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Citrobacter freundii is one of the most important nosocomial opportunistic pathogens, which causes sepsis, as well as different gross and histopathological lesions in various internal organs in humans and animals, especially dogs and fish. This study aimed to investigate the hematological parameters, immunological responses, and pathological effects of the infection induced by the virulent strain of C. freundii on rabbits. A total of 42 rabbits (local breed; male and female), with a mean weight of 1.5-2 kg, were housed under controlled environmental conditions (20±2°C, 14:10 h light: dark cycle) and allowed ad libitum access to food and water. After two weeks of adaption, the rabbits were divided randomly into three groups of 14 animals per group. Group one (G1) received 3×10 8 CFU/ml of the virulent isolate (intraperitoneally [IP]) of C. freundii . Group two (G2) was injected subcutaneously (SC) with 3×10 8 CFU/ml of the virulent strain of C. freundii , while group three was IP injected with phosphate buffer saline and considered a negative control group. Results showed the variable gross pathological effects which included hemorrhage, edema, and congestion of visceral organs. Furthermore, the microscopic lesions showed pneumonia due to inflammatory cells infiltration, mainly neutrophils, macrophages, plasmacytes, and lymphocytes, severe interstitial and intra-alveolar edema, extensive pulmonary hemorrhage, emphysema, and atelectasis. The recorded data from the liver samples revealed hepatitis which was characterized by perivascular and periportal leukocyte cuffing, marked centrilobular with periportal necrosis, extensive hepatic edema, and periportal edema in addition to extensive fibrosis in interlobular septa and periportal fibrosis with severe interstitial hemorrhage. In the kidneys, there were severe renal edema, mixed inflammatory exudation, mainly neutrophils, macrophages, plasmacytes, lymphocytes, fibroblast infiltration in renal parenchyma and renal cortex, extensive renal hemorrhage, edema, as well as fibrosis and severe renal tubular necrosis. In addition, enteritis appeared in the intestine with mucosal edema, especially in lamina propria; moreover, necrosis of entire villi, epithelial necrosis, mucosal and submucosal hemorrhage, and fibrosis were observed. The present study revealed a significant increase in total leukocytes count and the concentration of TNF-α in the infected groups. To the best of the authors' knowledge, this study is considered the first attempt aimed to detect the pathological effects of C. freundii on visceral organs in rabbits. It is concluded that this bacterium could induce a significant pathological, hematological, and immunological changes in the infected animals.

Background: Bloodstream infections (BSIs) are a major cause of morbidity and mortality in hospitalized neonates. Data on antibiotic resistance in neonatal BSIs and their impact on clinical outcomes in Africa are limited., Methods: We conducted a prospective cohort study at 2 tertiary level neonatal intensive care units (NICUs) in Ghana. All neonates admitted to the NICUs were included from October 2017 to September 2019. We monitored BSI rates and analyzed the effect of BSI and antibiotic resistance on mortality and duration of hospitalization., Results: Of 5433 neonates included, 3514 had at least one blood culture performed and 355 had growth of a total of 368 pathogenic microorganisms. Overall incidence of BSI was 1.0 (0.9-1.1) per 100 person days. The predominant organisms were Klebsiella pneumoniae 49.7% (183/368) and Streptococcus spp. 10.6% (39/368). In addition, 512 coagulase negative Staphylococci were isolated but considered probable contaminants. Among K. pneumoniae, resistance to gentamicin and amikacin was 91.8% and 16.4%, respectively, while carbapenem resistance was 4.4%. All-cause mortality among enrolled neonates was 19.7% (1066/5416). The mortality rate was significantly higher in neonates with BSI compared with culture-negative neonates in univariate analysis (27.9%, n = 99/355 vs. 16.5%, n = 520/3148; hazard ratio 1.4, 95% confidence interval 1.07-1.70) but not in multivariate analysis., Conclusion: The diversity of etiologic agents and the high-risk of antibiotic resistance suggest that standard empirical treatment is unlikely to improve the outcome of BSIs in low and middle income. Such improvements will depend on access to reliable clinical microbiologic services., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Raoultella ornithinolytica is an opportunistic, aquaphilic and Gram-negative bacterium. Immune deficiency states and indwelling catheters provide a basis for most of the infections arising. R. ornithinolytica septicemia (ROS) is extremely rare in neonates but can be life threatening. Community-acquired ROS has not been described in neonates before. The diagnosis of neonatal septicemia is occasionally complicated by unusual clinical presentations. Pyloric stenosis is manifested by projectile, nonbilious vomiting and late findings, including weight loss, dehydration and electrolyte abnormalities beyond 4-6 weeks old. Community-acquired neonatal septicemia symptoms can sometimes be confused with symptoms of gastrointestinal obstructions in patients without risk factors for sepsis. Early diagnosis and appropriate antibiotics are essentials for a good prognosis in neonatal septicemia. Herein, we present a novel case of community-acquired ROS with an unusual presentation in a term infant and a review of the literature about ROS in the neonatal period., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Carbapenem-resistant K. pneumoniae (CRKP) bloodstream infections (BSI) must be rapidly identified to improve patient survival rates. This study investigated a new mass spectrometry-based method for improving the identification of CRKP BSI and explored potential biomarkers that could differentiate CRKP BSI from sensitive., Methods: Mouse models of BSI were first established. MALDI-TOF MS was then used to profile serum peptides in CRKP BSI versus normal samples before applying BioExplorer software to establish a diagnostic model to distinguish CRKP from normal. The diagnostic value of the model was then tested against 32 clinical CRKP BSI and 27 healthy serum samples. Finally, the identities of the polypeptides used to establish the diagnostic model were determined by secondary mass spectrometry., Results: 107 peptide peaks were shared between the CRKP and normal groups, with 18 peaks found to be differentially expressed. Five highly expressed peptides in the CRKP group (m/z 1349.8, 2091.3, 2908.2, 4102.1, and 8129.5) were chosen to establish a diagnostic model. The accuracy, specificity and sensitivity of the model were determined as 79.66%, 81.48%, and 78.12%, respectively. Secondary mass spectrometry identified the Fibrinogen alpha chain (FGA), Inter-alpha-trypsin inhibitor heavy chain H4 (ITIH4) and Serum amyloid A-2 protein (SAA2) as the source of the 5 serum peptides., Conclusions: We successfully established a serum peptide-based diagnostic model that distinguished clinical CRKP BSI samples from normal healthy controls. The application of MALDI-TOF MS to measure serum peptides, therefore, represents a promising approach for early BSI diagnosis of BSI, especially for multidrug-resistant bacteria where identification is urgent., (© 2021 The Authors. Journal of Clinical Laboratory Analysis published by Wiley Periodicals LLC.)

Following prolonged hospitalization that included broad-spectrum antibiotic exposure, a strain of Providencia rettgeri was cultured from the blood of a patient undergoing extracorporeal membrane oxygenation treatment for hypoxic respiratory failure due to COVID-19. The strain was resistant to all antimicrobials tested including the novel siderophore cephalosporin, cefiderocol. Whole genome sequencing detected ten antimicrobial resistance genes, including the metallo-β-lactamase bla NDM-1 , the extended-spectrum β-lactamase bla PER-1 , and the rare 16S methyltransferase rmtB2 .

