GERMS最新文献

Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with poor outcomes, particularly among hematology-oncology patients. Appropriate use (selection and de-escalation) of antibiotics is a key component of management of febrile neutropenia particularly in high CRE prevalence regions like India.

Methods: This was a retrospective study done (April 2019-December 2021) in a dedicated oncology center in North India, which assessed the case records of the patients undergoing therapy for hematological malignancies who were diagnosed with CRE bacteremia. Demographic, clinical and microbiological data, as well as antibiotic prescription patterns were studied. Inter-group analysis was done between an antibiotic stewardship cohort (avoiding CRE therapy empirically or stopping CRE therapy if cultures negative; as per suggestions of the AMS team) and a non-antibiotic stewardship cohort (continuation of empirical CRE therapy; de-escalation advice was not followed).

Results: A total of 139 patients were identified, with median age of 41 years (range 13-74) out of which 82 (58.9%) were males. Acute myeloid leukemia (66.2%) was the most common malignancy, followed by lymphoma (8.6%) and myeloma (8.6%). Nearly 30% of patients were post allogenic stem cell transplant. Klebsiella pneumoniae was the predominant organism (78.4%) and combination of NDM+OXA-48 (46.3%) was the most common carbapenemase gene detected followed by OXA-48 alone (34.7%). Overall, 28-day mortality was 26.6%. On binary logistic regression analysis, lack of compliance with antibiotic stewardship intervention was an independent predictor of mortality (p=0.005).

Conclusions: Prior exposure to empirical CRE therapy or failure to de-escalate was associated with poor outcomes in patients with CRE bacteremia, which gives us a window of antibiotic stewardship in febrile neutropenia.

Introduction: Salivary gland lithiasis is one of the most frequent causes of sialadenitis. We report the case of a patient who presented multiple episodes of subangulomandibular tumefaction, until salivary lithiasis was finally identified as the underlying condition and resolved through a minimally invasive approach.

Case report: A 43-year-old male patient presented with a history of 12 episodes of recurring one-sided subangulomandibular tumefaction over the course of the past 3 years. A computed tomography of the head and neck revealed a large calculus on Wharton's duct and right lithiasic submaxillitis. Non-steroidal anti-inflammatory treatment and antibiotic treatment was administered, and after the complete resolution of the acute process, we performed a sialendoscopically-assisted sialolithotomy with complete removal of the calculus. Following the procedure, the patient was discharged on the same day, clinically well, and displayed no further recurrences over a follow-up duration of 12 months.

Conclusions: The case we have reported highlights the importance of performing a correct differential diagnosis and of determining the underlying cause of recurrent sialadenitis, in order to ensure the most adequate therapeutic and, when warranted, minimally-invasive surgical management for definitive treatment.

Introduction: Hafnia alvei is a Gram-negative, facultative anaerobic bacillus that is most often found as an enteric commensal. It is seldom considered to be pathogenic in immunocompetent individuals.

Case report: We describe a case of a 23-year-old, previously healthy male, who presented to the emergency department with a two-day history of hemoptysis, mild dyspnea, pleuritic chest pain, fevers, and chills. Bloods revealed leukocytosis and elevated C-reactive protein. Chest X-ray and CT of the thorax revealed a cavitating lesion in the right upper lobe. He was commenced on empiric antibiotic treatment with amoxicillin/clavulanate and clarithromycin for community-acquired pneumonia in accordance with local guidelines. He subsequently underwent a bronchoscopy, and the bronchoalveolar lavage sample revealed a heavy growth of H. alvei. Despite the widely documented natural resistance of H. alvei to penicillin, the patient demonstrated complete resolution of his symptoms and initial raised inflammatory markers.

Conclusions: We present a case of community-acquired cavitary pneumonia in a previously healthy young adult with H. alvei isolated from bronchoalveolar lavage samples. Parallels are drawn between our case and other cases of H. alvei respiratory isolates in our discussion of its clinical significance.

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy associated with severe ADAMTS13 deficiency that can be potentially fatal if not treated in a timely manner.

Case report: A 49-year-old previously healthy woman was admitted with a 3-month history of thoracoabdominal pain and headache associated with loss of appetite, emesis, nocturnal diaphoresis, and unintentional loss of 10 kg. On admission she presented anemia, thrombocytopenia, schistocytes in peripheral blood smear, and ADAMTS13 in 1.4%. Due to laboratory findings a diagnosis of TTP was established, and plasma exchange therapy and steroid pulses were started, with resolution of hematological alterations. Within the studies to determine etiology of TTP, pulmonary tuberculosis (TB) was found, neoplastic and autoimmune pathologies were excluded. The tetraconjugated treatment was initiated with optimal tolerance.

Conclusions: Upon clinical suspicion of TTP, plasma exchange therapy should be initiated urgently; infectious, neoplastic, or autoimmune pathologies can be triggers; in this case, pulmonary TB was confirmed.

