Sofia Kokkini

Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study.

Background:Dexmedetomidine, a potent &agr;-2-adrenergic agonist, is widely used as sedative in critically ill patients. This pilot study was designed to assess the effect of dexmedetomidine administration on sleep quality in critically ill patients. Methods:Polysomnography was performed on hemodynamically stable critically ill patients for 57 consecutive hours, divided into three night-time (9:00 PM to 6:00 AM) and two daytime (6:00 AM to 9:00 PM) periods. On the second night, dexmedetomidine was given by a continuous infusion targeting a sedation level −1 to −2 on the Richmond Agitation Sedation Scale. Other sedatives were not permitted. Results:Thirteen patients were studied. Dexmedetomidine was given in a dose of 0.6 &mgr;g kg−1 h−1 (0.4 to 0.7) (median [interquartile range]). Compared to first and third nights (without dexmedetomidine), sleep efficiency was significantly higher during the second night (first: 9.7% [1.6 to 45.1], second: 64.8% [51.4 to 79.9], third: 6.9% [0.0 to 17.1], P < 0.002). Without dexmedetomidine, night-time sleep fragmentation index (7.6 events per hour [4.8 to 14.2]) and stage 1 of sleep (48.0% [30.1 to 66.4]) were significantly higher (P = 0.023 and P = 0.006, respectively), and stage 2 (47.0% [27.5 to 61.2]) showed values lower (P = 0.006) than the corresponding values (2.7 events per hour [1.6 to 4.9], 13.1% [6.2 to 23.6], 80.2% [68.9 to 92.8]) observed with dexmedetomidine. Without sedation, sleep was equally distributed between day and night, a pattern that was modified significantly (P = 0.032) by night-time dexmedetomidine infusion, with more than three quarters of sleep occurring during the night (79% [66 to 87]). Conclusion:In highly selected critically ill patients, dexmedetomidine infusion during the night to achieve light sedation improves sleep by increasing sleep efficiency and stage 2 and modifies the 24-h sleep pattern by shifting sleep mainly to the night.

Prevalence of Anaplasma sp. in goats and sheep in Cyprus.

A seroprevalence study of Anaplasma infection was conducted in a stratified random sample of goats and sheep in Cyprus in which the sample locations were recorded using a geographical information system (GIS). The aim of the study was to estimate the prevalence of Anaplasma phagocytophilum and other Anaplasma species in sheep and goats, and to identify high-risk regions. A total of 689 serum samples (343 from sheep and 346 from goats) were randomly collected and tested for the detection of antibodies against A. phagocytophilum antigen using an indirect immunofluorescent assay. The polymerase chain reaction followed by sequencing analysis was used for the detection and molecular characterization of Anaplasma sp DNA in the blood samples. The prevalence of IgG antibodies against A. phagocytophilum antigen was 18% for goats, and 31% for sheep. Six new genotypes were detected in goats and sheep; by sequence analysis one was identified as A. phagocytophilum, one as Anaplasma platys and the remaining four as Anaplasma species. The results provide evidence for the presence of A. phagocytophilum and Anaplasma species in sheep and goats in Cyprus.

Q fever: clinical manifestations and treatment

Public awareness and advances in the diagnostic approach to Q fever have provided important information on epidemiological and clinical aspects of this zoonosis. Coxiella burnetii infection exhibits various acute or chronic clinical forms, and infection during pregnancy may jeopardize the integrity of the fetus. The presentation of infection is often nonspecific and this hinders prompt diagnosis. Therapeutic regimens vary, and treating Q fever during pregnancy and childhood is often challenging. Increasing clinical experience with C. burnetii infections has helped create treatment protocols and follow-up algorithms that have considerably improved management and prognosis. Vaccines are available, although their use is still limited.

Murine typhus in children: clinical and laboratory features from 41 cases in Crete, Greece