Purpose: Tigecycline is one of few antibiotics active against multidrug-resistant bacteria; however, the assessment of dosing strategies to optimize its activity is needed. The purpose was to use Monte Carlo Simulation (MCS) to determine if safe tigecycline dosing options attaining breakpoints for pharmacokinetic/pharmacodynamic (PK-PD) targets in non-critically ill adults could be identified., Methods: Publications that evaluated tigecycline dosing regimens and provided mean PK variables of interest (minimum 2 of: elimination rate constant or half-life and volume of distribution or clearance), with SDs, were included. Weighted mean (±SDs) for each PK parameter were determined. Food and Drug Administration minimum inhibitory concentration (MIC) tigecycline breakpoints for susceptible (MIC ≤ 2 μg/mL), intermediate (MIC 4 μg/mL), and resistant (MIC ≥ 8 μg/mL) Enterobacteriaceae were used. MCS probability distributions for PK-PD target attainment of AUC for total tigecycline plasma concentration from 0 to 24 h following an intravenous dose (AUC total, 0-24h ) to MIC ratios of ≥ 18, 7, and 4.5 were generated, with success defined as ≥ 80% probability of target attainment at a given MIC., Results: Ten studies (n = 442) were eligible. Tigecycline 150 mg IV q12h for ward patients with resistant bacteria up to a MIC of 0.48, 1, and 2 μg/mL for an AUC total, 0-24h /MIC target attainment of 18, 7, and 4.5, respectively, may be appropriate., Conclusion: Bacterial infections with tigecycline MICs ≥ 0.48-2 μg/mL, depending on AUC total, 0-24h /MIC target, may require treatment with alternate antibiotics due to target attainment failure.

We report a case of catheter associated bloodstream infection due to Enterobacter ludwigii with a massive aggregation on the outside surface of a central venous catheter (CVC). The 57 years old patient with a history of spondylodiscitis and Staphylococcus aureus-associated endocarditis was admitted to the intensive care unit for acute cerebral infarction. The patient developed signs of infections and the CVC was removed 11 days after placement. The infectious agent was identified by standard diagnostics to the genus level as belonging to the Enterobacter cloacae complex, and additional molecular testing determined the species as E. ludwigii. The catheter was selected for a study aiming to identify the influence of blood components on the formation of central venous catheter-associated biofilms. In this course a massive biofilm was recognized and is presented here.

We prospectively compared the performance of RESIST-5 O.O.K.N.V. and NG-Test Carba 5 assays directly from blood cultures spiked with 130 characterized Enterobacterales isolates. Overall, both assays yielded 100% sensitivity to detect KPC-type carbapenemases and OXA-48-like carbapenemases. Both assays failed to detect KPC-31 and KPC-33, D179Y point mutation variants of KPC-3 and KPC-2, that are deprived of carbapenemase activity and confer resistance to ceftazidime-avibactam. On blood culture bacterial pellets, NDM- and VIM-type carbapenemases were detected in 50.0% and 52.2%, respectively, by RESIST-5 O.O.K.N.V. vs 100% by NG-Test Carba 5. The sensitivity of RESIST-5 O.O.K.N.V. improved to 100% and 95.6%, respectively, by performing the assay on 4-h early subculture., (Copyright © 2020. Published by Elsevier Ltd.)

We determined the clinical signs and blood ionized calcium (iCa) levels in dairy cows with peracute coliform mastitis (PCM). The clinical scores at the onset of the disease (day 0) and on day 2 and subsequent days were significantly (P<0.01) higher than those of healthy cows. We found a positive correlation (r=0.894, P<0.01) between iCa and total calcium (TCa) concentrations in the blood of healthy cows ; however there was no correlation from day 0 to day 3 in the blood of PCM cows. Multiple regression analysis revealed that the concentration of iCa was correlated with rectal temperature, hematocrit value, platelet count, and albumin level of PCM cows at the onset of disease (r= -0.804, r=0.6576, r=0.6182, r=0.284, P<0.01, respectively). There was no correlation between the TCa concentration and these parameters for PCM cows at day 0. Low blood iCa concentration at day 0 for PCM cows was related to symptoms of septic shock involving hypothermia, activation of the blood coagulation system, and dehydration.

The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE ( Enterococcus faecium , Staphylococcus aureus , Klebsiella pneumoniae , Acinetobacter baumannii , Pseudomonas aeruginosa , and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.

Benapenem is a novel carbapenem. The objective of this study was to determine the pharmacokinetic (PK)/pharmacodynamic (PD) cutoff values and evaluate the optimal administration regimens of benapenem for the treatment of bacterial infections via PK/PD modeling and simulation. Ertapenem was used as a control. Infected mice received an intravenous (i.v.) injection of benapenem or ertapenem of 14.6, 58.4, or 233.6 mg/kg of body weight, and the PK/PD profiles were evaluated. The MICs were determined by using a 2-fold agar dilution method. Mathematical models were developed to characterize the pharmacokinetic profile of benapenem in humans and mice. Monte Carlo simulations were employed to determine the cutoff values and the appropriate benapenem dosing regimens for the treatment of infections caused by clinical isolates of Enterobacteriaceae Two 2-compartment models were developed to describe the PK profiles of benapenem in humans and mice. A two-site binding model was applied to fit the protein binding in mouse plasma. Through correlation analysis, the percentage of the time that the free drug concentration remains above the MIC (% fT >MIC ) was determined to be the indicator of efficacy. Results from the simulation showed that the probability of target attainment (PTA) against the tested isolates was over 90% with the dosing regimens studied. The PK/PD cutoff value of benapenem was 1 mg/liter at a % fT >MIC of 60% when given at a dose of 1,000 mg/day by i.v. drip for 0.5 h. The established model provides a better understanding of the pharmacological properties of benapenem for the treatment of Enterobacteriaceae infections. The proposed PK/PD cutoff value suggests that benapenem is a promising antibacterial against the Enterobacteriaceae The cutoff value of 1 mg/liter may be a useful guide for the clinical use of benapenem and for surveillance for benapenem resistance., (Copyright © 2020 Ji et al.)

Yellow catfish (Pelteobagrus fulvidraco) has been an economically important freshwater species in China because of its good meat quality. In present, the high-density breeding industry has suffered great damage from bacterial infections, in especial, the rapid illness and death of fish caused by bacterial septicemia leads to huge economic losses. Therefore, it is urgent and important to identify pathogenic bacteria and study its pathogenicity. In this study, we isolated a bacterial strain from the yellow catfish with typical septicemia and named it E. 719, then, by morphological observations, regression infection, biochemical identification, 16S rDNA sequence analysis and triple PCR identification, E. 719 was determined to be Edwardsiella ictaluri. Further, we infected yellow catfish with E. ictaluri to study its effects on mortality rate, hematological, histopathological disturbances and expression of immune genes. The mortality results showed that E. ictaluri was highly pathogenic, all infected fish died after 14 days post injection, and the distribution of bacteria in body kidney, spleen, liver, head kidney and brain of fish was continuously detected by measuring the amount of bacteria in the tissues. In addition, the number of red blood cells decreased significantly with the time of infection, while the number of white blood cells and thrombocytes increased. In particular, the number of monocytes and neutrophils increased significantly in the differential leucocyte count (DLC). Histopathologic changes observed by HE staining showed similar results, gill, intestine, spleen and head kidney showed obvious inflammation, bleeding and necrosis. Besides, checking by real time quantitative RT-PCR assays, in both spleen and head kidney tissues which were the major immune organs, mRNA expressions of immune gene IL-1β, TNF-α, and MR significantly increased in the early and middle stages of infection, which suggested that the infection of E. ictaluri caused a strong immune response in yellow catfish. This study provides a preliminary basis for the diagnosis and treatment of pathophysiology septicemia in yellow catfish induced by E. ictaluri., (Copyright © 2019. Published by Elsevier Ltd.)