Introduction: Intravesical Bacillus Calmette-Guérin (BCG) instillation is the most effective adjuvant therapy for superficial urinary bladder carcinoma, prolonging disease-free survival. Although it is usually well tolerated, moderate to severe local or systemic infectious complications, including sepsis involving multiple organs, may occur.

Case report: We report the unusual case of a man in his mid '70s who presented with septic shock and severe acute respiratory failure requiring intubation. Lack of response to antibiotics, history of intravesical BCG instillation and consistent imaging findings led to further investigations, with bronchoalveolar lavage (BAL) fluid polymerase chain reaction (PCR) results indicating pneumonitis due to Mycobacterium bovis dissemination. Prompt anti-tuberculosis treatment combined with corticosteroids resulted in significant clinical and radiological improvement, supporting the diagnosis of disseminated BCG infection.

Conclusions: Due to its non-specific clinical presentation and the relatively low diagnostic yield of conventional microbiological tests, a high index of suspicion is required for prompt diagnosis and treatment of systemic BCG infection. PCR-based assays for mycobacterial DNA identification may represent a valuable tool facilitating timely diagnosis of this uncommon, yet potentially life-threatening infection.

Introduction: The annual incidence of infective endocarditis (IE) is 3-9 cases per 100000 in developed countries and most cases are due to staphylococci and streptococci. IE due to Gram-positive anaerobic cocci (GPAC) is very rare.

Case report: We present a case of a 38-year-old female with Anaerococcus hydrogenalis bacteremia and infective endocarditis of the native mitral valve. She presented with fever, chills, and abdominal pain. A computed tomographic scan of the abdomen showed splenic abscesses. Blood cultures and broad-range PCR from the splenic abscess sample were negative. Transthoracic echocardiography showed a mobile filamentous structure on the atrial side of the anterior mitral leaflet which was suggestive for infective endocarditis. Karius test (cell-free microbial DNA testing) showed Gram-positive anaerobic cocci Anaerococcus hydrogenalis. She was successfully treated with antibiotics.

Conclusions: In cases of infection with fastidious organisms like GPACs, the use of next-generation sequencing (NGS) can allow the correct identification of culprit pathogens and streamlined treatment.

Introduction: Bordetella bronchiseptica is a rare cause of hemorrhagic bronchopneumonia. Important to the clinician is a clear understanding that the treatment of this rare organism differs greatly from the successful antibiotic treatment of the more common Bordetella species, pertussis and parapertussis.

Case report: A 64-year-old female presented to the emergency department after experiencing one week of worsening hemoptysis. Upon admission, she was afebrile and all initial laboratory test results were normal. Bronchoalveolar hemorrhage suggested by radiographic imaging was confirmed by bronchoscopy. Bronchoalveolar lavage (BAL) cultures contained unspeciated Bordetella. Rapid worsening of the hemoptysis led to intubation and the decision to perform bronchial artery embolization. However, the intensity of the hemoptysis persisted. Septic shock ensued despite treatment with broad spectrum antibiotics including azithromycin, vancomycin, and cefepime. The microbiological speciation results finalized shortly after the patient's death. The identified organism was B. bronchiseptica.

Conclusions: Although macrolide antibiotics are first line treatment for B. pertussis and parapertussis, macrolide antibiotics are generally not effective against B. bronchiseptica. Clinical suspicion of B. bronchiseptica infection should prompt consideration of alternative antibiotics known to be effective against this rare species, including carbapenems and fluoroquinolones. The use of these latter antibiotics may advisably be considered as an empirical treatment during the delay of microbiological speciation.

Introduction: The aim of this study was to assess the incidence of Corynebacterium striatum prosthetic joint infections (PJI) to determine if an increase has occurred recently. Moreover, susceptibility testing was conducted on C. striatum preserved isolates to determine antibiotic options for these infections.

Methods: Retrospective review of PJI cases was conducted from 1/2017 through 1/2021 compared to 1/2021 through 7/2022 to determine how many cases of C. striatum have occurred for each of these time points. From these cases, demographics, outcomes and risk factors for C. striatum PJI were recorded. The preserved clinical isolates from these cases were tested for susceptibility to different antibiotics.

Results: A statistically significant increase in the proportion of C. striatum PJI cases (1.98 to 7.84, p=0.0489) has occurred over the past 16 months at a single institution. Chronic wounds and exposure to daptomycin were associated with the majority of these cases. Susceptibility testing of the clinical isolates showed uniform susceptibility to vancomycin, linezolid and dalbavancin. Uniform resistance was seen with ciprofloxacin, tetracycline and doxycycline as well. Interestingly, 85.7% of the isolates displayed inducible daptomycin resistance after overnight exposure to daptomycin.

Conclusions: C. striatum is an emerging PJI pathogen. It is important for clinicians to be cognizant that this pathogen can have inducible high level daptomycin resistance and that daptomycin is likely not a reliable antibiotic for these infections. While vancomycin and linezolid are the traditional antibiotics to use in these infections, other antibiotics such as dalbavancin, may also have utility, but more research is needed to determine the effectiveness of this antibiotic in C. striatum infections.