MDR) strain that emerged within sequence type (ST) 131 [1]. Although the strong predominance of the ST131 clone has been well described in the literature since 2008 [2– 5], the peculiarity of Johnson et al’s study was to analyze historical and recent ST131 isolates at the sub-ST level, revealing that a specific fimH-based subclone (H30) is currently responsible for most FQ-resistant ExPEC infections, at least in the United States. This H30 subclone was demonstrated to possess a unique and conserved gyrA/parC allele combination conferring FQ resistance, and the authors rightly commented on these data in support of its strict clonality. We are particularly interested in this issue, since ST131 is also currently predominant among MDR ExPEC in Italy and because some ST131 strains we previously analyzed were found to carry the same pattern of gyrA/parC substitutions described by Johnson et al [1, 6]. No information is available on the fimH-based subclones circulating in European countries. In this study, 172 ExPEC strains isolated from cases of urinary tract infections and sepsis in Italy during April 2012– December 2012 were analyzed. Staff a the 3 enrolled hospitals were asked to collect all consecutive MDR E. coli strains and 1 ciprofloxacin-susceptible non-MDR E. coli strain for every 3 MDR strains collected. “MDR” was defined as resistance to at least 3 antimicrobial agents of different classes (ampicillin, third-generation cephalosporins, ciprofloxacin, gentamicin, and trimethoprim/sulfamethoxazole). Of 172 strains, 119 were MDR strains that were resistant to ciprofloxacin; 9 were MDR strains that were susceptible to ciprofloxacin; and 44 were non-MDR strains that were susceptible to ciprofloxacin. Antimicrobial susceptibility testing, phylogenetic typing, polymerase chain reaction screening for ST131 followed by confirmation (by mdh and gyrB gene sequencing), characterization of the extended-spectrum β-lactamase (ESBL) and/or AmpC genes, and fimH-based subtyping of the ST131 strains were performed as previously described [1, 7–9]. To investigate which fimH allele circulated in Italy before 2012, an additional 91 E. coli ST131 strains previously identified were also subtyped [7, 10]. Of these 91 strains, 28 (24 ciprofloxacinresistant strains and 4 ciprofloxacinsusceptible strains) were isolated in 2006, and 63 (58 ciprofloxacin-resistant strains and 4 ciprofloxacin-susceptible strains) were isolated in 2009. By phylogenetic typing, overall, the majority of strains isolated in 2012 (110/ 172 [64%]) fell into phylogenetic group B2, followed by groups D (30/172 [17.4%]),

Isolation Frequency and Antimicrobial Susceptibility of Pseudomonas aeruginosa Bloodstream Infections in Neutropenic Patients with Acute Leukemia

Nosocomial infections continue to be a major threat to neutropenic patients. Although in the past two decades most centers have reported a relative increase in the number of bacteremias caused by Gram-positive microorganisms and fungi,1,2 infections caused by Gram-negative bacilli (GNB), particularly by Pseudomonas aeruginosa, are still responsible for high morbidity and mortality rates in cancer patients, mainly in acute leukemic patients 3,4,5. Moreover, extensive use of empiric combination antibiotic therapy often exerts a selection pressure and consequently many nosocomial pathogens have acquired multidrug resistance 6,7. In order to assess the current impact of P. aeruginosa infections in febrile patients with acute leukemia and antimicrobial suceptibility of blood isolates, a survey was undertaken at our hematology-oncology unit from June 1995 to June 1998. All patients presenting fever (axillary temperature >38°C) during neutropenia (absolute neutrophil count <1000/mL) were treated empirically with a betalactam agent (mainly Journal of Chemotherapy Vol. 13 n. 2 (213-215) 2001

Treatment of Stomatococcus mucilaginosus Bloodstream Infection in Two Acute Leukemia Patients, First Reported at Our Cancer Center

Stomatococcus mucilaginosus, formerly cal led Micrococcus mucilaginosus or Staphylococcus salivarius, is a Gram–positive, encapsulated, non spore-forming coccus. This commensal organism is considered part of the normal flora of the mouth and upper respiratory tract of humans 1. Recently, S. mucilaginosus was recognized in patients with septicemia, endocarditis, indwelling vascular catheters and most often in patients with multidrug intravenous therapy, indwelling vascular catheters or in immunocompromised patients 2,3. This is the first report of two cases of S. mucilagonosus bloodstream infection occurring in 1999 at our hematology-oncology center. Blood specimens were inoculated into Bactec Plus Aerobic/F and Bactec Anaerobic/F vials (Becton-Dickinson) for microbiological investigations. Biochemical testing was done using ATB 32 Staph (API System Biomerieux) and BBL Crystal GP (Becton-Dickinson). The disc diffusion test employing sheep blood agar was used for susceptibility testing. Journal of Chemotherapy Vol. 12 n. 6 (536-537) 2000

Aztreonam versus Colistin-Neomycin for Selective Decontamination of the Digestive Tract in Patients Undergoing Bone Marrow Transplantation: a Randomized Study

Aztreonam (Az), a minimally absorbable monobactam antibiotic, was compared to colistin plus neomycin (CN), for intestinal decontamination during Bone Marrow Transplantation (BMT) in a controlled study. Thirty-four consecutive patients were randomized in two groups and evaluated for number of febrile episodes, days of fever, fecal cultures and clinical symptoms related to infections or colonizations. No significant differences were observed suggesting that Az is at least as effective as the CN regimen and may be considered as an alternative approach for intestinal decontamination in BMT patients.