KHM-1 was first reported in 1997 in Japan as a novel metallo-β-lactamase mediated by Citrobacter freundii carrying pKHM-1 plasmid. There have been few reports in the clinical field since then. A blaKHM-1-positive Enterobacter hormaechei subsp. hoffmannii in E. cloacae complex, isolate OIPH-N069 was isolated from an inpatient blood culture in 2016. The isolate was characterized by whole-genome sequencing, comparative analysis of the blaKHM-1 encoding plasmid, antimicrobial susceptibility tests, and bacterial conjugation. OIPH-N069 was classified into ST78 of E. cloacae complex, and was multidrug resistant because of the presence of antimicrobial resistance genes in addition to blaKHM-1 on its chromosome and plasmids. blaKHM-1 was located on 136,816 bp of the IncA/C2 plasmid pN069-1, which could be transferred to different bacterial species. The backbone structure, genetic arrangement of the class 1 integron cassette, and the blaKHM-1 gene located downstream of the IncA/C2 antibiotic resistance island, ARI-A, in pN069-1 and pKHM-1 were identical. Horizontal gene transfer of the blaCTX-M-2-ISEcp1 resistance gene module only occurred with pN069-1. The study findings indicate not only the structural conservation of blaKHM-1 encoding plasmids over time and across species, but also the risk of the spread of blaKHM-1 encoding plasmids to other bacterial species and the accumulation of additional resistance genes., Competing Interests: The authors have declared that no competing interests exist.

Objective: To describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) healthcare-associated infections (HAI) in Egyptian hospitals reporting to the national HAI surveillance system., Methods: Design : Descriptive analysis of CRE HAIs and retrospective observational cohort study using national HAI surveillance data . Setting: Egyptian hospitals participating in the HAI surveillance system. The patient population included patients admitted to the intensive care unit (ICU) in participating hospitals . Enterobacteriaceae HAI cases were Klebsiella, Escherichia coli, and Enterobacter isolates from blood, urine, wound or respiratory specimen collected on or after day 3 of ICU admission. CRE HAI cases were those resistant to at least one carbapenem. For CRE HAI cases reported during 2011-2017, a hospital-level and patient-level analysis were conducted using only the first CRE isolate by pathogen and specimen type for each patient. For facility, microbiology, and clinical characteristics, frequencies and means were calculated among CRE HAI cases and compared with carbapenem-susceptible Enterobacteriaceae HAI cases through univariate and multivariate logistic regression using STATA 13., Results: There were 1598 Enterobacteriaceae HAI cases, of which 871 (54.1%) were carbapenem resistant. The multivariate regression analysis demonstrated that carbapenem resistance was associated with specimen type, pathogen, location prior to admission, and length of ICU stay. Between 2011 and 2017, there was an increase in the proportion of Enterobacteriaceae HAI cases due to CRE ( p -value = 0.003) and the incidence of CRE HAIs ( p -value = 0.09)., Conclusions: This analysis demonstrated a high and increasing burden of CRE in Egyptian hospitals, highlighting the importance of enhancing infection prevention and control (IPC) programs and antimicrobial stewardship activities and guiding the implementation of targeted IPC measures to contain CRE in Egyptian ICU's ., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

Purpose: To evaluate the performance of the Uro4 HB&L™ system in screening ESBL/AmpC-producing Enterobacteriaceae as compared with the resistant test by VITEK 2. The resistance profile of the ESBL-producing bacteria was also evaluated., Methodology: Blood culture samples were collected at bedside, inoculated directly into BD BACTEC™ culture bottles, and incubated. When microbial growth was found, samples were prepared for identification using MALDI-ToF. The Uro4 HB&L™ system was used for direct detection of ESBL/AmpC-producing bacteria compared with conventional methods., Results: A total of 103 positive blood cultures containing Gram-negative bacteria were tested. Uro4™ HB&L screening results were obtained in up to 6.5 h, with 91.3% concordance with the VITEK2 system, with 85% sensitivity, 95.2% specificity, and 91.1% positive and 90.9% negative predictive values. The resistance profile of ESBL-producing bacteria tested in the present study showed increased resistance ratio to ciprofloxacin, gentamicin, and trimethoprim/sulfamethoxazole. In parallel, susceptibility to amikacin and meropenem was not affected., Conclusions: The performance of the Uro4 HB&L™ system is acceptable for rapid screening ESBL/AmpC-producing Enterobacteriaceae. The data related to detecting ESBL-producing bacteria are crucial for managing antimicrobial therapy.

The emergence of carbapenem-resistant Enterobacterales (CRE) is a matter of public health concern. Carbapenemases are the main mechanism of resistance among CRE, and its rapid detection is essential. The detection of carbapenemases usually requires culture-based methods and molecular assays, which may be costly and need long turnaround times. Recently, an easy and rapid immunochromatographic assay for carbapenemases (OXA-48, KPC, and NDM) detection based in lateral flow immunoassay with specific monoclonal antibodies on a nitrocellulose membrane has been developed. We aimed to evaluate the RESIST-3 O.K.N. in colonies from pure culture as well as in spiked blood cultures with Enterobacterales. All carbapenemase producers (CP) presenting the OXA-48-like, KPC, and NDM enzymes presented positive results in both pure colonies and spiked blood cultures. None of the carbapenemase non-producers (CNP) presented positive results in the tests. A total of 97% CP isolates presented positive results in pure colonies in less than 5 min. For CP directly from blood culture, the mean time to positivity for OXA-48-like and KPC was 1 min, whereas it was 25 min for NDM. Our results indicate that this immunoassay can be used to detect carbapenemases directly from blood culture bottles in a routine diagnostic laboratory, which would reduce the turnaround time of CP detection.

Efficacy of ceftaroline fosamil, the prodrug of the active metabolite ceftaroline, was demonstrated in a phase 3 study of hospitalized Asian patients with Pneumonia Outcomes Research Team (PORT) risk class III-IV community-acquired pneumonia (NCT01371838). The objectives of the current analysis were to expand an existing ceftaroline and ceftaroline fosamil population pharmacokinetic (PK) model with data from this phase 3 study and a phase 1 study (NCT01458743) assessing ceftaroline PK in healthy Chinese volunteers and to evaluate the probability of PK/pharmacodynamic (PK/PD) target attainment (PTA) in Asian patients with community-acquired pneumonia (CAP) treated with ceftaroline fosamil. The ceftaroline plasma concentration-time course was simulated for 5000 Asian patients with CAP for different renal function subgroups using the final model. PTA was calculated for Streptococcus pneumoniae, Staphylococcus aureus, and non-extended-spectrum β-lactamase-producing Enterobacteriaceae. PTA was also evaluated for ceftaroline MIC 90 values of isolates collected from Asia-Pacific surveillance studies (2012-2014) and for EUCAST and FDA/CLSI ceftaroline susceptibility break points. The final model reasonably described the ceftaroline PK. Race was not found to be a significant covariate impacting ceftaroline PK, suggesting similar ceftaroline PK in Asian and Western populations when corrected for body weight. High PTAs (90%-100%) were predicted for Asian patients with CAP treated with ceftaroline fosamil, covering MIC 90 values of target CAP pathogens from the region. Similarly, >90% PTAs were predicted at EUCAST and FDA/CLSI clinical break points for these pathogens. These results support the use of the ceftaroline fosamil dosing regimens approved in Europe and the United States in Asian patients with PORT III-IV CAP., (© 2019, The American College of Clinical Pharmacology.)