Murine typhus, also known as endemic typhus, is a flea-borne infectious disease with a worldwide distribution, caused by an obligate intracellular, gram-negative microorganism, Rickettsia typhi [1]. The transmitting agent of R. typhi is the rat flea, Xenopsylla cheopis, although the cat flea, Ctenocephalides felis, has also been implicated [1–4]. Main reservoirs are rats, house mice, opossums, skunks and cats [1–3]. The actual incidence of murine typhus is unclear, as the common clinical manifestations of the disease are non-specific [1,2]. In children, only a small number of studies have focused on the occurrence and on clinical profiles of the disease [3–5]. The aim of this study was to confirm the presence and to assess the clinical and laboratory characteristics of R. typhi infection among children in the area of Chania, Crete, Greece. Forty-one children were hospitalised with acute R. typhi infection in the Pediatric Department of the General Hospital of Chania, from 2001 through to 2006. All other causes included in the differential diagnosis were ruled out. Diagnosis of acute R. typhi infection was considered positive by the combination of compatible clinical features and an indirect immunofluorescence test (Biomerieux, Lyon, France), when specific IgM and ⁄ or IgG titres on admission were >1 ⁄ 400 and >1 ⁄ 960, respectively. All cases were reviewed retrospectively for demographic, clinical and laboratory findings, treatment and outcome. Most admissions (87.8%) occurred between May and October. The mean age was 9.8 years old (range, 1–15 years old). Twenty children (48.8%) were males. History of recent contact with animals was positive in 13 children (31.7%); all 13 children reported contact with cats and 10 ⁄ 13 reported contact with dogs. On admission all patients had fever. Common clinical characteristics were fever, rash, hepatomegaly, splenomegaly and anorexia. Main laboratory features included elevated aspartate aminotransferase and alanine aminotransferase, abnormal chest radiography, thrombocytopenia and leucopenia. CSF analysis in one patient with confusion did not reveal any abnormalities. Clinical and laboratory manifestations found on admission are presented in Table 1. Serologic testing through IFA performed on admission was diagnosed for all 41 children, with a median IgM titre of 1 ⁄ 3200 (range, 1 ⁄ 400 to 1 ⁄ 31200) and a median IgG titre of 1 ⁄ 2880 (range, 1 ⁄ 480 to 1 ⁄ 30720). All children were treated upon admission. Combination therapy was administered to two of them. Antibiotics administered were doxycycline in 19 children (46.3%), chloramphenicol in 12 (29.3%), quinolones in five (12.2%), cephalosporins in three children (7.3%), and a combination of trimethoprim ⁄ sulfamethoxazole and b-lactams in two children (4.9%). The outcome was favourable for all 41 patients; apyrexia was recorded on a mean of 4.9 days after admission (range, 2–12 days). The mean total duration of fever was 9.1 days (range, 3–17 days). No complication or relapse was observed within 1 month of follow-up.

Q fever endocarditis in Greece: report of five cases

Laboratory of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine, WHO Collaborating Center for Mediterranean Zoonoses, University of Crete, Greece, Department of Internal Medicine, University Hospital of Heraklion, Crete, Greece, Department of Internal Medicine, University General Hospital ‘Attikon’, Athens, Greece and 4 Department of Pathophysiology, Athens University Medical School, Athens, Greece

First evidence of Anaplasma infection in Crete, Greece. Report of six human cases

In this study we investigate the demographic, clinical and laboratory features of six human cases of human granulocytic anaplasmosis (HGA) in Crete, Greece. Six patients, residents of the city of Chania, Crete, were hospitalised in the General Hospital of Chania with clinical manifestations and laboratory findings suggestive of acute A. phagocytophilum infection. Blood samples were taken from all patients on admission before the administration of antibiotics. Acute-phase serum samples were tested using an indirect immunofluorescence assay (IFA) for the presence of IgG and IgM antibodies against A. phagocytophilum antigen (Focus Diagnostics, CA, USA), according to the manufacturer’s recommendations (cut-off for positivity IgG‡1 ⁄ 64 and IgM‡1 ⁄ 20). Whole blood samples were tested by PCR-sequencing analysis of the 16s rRNA gene. DNA extraction was carried out using the QIAamp DNA blood mini kit (Qiagen, Hilden, Germany). PCR reactions were carried out using the primer set EHR16SD– EHR16SR targeting a fragment of 345 bp of the 16s rRNA gene of Anaplasmataceae using the conditions previously described [4]. Positive PCR products were directly sequenced using the sequencer CEQ 8000 Beckman Coulter. Three consecutive blood samples were taken for culture from each patient. Serological testing for suspected potential pathogens that are endemic in the area was also performed. Six patients were diagnosed as having acute A. phagocytophilum infection. Four infections were acquired in September 2006, one in August 2007 and one in September 2007. The mean age was 46.7 years old, ranging from 17 to 69 years old. Five patients were males. Three out of six patients reported contact with wild animals within 1 month before the onset of symptoms. None of the patients had travelled recently. Demographic characteristics, clinical presentation and laboratory findings are presented in Table 1. Symptoms persisted for 2–6 days before presentation. On admission, fever was present in all of the six patients and was accompanied by chills in two patients. Other symptoms observed were a maculopapular rash of the trunk (3 ⁄ 6), headache (2 ⁄ 6), malaise (2 ⁄ 6), splenomegaly (2 ⁄ 6), cervical lymphadenopathy (1 ⁄ 6), and gastrointestinal disturbances (1 ⁄ 6 patients). Common laboratory abnormalities found were high lactate dehydrogenase titres (all patients), elevated transaminases (5 ⁄ 6), elevated serum C-reactive protein (4 ⁄ 6), thrombocytopenia (4 ⁄ 6), and leucopenia (2 ⁄ 6 patients). All blood cultures were negative for common pathogens. Acute infection by other suspected pathogens included in the differential diagnosis was ruled out. All patients revealed IgM antibodies with titres ranging from 1 ⁄ 20 to 1 ⁄ 40. Only one patient revealed both IgM and IgG antibodies against Anaplasma phagocytophilum (IgG 1 ⁄ 128, IgM 1 ⁄ 40). DNA sequences of the PCR products in all patients (Genbank number EU448142), when compared using nucleotide Blast (National Center for Biotechnology Information) (http:// www.ncbi.nlm.nih.gov/BLAST), revealed 100% identity with each other and 98% identity with Anaplasma sp deposited sequences (EU448141, Anaplasma sp. panagCy 16S ribosomal RNA gene; Corresponding author and reprint requests: A. Psaroulaki, Laboratory of Clinical Bacteriology, Parasitology, Zoonoses and Geographical Medicine, Voutes, Heraklion, Crete 71100, Greece E-mail: annapsa@med.uoc.gr

