Zohreh Aminzadeh

Country-to-Country Transfer of Patients and the Risk of Multi-Resistant Bacterial Infection

Management of patients with a history of healthcare contact in multiple countries is now a reality for many clinicians. Leisure tourism, the burgeoning industry of medical tourism, military conflict, natural disasters, and changing patterns of human migration may all contribute to this emerging epidemiological trend. Such individuals may be both vectors and victims of healthcare-associated infection with multiresistant bacteria. Current literature describes intercountry transfer of multiresistant Acinetobacter spp and Klebsiella pneumoniae (including Klebsiella pneumoniae carbapenemase- and New Delhi metallo-β-lactamase-producing strains), methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and hypervirulent Clostridium difficile. Introduction of such organisms to new locations has led to their dissemination within hospitals. Healthcare institutions should have sound infection prevention strategies to mitigate the risk of dissemination of multiresistant organisms from patients who have been admitted to hospitals in other countries. Clinicians may also need to individualize empiric prescribing patterns to reflect the risk of multiresistant organisms in these patients.

Vancomycin minimum inhibitory concentration for methicillin-resistant Staphylococcus aureus infections; is there difference in mortality between patients?

Background: New data indicates that vancomycin may be less effective against methicillin-resistant Staphylococcus aureus (MRSA) infections with minimum inhibition concentration (MIC) within a sensitive range. Objectives: The aim of this study was to determine the distribution of the vancomycin MIC between MRSA strains and observe the difference in mortality between patients, while the influence of changes in MIC on the efficacy of vancomycin was also examined. Patients and Methods: A routine date-based study was conducted on 41 MRSA isolates in a hospital in Tehran, Iran. The isolates were assessed for MIC by using the E-test method, and results were categorized into three groups: A (MIC < 1.5 μg/mL), B (1.5 ≤ MIC < 2 μg/mL) and C (MIC ≥ 2 μg/mL) MRSA. Results: Group A was the most common group, followed by groups C and B. Although there was no statistically significant difference between patients’ mortality with the MIC group, the mortality rate of group A was higher than C and B. Conclusions Regarding Clinical and Laboratory Standards Institute (CLSI) definition for vancomycin susceptibility (MIC < 2 μg/mL), it seems that vancomycin may not be considered as the best antibiotic in order to treat heteroresistant vancomycin intermediate S. aureus (hVISA) and vancomycin sensitive S. aureus (VSSA) infections, and a new breakpoint for vancomycin and alternative antibiotics should be considered.

Drug-resistant post-neurosurgical nosocomial Acinetobacter baumannii meningitis in two Iranian hospitals

Acinetobacter baumannii may cause meningitis and ventriculitis, particularly after head trauma and/or neurosurgery. The rate of multidrug-resistant Acinetobacter meningitis has increased over the past years. This study was conducted to determine prevalence of drug-resistant post-neurosurgical nosocomial A. baumannii meningitis. During the period of study between 2007 and 2009, a total of 39 patients with positive culture of A. baumannii in their cerebrospinal fluid were evaluated. Standard bacteriological methods were used for identification of A. baumannii. The method which has been recommended by Clinical Laboratory and Standards Institute (CLSI) was applied to determine susceptibility and resistant pattern. All patients had a history of neurosurgical intervention and more than half of them stayed in the intensive care units (ICU) at the time of isolation. The highest rate of resistant pattern accounted for the third generation cephalosporins, followed by ciprofloxacin, amikacin, gentamicin and co-terimoxazole. Of all the isolates, 39% were resistant to imipenem and 15.5% to meropenem. The majority of carbapenem-resistant isolates were resistant to at least three other antibiotic classes. The emergence of postsurgical multi-drug resistant Acinetobacter meningitis highlights the importance of implementing preventative strategies towards nosocomial infections. Key words: Acinetobacter baumannii, resistance, meningitis, neurosurgery.

Cerebellar syndrome with meningoencephalitis due to Mycoplasma pneumoniae

We report a 24-year-old woman with a Mycoplasma pneumonitis associated with subacute meningoencephalitis and acute cerebellitis that caused a cerebellar atrophy. Electroencephalogram showed diffuse dysfunction in the brain. There was few white blood cell but normal glucose and protein in the cerebrospinal fluid (CSF). Brain MRI showed bilateral atrophy of cerebellum.

PP-034 Jolt accentuation of headache in diagnosis of acute meningitis

Background: Optimal use of the clinical examination aids physicians in identifying patients at risk for meningitis. The low specificity of the meningeal signs may be due to the presence of cervical arthritis and spondylosis. One of the most sensitive maneuvers in the diagnosis of meningitis is jolt accentuation of headache. Patients and methods: A descriptive research was performed on suspected acute meningitis patients. The patients were evaluated for presence of meningeal signs before lumbar puncture. Sensitivity, specificity, positive and negative predictive values, likelihood-ratio-positive (LR+), and likelihood-ratio-negative (LR-) were determined. A p-value of <0.05 was considered to be statistically significant. Results: Totally, 14 patients were evaluated. Neck stiffness, Kernig, Brudzinski and jolt accentuation sign were positive in 78.6%, 14.3%, 14.3%, and 64.3% of patients, respectively. The prevalence, sensitivity, specificity, PPV, NPV, LR+, and LR- of neck stiffness in comparison with pleocytosis was 50%, 100%, 57%, 70%, 100%, 2.33, and 0, respectively. The prevalence, sensitivity, specificity, PPV, NPV, LR+, and LR- of jolt accentuation sign in comparison with neck stiffness was 78.5%, 82%, 60%, 100%, 60%, 0, and 0.18, respectively, however, when jolt accentuation sign was compared with pleocytosis these parameters were 50%, 100%, 71.5%, 78%, 100%, 1, and 0, respectively. Conclusion: When evaluating suspected cases of meningitis with limitations for neck stiffness examination, we can alternatively evaluate jolt accentuation sign. The LR- of 0.18 for jolt accentuation sign when compared with neck stiffness revealed that jolt accentuation sign is an appropriate maneuvers in the diagnosis of meningitis.