The objective of this study is to evaluate the impact of carbapenem-resistant Enterobacteriaceae (CRE) infection on sepsis 30-day mortality. A retrospective cohort of patients >18 years old with sepsis and organ dysfunction or septic shock was conducted. Univariate analysis was done for variables potentially related to 30-day mortality, and the ones with P values of <0.05 were included in a backward stepwise hierarchic Cox regression model. Variables that remained with P values of <0.05 were retained in the model. A total of 1,190 sepsis episodes were analyzed. Gram-negative bacterial infections occurred in 391 (68.5%) of 571 patients with positive cultures, of which 69 (17.7%) were caused by a CRE organism. Patients with CRE infections had significantly higher 30-day mortality: 63.8% versus 33.4% ( P  < 0.01). CRE infection was also associated with a lower rate of appropriate empirical therapy ( P  < 0.01) and with the presence of septic shock ( P  < 0.01). In the hierarchic multivariate model, CRE remained significant when controlling for demographic variables, comorbidities, and infection site but lost significance when controlling for septic shock and appropriate empirical therapy. Older age ( P  < 0.01), HIV-positive status ( P  < 0.01), cirrhosis ( P  < 0.01), septic shock ( P  < 0.01), higher quick sepsis-related organ failure assessment (quick-SOFA) ( P  < 0.01), and appropriate empirical therapy ( P  = 0.01) remained in the final model. CRE infections were associated with higher crude mortality rates. A lower rate of appropriate empirical therapy and late diagnosis were more frequent in this group, and improvement of stewardship programs is needed. IMPORTANCE The importance of this work relies on exploring the impact of multidrug-resistant bacterial infections such as those with carbapenem-resistant Enterobacteriaceae (CRE) on sepsis mortality. These infections are growing at alarming rates worldwide and are now among the most frequent and difficult-to-treat bacteria due to the very few options for susceptible antimicrobials available. This study examined 1,190 sepsis episodes, and the main findings were as follows: (i) the prevalence of CRE infections significantly increased over time, (ii) CRE infection was associated with higher 30-day mortality than that of patients with other infections (63.8% versus 33.4%), and (iii) the effect of CRE on mortality was probably influenced by the fact that those patients received lower rates of empirical therapy with active antibiotics and were also diagnosed in more advanced stages of sepsis (septic shock). Those findings point to the need for rapid diagnostic methods to identify these bacteria and the need to adjust therapeutic guidelines to this worrisome epidemiological scenario., (Copyright © 2019 Sabino et al.)

Background: Dengue is an important mosquito-borne tropical viral disease and dual infection, though rare, has been regarded as a risk factor for severe disease and mortality. However, few studies focused on bloodstream infections (BSIs) and empirical antibiotic therapy rarely addressed., Methods: Dengue patients with concurrent or subsequent BSIs between July 1 and December 31, 2015 were included. Clinical information, laboratory data, and drug susceptibility data were collected., Results: Totally 80 patients, with an in-hospital mortality rate of 32.5%, were included and categorized into three groups. 32 patients in Group I (BSI onset within 48 h after admission), 32 in Group II (between 48 h and one week), and 16 in Group III (more than one week). Patients in Group I were older (mean age: 75.6 vs. 72.6 or 69.6 years; P = 0.01) and had a higher Charlson comorbidity index (3.1 vs. 1.8 or 1.9; P = 0.02) than those in Group II or III. Streptococcus species (28.9%, 11/38) and Escherichia coli (23.7%, 9/38) were major pathogens in Group I. Enterobacteriaceae (38.2%, 13/34) isolates predominated in Group II. Fatal patients more often received inappropriate empirical antibiotic than the survivors (61.5% vs. 35.2%; P = 0.03). According to susceptibility data, pathogens in Group I and II shared similar susceptibility profiles, and levofloxacin, cefepime, or piperacillin/tazobactam, can be empirically prescribed for those hospitalized within one week., Conclusions: BSI pathogens vary among dengue patients. For adults with dengue and suspected BSI hospitalized within one week, empirical antimicrobial agents are recommended., (Copyright © 2018. Published by Elsevier B.V.)

Background: Pantoea is a Gram-negative, non-encapsulated, non-spore-forming, ubiquitous straight rod which can be isolated from geographical and ecological sources such as plant surfaces, buckwheat seeds, human feces, and the environment. The genus Pantoea is a rare pathogen in a clinical setting, and is divided into 20 different species such as Pantoea agglomerans, Pantoea ananatis, Pantoea deleyi, Pantoea dispersa, Pantoea septica, Pantoea stewartii or Pantoea rwandensis. Pantoea dispersa has been reported to cause other infections, including respiratory infections, neonatal sepsis, and bloodstream infections. We report a case of Pantoea dispersa bacteremia caused by acute cholangitis. This is the first case report of Pantoea dispersa bacteremia caused by acute cholangitis as far as we had searched., Case Presentation: A 38-year-old Japanese woman suffered from acute cholangitis; a blood culture showed that Gram-negative rod was positive. The treatment was successful with intravenously administered meropenem, and it was switched to orally administered levofloxacin according to microbiological susceptibility. The organism was identified as Pantoea dispersa by both genetic investigation by 16S ribosomal RNA and additional biochemical tests. To the best of our knowledge, this is the first case report of Pantoea dispersa bacteremia caused by acute cholangitis., Conclusion: The epidemiology and clinical features of Pantoea dispersa are still unknown. More cases of infections caused by Pantoea dispersa might be revealed with advancing technical methods, such as matrix-assisted laser desorption/ionization time-of-flight mass spectrometry or 16S ribosomal RNA analysis. Physicians must know that a variety of infections caused by Pantoea dispersa could occur in immunocompromised as well as immunocompetent patients.

Carba-NP original report for blood cultures described the need of subculture and mechanical lysis before testing, reaching the turnaround time of approximately 4 hours for sample preparation. We tested 100 consecutive blood cultures positive for Gram-negative bacilli on the Gram stain from a large clinical laboratory. Bacterial pellets were prepared by centrifugation and submitted to Carba-NP and Blue-Carba tests and used further to prepare smears for Vitek MS. Results obtained with colonies grown on sheep blood agar using the same methodologies were used as the gold standard. Carbapenemase genes were confirmed by PCR and DNA sequencing. Vitek MS identified correctly 86% of the samples. Of note, 7% of the samples were incorrectly reported by the instrument as containing a single isolate. KPC-2 was the predominant carbapenemase detected. There was 100% concordance for both negative and positive results for Carba-NP. In contrast, for Blue-Carba the concordance for positive results was 92.8%, and 41% of strains negative for carbapenemases presented a yellowish color on control well turning the test non-interpretable. The turnaround time for sample preparation for preparing the pellet was 13 min, and no subculture or mechanical lysis is needed when detecting KPC production in Enterobacterales.