Serological survey of Q fever in Crete, southern Greece

Coxiella burnetii, the causative agent of Q fever, is an obligatory intracellular bacterium with worldwide distribution. The aim of this study was to determine the prevalence of C. burnetii phase II antibodies in two different groups (high and low risk) of healthy human population and investigate the epidemiological characteristics of the infection in the island of Crete (southern Greece). Collection and testing by IFA of 493 sample sera for IgG and IgM antibodies against C. bumetii phase II antigen indicated a prevalence of IgG antibodies of 48.7%. Of the seropositive individuals, 34% also revealed IgM seropositive antibody titers. Analysis of 225 sample sera by IFA from high risk population presented a prevalence for C. burnetii of 62.2%. Our findings revealed that C. burnetii is highly endemic in Crete, indicating a high exposure of the population to the pathogen regardless of occupation or place of residence.

Clinical epidemiology, treatment and prognostic factors of extensively drug-resistant Acinetobacter baumannii ventilator-associated pneumonia in critically ill patients

Limited data exist regarding prognostic factors and optimal antimicrobial treatment of infections caused by extensively drug-resistant Acinetobacter baumannii (XDR-AB). This retrospective cohort study included 93 adult patients who developed ventilator-associated pneumonia (VAP) due to XDR-AB in the ICU of the University Hospital of Heraklion, Greece, from October 2012 to April 2015. XDR-AB isolates were mainly susceptible to colistin (93.5%) and tigecycline (25.8%), whereas 6 (6.5%) were pandrug-resistant. Prior to infection, patients had long durations of mechanical ventilation and hospital stay and multiple exposures to antibiotics. Median Charlson co-morbidity and APACHE II scores were 2 and 17, respectively. Mortality at 28 days of infection onset was high (34.4%) despite high rates of in-vitro-active empirical (81.7%) and definitive (90.3%) treatment. Active colistin-based combination therapy (n = 55) and monotherapy (n = 29) groups had similar 28-day mortality (27.6% vs. 30.9%, respectively) and Kaplan-Meier survival estimates over time. In multivariable Cox regression, advanced age (aHR = 1.05 per year increase, 95% CI 1.02-1.09), rapidly fatal underlying disease (aHR = 2.64, 95% CI 0.98-9.17) and APACHE II score (aHR = 1.06 per unit increase, 95% CI 0.99-1.14) were identified as independent predictors of 28-day mortality, but no difference in mortality hazards between the active colistin-based combination therapy and monotherapy groups was produced (aHR = 0.88, 95% CI 0.35-2.38). These results support the use of colistin as a first-line agent against VAP in settings where XDR-AB is endemic, but oppose the introduction of colistin-based combination therapy as standard treatment.

Murine typhus in elderly patients: a prospective study of 49 patients

Abstract Background: The characteristics of Rickettsia typhi infection in elderly patients have not been extensively described in the literature. Methods: We conducted a prospective study on murine typhus in patients > 65 years old in two endemic areas of Greece. Results: Forty-nine elderly patients were analyzed, including 30 (61.2%) males. The clinical triad of fever (100% of patients), headache (83.7%), and rash (73.5%), occurred in 63% of patients, whereas malaise (85.7%), anorexia (65.3%), and myalgia (59.2%) were also common. Frequent laboratory findings were transaminasemia (89.8%), lactate dehydrogenase elevation (65.3%), hematuria (55.1%), thrombocytopenia (53.1%), anemia (51%), leucopenia (40.8%), and mild hyponatremia (23.5%). Complications developed in 16 patients (32.7%); no deaths were recorded. Conclusions: The main clinical and laboratory characteristics of murine typhus are similar in elderly and younger adults. However, elderly patients have a more severe clinical picture, evidenced by a higher complication rate and longer duration of fever, even with appropriate treatment. To our knowledge, this is the first study to focus on murine typhus in a geriatric population.

Seroprevalence of Bartonella henselae antibodies in blood donors in Crete

Bartonella henselae are aerobic, Gram-negative, rod shaped bacteria responsible for the disease known as cat-scratch disease (CSD), which encompasses a worldwide distribution. Cats, the main reservoirs of the pathogen, are usually asymptomatic; however, human infection can cause symptoms ranging from mild to relatively serious (such as bacillary angiomatosis and Parinaud’s oculolandular syndrome), particularly if a person has a weak immune system. The aim of the present study was to investigate the presence of the bacterium in a healthy Cretan population (blood donors) in order to assess the potential risk of exposure to the bacterium.