Background: Carbapenem resistant Enterobacteriaceae (CRE) has become a serious public health problem. Limited information is available about the treatment options that physicians used to fight CRE infections and related clinical outcomes in China. The aim of the present study was to explore the treatment options and clinical outcomes of patients with CRE bloodstream infection (BSI) in a Chinese teaching hospital., Methods: A retrospective study was conducted during 2011 to 2015 in one Chinese teaching hospital. Demographic, microbiological and clinical characteristics of enrolled subjects were collected from medical records. Data were analyzed by Kaplan-Meier graphs, log-rank test, and Cox regression., Results: A total of 98 inpatients with CRE BSI were enrolled in this study. For empirical therapy, 26 patients (26.5%) received at least one active drug within 48h after the onset of bacteremia. For definitive treatment, 59.2% (49/82) patients received at least one active drug and 40.2% (33/82) patients received therapy with no active drug. The overall 30-day mortality was 53.1% (52/98). Adverse outcome appeared to be more likely among patients with previous carbapenem exposure, neutropenia, severity of septic and time to initiation of BSIs. There was no significant difference in the mortality between the two groups of patients with combination therapy versus monotherapy (p=0.105). Severity of sepsis and neutropenia were identified as independent predictors of mortality., Conclusions: Our study demonstrated a high mortality associated with CRE BSI and a high percentage of inappropriate empirical treatment for CRE BSI patients in a Chinese teaching hospital. Particular attention should be given to the patients with CRE BSI., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pemphigus vulgaris is an autoimmune bullous disease that involves the skin and mucous membranes. Current therapies aim to decrease antibody production by means of the use of systemic corticosteroids, immunosuppressive agents and, recently, rituximab, an anti-CD20 monoclonal antibody. However, the chronic immune suppression could entail complications, like infections and secondary malignancies. We describe a case of a patient with pemphigus who developed a sepsis due to Citrobacter freundii infection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Current guidelines for the empirical antibiotic treatment predict the presence of third-generation cephalosporin-resistant enterobacterial bacteraemia (3GCR-E-Bac) in case of infection only poorly, thereby increasing unnecessary carbapenem use. We aimed to develop diagnostic scoring systems which can better predict the presence of 3GCR-E-Bac., Methods: A retrospective nested case-control study was performed that included patients ≥18 years of age from eight Dutch hospitals in whom blood cultures were obtained and intravenous antibiotics were initiated. Each patient with 3GCR-E-Bac was matched to four control infection episodes within the same hospital, based on blood-culture date and onset location (community or hospital). Starting from 32 commonly described clinical risk factors at infection onset, selection strategies were used to derive scoring systems for the probability of community- and hospital-onset 3GCR-E-Bac., Results: 3GCR-E-Bac occurred in 90 of 22 506 (0.4%) community-onset infections and in 82 of 8110 (1.0%) hospital-onset infections, and these cases were matched to 360 community-onset and 328 hospital-onset control episodes. The derived community-onset and hospital-onset scoring systems consisted of six and nine predictors, respectively. With selected score cut-offs, the models identified 3GCR-E-Bac with sensitivity equal to existing guidelines (community-onset: 54.3%; hospital-onset: 81.5%). However, they reduced the proportion of patients classified as at risk for 3GCR-E-Bac (i.e. eligible for empirical carbapenem therapy) with 40% (95%CI 21-56%) and 49% (95%CI 39-58%) in, respectively, community-onset and hospital-onset infections., Conclusions: These prediction scores for 3GCR-E-Bac, specifically geared towards the initiation of empirical antibiotic treatment, may improve the balance between inappropriate antibiotics and carbapenem overuse., (Copyright © 2018 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Plazomicin is an FDA-approved aminoglycoside for the treatment of complicated urinary tract infections. In this open-label study, 24 adults with normal renal function or mild, moderate, or severe renal impairment ( n = 6 per group) received a single 7.5-mg/kg of body weight dose of plazomicin as a 30-min intravenous infusion. Total clearance declined with renal impairment, resulting in 1.98-fold and 4.42-fold higher plazomicin exposures, as measured by the area under the concentration-time curve from 0 h to infinity, in subjects with moderate and severe impairment, respectively, than in subjects with normal renal function. (This study has been registered at ClinicalTrials.gov under identifier NCT01462136.)., (Copyright © 2018 Komirenko et al.)

Objectives: Carbapenems are widely recommended for the treatment of infections caused by ESBL producers however, non-carbapenem β-lactams such as β-lactam/β-lactamase inhibitor combinations (BLBLIs) deserve consideration for the treatment of ESBL infections. Cefoperazone/sulbactam is one of the most commonly used BLBLIs in China; however, few outcome studies have been reported. In this study, we evaluated and compared the clinical efficacy of cefoperazone/sulbactam with that of a carbapenem in the treatment of bloodstream infections (BSIs) caused by ESBL-producing Enterobacteriaceae., Methods: Patients with monomicrobial ESBL-producing Enterobacteriaceae BSIs empirically treated with cefoperazone/sulbactam or a carbapenem were included. Outcomes of interest were clinical response and 14 day mortality. To make a comparison of the efficacy of cefoperazone/sulbactam and a carbapenem more accurate, propensity score analysis was performed., Results: No statistically significant differences in success rates or 14 day mortality were found between the cefoperazone/sulbactam (n = 17) and carbapenem (n = 46) groups. In the propensity score analysis with 17 case-control pairs, the success rate in the cefoperazone/sulbactam group (70.6%, 12/17) was lower than that in the carbapenem group (94.1%, 16/17), but the difference was not significant (P = 0.175). Sepsis-related mortality and 14 day mortality rates did not significantly differ either (P = 1.000 for both). In the cefoperazone/sulbactam group, 66.7% (2/3) of the patients with a Pitt bacteraemia score ≥5 died within 14 days, whereas none (0/14) of the patients with a Pitt bacteraemia score <5 died within 14 days (P = 0.022)., Conclusions: This study showed that cefoperazone/sulbactam had a lower success rate and a higher 14 day mortality rate compared with carbapenems, although the differences were not statistically significant because of the small patient numbers. Further evaluation of cefoperazone/sulbactam is needed.

This report describes a case of systemic bacterial infection caused by Edwardsiella tarda in a Western African lungfish (Protopterus annectens) exposed to poor environmental and husbandry conditions. The fish presented with a large, external ulcerative lesion and died 2 weeks after developing anorexia. Histological evaluation revealed multifocal areas of necrosis and heterophilic and histiocytic inflammation throughout multiple tissues. Gram stain identified small numbers of intra- and extracellular monomorphic Gram-negative 1 to 2 μm rod-shaped bacilli. Cytology of lung granuloma, kidney and testes imprints identified heterophilic inflammation with phagocytosis of small monomorphic bacilli and some heterophils exhibiting cytoplasmic projections indicative of heterophil extracellular traps (HETs). Initial phenotypic analysis of isolates from coelomic fluid cultures identified E. tarda. Subsequent molecular analysis of spleen, liver and intestine DNA using an E. tarda-specific endpoint PCR assay targeting the bacterial fimbrial subunit yielded a 115 bp band. Sequencing and BLASTN search revealed the sequence was identical (76/76) to E. tarda strain FL95-01 (GenBank acc. CP011359) and displayed 93% sequence identity (66/71) to Edwardsiella hoshinae strain ATCC 35051 (GenBank acc. CP011359). This is the first report of systemic edwardsiellosis in a lungfish with concurrent cytologically identified structures suggestive of HETs., (© 2018 John Wiley & Sons Ltd.)

Sepsis resulting from microbial colonization of the bloodstream is a serious health concern associated with high mortality rates. The objective of this study was to define the physiologic requirements of Citrobacter freundii in the bloodstream as a model for bacteremia caused by opportunistic Gram-negative pathogens. A genetic screen in a murine host identified 177 genes that contributed significantly to fitness, the majority of which were broadly classified as having metabolic or cellular maintenance functions. Among the pathways examined, the Tat protein secretion system conferred the single largest fitness contribution during competition infections and a putative Tat-secreted protein, SufI, was also identified as a fitness factor. Additional work was focused on identifying relevant metabolic pathways for bacteria in the bloodstream environment. Mutations that eliminated the use of glucose or mannitol as carbon sources in vitro resulted in loss of fitness in the murine model and similar results were obtained upon disruption of the cysteine biosynthetic pathway. Finally, the conservation of identified fitness factors was compared within a cohort of Citrobacter bloodstream isolates and between Citrobacter and Serratia marcescens, the results of which suggest the presence of conserved strategies for bacterial survival and replication in the bloodstream environment.

Objectives: Tigecycline (TIG) is one of the most important antimicrobial agents used to treat infections by multidrug-resistant bacteria. However, rates of TIG-resistant pathogens have increased recently. This study was conducted to identify the antimicrobial susceptibility profiles and to investigate the role of efflux pumps in high-level TIG-resistant Enterobacter spp. isolates causing bacteraemia., Methods: A total of 323 Enterobacter spp. causing bacteraemia were collected from eight hospitals in various regions of South Korea. Minimum inhibitory concentrations (MICs) were determined by the broth microdilution method and Etest. Expression levels of the efflux pump gene acrA and its regulators (ramA and rarA) were examined by quantitative real-time PCR. Isolate relatedness was determined by multilocus sequence typing (MLST)., Results: Among the 323 clinical isolates included in this study, 37 (11.5%) were TIG-non-susceptible, of which 8 isolates were highly resistant to TIG with MICs of 8mg/L (4 isolates) or 16mg/L (4 isolates). All high-level TIG-resistant isolates showed increased expression of acrA (0.93-13.3-fold) and ramA (1.4-8.2-fold). Isolates with a tigecycline MIC of 16mg/L also showed overexpression of rarA compared with TIG-susceptible isolates., Conclusions: In this study, overexpression of acrA, ramA and rarA was observed in high-level TIG-resistant Enterobacter spp. isolates. We suggest that rarA might be involved in the regulation of acrA overexpression in high-level TIG-resistant Enterobacter spp. isolates. Efflux pump-mediated resistance should be closely monitored because it could be indirectly attributed to the use of other antibiotics transported by the same efflux pump., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Raoultella planticola, a Gram-negative, aerobic bacillus commonly isolated from soil and water, rarely causes invasive infections in humans. Septic shock from R. planticola after burn injury has not been previously reported., Case Presentation: A 79-year-old male was admitted to the emergency intensive care unit after extensive flame burn injury. He accidently caught fire while burning trash and plunged into a nearby tank filled with contaminated rainwater to extinguish the fire. The patient developed septic shock on day 10. The blood culture detected R. planticola, which was identified using the VITEK-2 biochemical identification system. Although appropriate antibiotic treatment was continued, the patient died on day 12., Conclusions: Clinicians should be aware of fatal infections in patients with burn injury complicated by exposure to contaminated water.

Pantoea agglomerans is an environmental Gram-negative bacterium that rarely is responsible for the infections in humans but it is often a causative factor of a number of occupational diseases. This study evaluated the clinical and microbiological characteristics and pathogenicity of P. agglomerans in children. We retrospectively reviewed microbiological test results for all children (1 month old to 18 years old) who were admitted to our pediatric hospital between January 2000 to June 2015 and had positive clinical specimen cultures for P. agglomerans. Isolates were identified using conventional tests and the BBL Crystal E/NF ID or MALDI-TOF MS systems. Antibiotic susceptibilities were evaluated using the Kirby-Bauer disc diffusion method. We identified fifteen positive cultures from 14 patients with confirmed infections. The positive specimens included pus, urine, tracheal aspirate, blood, and central venous line samples that yielded P. agglomerans. The median patient age was 8.8 years (range: 1.5 months to 16.5 years), and all patients had underlying comorbidities. Five patients had medical devices, and two devices were removed. The most common P. agglomerans infections involved wound infections (35.7%), pneumonia (21.4%), and urinary tract infections (21.4%). Three patients had concomitant infections (Enterococcus faecium, Pseudomonas aeruginosa, and Aspergillus fumigatus). Five patients had anemia. Three patients (21.4%) died, and all three had carbapenem-resistant P. agglomerans that was detected after the first week of hospitalization; two cases involved pneumonia, which was ineffectively treated. P. agglomerans infections may be life-threatening, especially in young patients with pneumonia. Hospital-acquired P. agglomerans may have different pathogenicity and clinical features, compared to community-acquired P. agglomerans, although further studies are needed to understand the drug-resistance patterns in this bacterium., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Bloodstream infection (BSI) represents an important source of morbidity and mortality, as well as an increasing therapeutic challenge, among solid organ transplant recipients. Understanding the epidemiological and microbiological characteristics of BSI following renal transplantation is paramount to the implementation of appropriate preventative and therapeutic measures., Methods: We conducted a retrospective review of all BSI episodes occurring between July 2009 and April 2016 in adult patients, who received a renal transplant at Royal Free London hospital., Results: A total of 116 episodes of BSI occurred in 87 patients, 43 (49.4%) of them men. The mean age at BSI was 54.37 ± 12.81 years. Late-onset BSI (>12 months post transplant) represented 55.2%, with the median time to BSI being 16.28 month. Sixty-seven patients had single BSI and 20 had recurrent episodes. Enterobacteriaceae were responsible for 73.7% of BSI, with Escherichia coli the commonest causative organism (46.6%). The urinary tract was the most frequent source of infection in 56.9%. Among the E. coli infections, 100% of the tested isolates were sensitive to meropenem, ertapenem, tigecycline, and fosfomycin, and >90% were sensitive to piperacillin-tazobactam, amikacin, and colistin. Lower susceptibility rates were encountered for ceftriaxone (70.6%), amoxicillin-clavulanic acid (48.1%), cotrimoxazole (40.4%), trimethoprim (37.3%), and amoxicillin (21.6%). During BSI, the median serum creatinine increased from a reference of 131 μmol/L to a peak of 219 μmol/L. Acute kidney injury (AKI) complicated 75/116 BSI episodes (64.7%)-stage 1: 34, stage 2: 31, and stage 3 AKI: 10 episodes. After 3 months, the median creatinine remained elevated at 146 μmol/L. The 3-month mortality rate was 8% (7/87), and the death-censored graft loss was 6.9% (6/87). No significant difference was seen between BSI of urinary and non-urinary sources in the incidence of AKI (χ 2  = 0.24, P = .6) or the percentage of creatinine change between baseline and peak and 3-month creatinines (P = .2 and .7 respectively)., Conclusions: Urinary tract infection remains the commonest source of systemic infection among kidney transplant recipients and resistance to commonly used frontline antibiotics is common; thus, prevention and early detection are paramount. The appropriate choice of initial empirical antibiotic is vital to improve the outcome. Each unit needs to understand the epidemiology of organisms causing BSI in their transplant patients and their antibiotic susceptibilities., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The aim of the present study was to examine the applicability of the direct determination of trace and major element concentrations in serum samples collected from Holstein dairy cattle with acute coliform mastitis (n = 53) compared with a healthy control group (n = 39). Twenty-eight elements (Na, Mg, Al, Si, S, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Ce, Ni, Cu, Zn, Ga, As, Se, Br, Rb, Sr, Y, Zr, Nb, Mo, and Pb) were detected by particle-induced X-ray emission (PIXE). Significant differences were observed in serum K, Fe, Zn, and Br concentrations, but not in those of the remaining twenty-four elements. Furthermore, serum Fe concentrations (0.751 ± 0.583 μg/ml, n = 18) were significantly lower in dairy cattle with a poor prognosis than in those with a good prognosis (0.945 ± 0.393 μg/ml, n = 35, P < 0.05) and healthy controls (1.458 ± 0.391 μg/ml, n = 39, P < 0.01). We proposed a diagnostic cut-off point for serum Fe concentrations of <0.82 μg/ml based on receiver operating characteristic (ROC) curves in order to identify cattle with a poor prognosis. The results of the present study indicated that assessing the elemental composition of serum, particularly iron, is a promising prognostic tool for determining the outcomes of cattle with severe acute coliform mastitis.

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are associated with considerable mortality. As mechanisms of carbapenem resistance are heterogeneous, it is unclear if mortality differs based on resistance mechanisms. We sought to determine whether CRE resistance mechanism determination is prognostically informative., Methods: We conducted an observational study comparing 14-day mortality between patients with carbapenemase-producing (CP)-CRE compared with non-CP-CRE bacteremia. Clinical data were collected on all patients. A comprehensive DNA microarray-based assay was performed on all isolates to identify β-lactamase-encoding genes., Results: There were 83 unique episodes of monomicrobial CRE bacteremia during the study period: 37 (45%) CP-CRE and 46 (55%) non-CP-CRE. The majority of CP-CRE isolates were bla KPC (92%), followed by bla NDM (5%) and bla OXA-48-type (3%). CP-CRE isolates were more likely to have meropenem minimum inhibitory concentrations (MICs) ≥16 µg/mL, while non-CP-CRE isolates were more likely to have meropenem MICs ≤1 µg/mL (P value < .001). A total of 18 (22%) patients died within 14 days, including 12 (32%) in the CP-CRE group and 6 (13%) in the non-CP-CRE group. Adjusting for severity of illness on day 1 of bacteremia, underlying medical conditions, and differences in antibiotic treatment administered, the odds of dying within 14 days were more than 4 times greater for CP-CRE compared with non-CP-CRE bacteremic patients (adjusted odds ratio, 4.92; 95% confidence interval, 1.01-24.81)., Conclusion: Our findings suggest that CP-CRE may be more virulent than non-CP-CRE and are associated with poorer outcomes. This underscores the added importance of delineating underlying resistance mechanisms of CRE to direct antibiotic treatment decisions., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

Background: Pediatric bloodstream infections (BSIs) with Extended-Spectrum Beta-Lactamase- producing Enterobacteriaceae (ESBL-PE) are associated with worse clinical outcomes. We aimed to estimate the prevalence of and the mortality associated with ESBL-PE in this patient population., Methods: A systematic review and meta-analysis using PubMed and EMBASE and included studies reporting the prevalence of ESBL-PE among confirmed BSIs in patients <19 years old., Results: Twenty three (out of 1,718 non-duplicate reports) studies that provided data on 3,381 pediatric BSIs from 1996 to 2013 were included. The prevalence of ESBL-PE was 9% [95%CI (6, 13)] with an annual increase of 3.2% (P = 0.04). The prevalence was 11% [95%CI (6, 17)] among neonates, compared to 5% [95%CI (0, 14)] among children older than 28 days. The pooled prevalence was 15% in Africa [95%CI (8, 23)], 12% in South America [95%CI (5, 23)], 11% in India [95%CI (7, 17)], 7% in the rest of Asia [95%CI (0, 22)], 4% in Europe [95%CI (1, 7)] and 0% in Oceania [95%CI (0, 3)]. Importantly, the mortality in neonates with BSI due to ESBL-PE was 36% [95%CI (22, 51)], compared to 18% [95%CI (15, 22)] among all other neonates with BSI and this difference was statistically significant (P = 0.01)., Conclusions: In the pediatric population, the prevalence of BSI due to ESBL-PE is significant and is associated with increased mortality in neonates. Further studies are warranted to establish a high-risk group and the evaluation of preventive measures, such as antibiotic stewardship programs and infection control measures, in this population is urgently needed., Competing Interests: The authors have declared that no competing interests exist.

The purpose of this study was to determine prevalence and molecular characterization of plasmid-mediated quinolone resistance (PMQR) genes [qnrA, qnrB, qnrC, qnrD, qnrS, aac(6')-Ib-cr, qepA, and oqxAB] among extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. isolates from bloodcultures in Hungary. A total of 103 isolates were tested for quinolone susceptibility by microdilution method and PMQR genes were detected by polymerase chain reaction. About 40 ESBL-producing E. coli (39%) and 50 ESBL-producing Klebsiella spp. strains (48%) were resistant to ciprofloxacin; 40 ESBL-producing E. coli (39%) and 47 ESBL-producing Klebsiella spp. strains (45%) were resistant to levofloxacin; and 88 strains including 40 ESBL-producing E. coli (39%) and 48 (47%) ESBL-producing Klebsiella spp. were resistant to moxifloxacin. Among the 103 ESBL-producing isolates, 77 (75%) isolates (30 E. coli and 47 Klebsiella spp.) harbored PMQR genes. The most commonly detected gene was aac(6')-Ib-cr (65%). The occurrence of qnrS gene was 6%. Interestingly, qnrA, qnrB, qnrC, qnrD, and qepA were not found in any isolates. Among 77 PMQR-positive isolates, 27 (35.1%) and 1 (1.3%) carried two and three different PMQR genes, respectively. Only Klebsiella spp. harbored more than one PMQR genes. Observing prevalence of PMQR genes in the last 8 years, the increasing incidence of aac(6')-Ib-cr and oqxAB can be seen. Our results highlight high frequency of PMQR genes among ESBL-producing Klebsiella pneumoniae and E. coli isolates with an increasing dynamics in Hungary.

Procalcitonin (PCT) levels are elevated early after birth in newborn infants; however, the physiological features and reference of serum PCT concentrations have not been fully studied in preterm infants. The aims of the current study were to establish an age-specific percentile-based reference curve of serum PCT concentrations in preterm infants and determine the features. The PCT concentration peaked in infants at 1 day old and decreased thereafter. At 1 day old, serum PCT concentrations in preterm infants <34 weeks' gestational age were higher than those in late preterm infants between 34 and 36 weeks' gestational age or term infants ≥37 weeks' gestational age. Although the 50-percentile value in late preterm and term infants reached the adult normal level (0.1 ng/mL) at 5 days old, it did not in preterm infants. It took 9 weeks for preterm infants to reach it. Serum PCT concentrations at onset in late-onset infected preterm infants were over the 95-percentile value. We showed that the physiological feature in preterm infants was significantly different from that in late preterm infants, even in those <37 weeks' gestational age. To detect late-onset bacterial infection and sepsis, an age-specific percentile-based reference curve may be useful in preterm infants.

The Clinical and Laboratory Standards Institute (CLSI) revised cefepime (CFP) breakpoints forEnterobacteriaceaein 2014, and MICs of 4 and 8 μg/ml were reclassified as susceptible-dose dependent (SDD). Pediatric dosing to provide therapeutic concentrations against SDD organisms has not been defined. CFP pharmacokinetics (PK) data from published pediatric studies were analyzed. Population PK parameters were determined using NONMEM, and Monte Carlo simulation was performed to determine an appropriate CFP dosage regimen for SDD organisms in children. A total of 664 CFP plasma concentrations from 91 neonates, infants, and children were included in this analysis. The median patient age was 1.0 month (interquartile range [IQR], 0.2 to 11.2 months). Serum creatinine (SCR) and postmenstrual age (PMA) were covariates in the final PK model. Simulations indicated that CFP dosing at 50 mg/kg every 8 h (q8h) (as 0.5-h intravenous [i.v.] infusions) will maintain free-CFP concentrations in serum of >4 and 8 μg/ml for >60% of the dose interval in 87.1% and 68.6% of pediatric patients (age, ≥30 days), respectively, and extending the i.v. infusion duration to 3 h results in 92.3% of patients with free-CFP levels above 8 μg/ml for >60% of the dose interval. CFP clearance (CL) is significantly correlated with PMA and SCR. A dose of 50 mg/kg of CFP every 8 to 12 h does not achieve adequate serum exposure for older children with serious infections caused by Gram-negative bacilli with a MIC of 8 μg/ml. Prolonged i.v. infusions may be useful for this population., (Copyright © 2016, American Society for Microbiology. All Rights Reserved.)

Background: Severe mammary tissue damage during acute coliform mastitis in cattle is partially caused by oxidative stress. Although considered a gold standard biomarker in some human conditions, the utility of 15-F2t-Isoprostanes (15-F2t-Isop) in detecting oxidative stress in dairy cattle has not been validated., Hypothesis: Concentrations of 15-F2t-Isop in plasma, urine, and milk correlate with changes in oxidant status during severe coliform mastitis in cattle., Animals: Eleven lactating Holstein-Friesian dairy cows in their 3rd-6th lactation., Methods: A case-control study using cows with acute coliform mastitis and matched healthy controls were enrolled into this study. Measures of inflammation, oxidant status, and redox status in plasma and milk samples were quantified using commercial assays. Plasma, urine, and milk 15-F2t-Isop were quantified by liquid chromatography/tandem mass spectrometry (LC-MS/MS) and ELISA assays. Data were analyzed by Wilcoxon rank sum tests (α = 0.05)., Results: Plasma 15-F2t-Isop quantified by LC-MS/MS was positively correlated with systemic oxidant status (r = 0.83; P = .01). Urine 15-F2t-Isop quantified by LC-MS/MS did not correlate with systemic oxidant status, but was negatively correlated with redox status variables (r = -0.83; P = .01). Milk 15-F2t-Isop quantified by LC-MS/MS was negatively correlated (r = -0.86; P = .007) with local oxidant status. Total 15-F2t-Isop in milk quantified by a commercial ELISA (cbELISA) was positively correlated with oxidant status in milk (r = 0.98; P < .001)., Conclusions and Clinical Importance: Free plasma 15-F2t-Isop quantified by LC-MS/MS and total milk 15-F2t-Isop quantified by cbELISA are accurate biomarkers of systemic and mammary gland oxidant status, respectively. Establishing reference intervals for free and total 15-F2t-Isops for evaluating oxidative stress in dairy cows should currently be based on the LC-MS/MS method., (Copyright © 2015 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Infections with Cronobacter sakazakii are mainly described among neonates and infants, with contaminated powdered infant formulas most often incriminated as the cause. We describe here a case of C. sakazakii bacteremia secondary to a suspected cyst infection in a heart-and-kidney transplant patient with polycystic kidney disease., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The study objective was to evaluate the population pharmacokinetics and pharmacodynamics of extended-infusion piperacillin-tazobactam in children hospitalized in an intensive care unit. Seventy-two serum samples were collected at steady state from 12 patients who received piperacillin-tazobactam at 100/12.5 mg/kg of body weight every 8 h infused over 4 h. Population pharmacokinetic analyses were performed using NONMEM, and Monte Carlo simulations were performed to estimate the piperacillin pharmacokinetic profiles for dosing regimens of 80 to 100 mg/kg of the piperacillin component given every 6 to 8 h and infused over 0.5, 3, or 4 h. The probability of target attainment (PTA) for a cumulative percentage of the dosing interval that the drug concentration exceeds the MIC under steady-state pharmacokinetic conditions (TMIC) of ≥50% was calculated at MICs ranging from 0.25 to 64 mg/liter. The mean ± standard deviation (SD) age, weight, and estimated glomerular filtration rate were 5 ± 3 years, 17 ± 6.2 kg, and 118 ± 41 ml/min/1.73 m(2), respectively. A one-compartment model with zero-order input and first-order elimination best fit the pharmacokinetic data for both drugs. Weight was significantly associated with piperacillin clearance, and weight and sex were significantly associated with tazobactam clearance. Pharmacokinetic parameters (mean ± SD) for piperacillin and tazobactam were as follows: clearance, 0.22 ± 0.07 and 0.19 ± 0.07 liter/h/kg, respectively; volume of distribution, 0.43 ± 0.16 and 0.37 ± 0.14 liter/kg, respectively. All extended-infusion regimens achieved PTAs of >90% at MICs of ≤16 mg/liter. Only the 3-h infusion regimens given every 6 h achieved PTAs of >90% at an MIC of 32 mg/liter. For susceptible bacterial pathogens, piperacillin-tazobactam doses of ≥80/10 mg/kg given every 8 h and infused over 4 h achieve adequate pharmacodynamic exposures in critically ill children., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

We examined patients with type 1 (DM 1) and type 2 (DM 2) diabetes mellitus. The concentration of C-reactive protein (CRP) in the blood and levels of serum antibodies to different classes of enterobacterial lipopolysaccharides (LPS) were determined by ELISA. Using cluster analysis it was shown that in 40.8% DM-1 patients the increased concentration of CRP is associated with a decrease in the levels of serum anti-LPS-IgA, anti-LPS-IgM and anti-LPS-IgG. In 56.7% of DM-2 patients with increased concentration of CRP levels of serum anti-LPS-IgA and anti-LPS-IgM were not significantly different from the normal values, but the levels of serum anti-LPS-IgG were significantly increased. Activation of inflammation and increase of concentration of the CRP in the blood of DM-2 patients is accompanied by a significant increase in the levels of serum anti-LPS-A and anti-LPS-G, as well as the tendency to reduce the levels of anti-LPS-IgM. The results of this study suggest an association between low intensity inflammation and immune response to enterobacterial LPS in type 1 and 2 diabetes mellitus.

Introduction: Although dengue management guidelines do not advice on use of antibiotics in dengue shock syndrome, unrecognised bactraemia is likely to contribute to morbidity and mortality., Objectives: To assess the occurance of secondary bacteraemia in adult patients with prolonged dengue fever., Methods: A prospective study was conducted recruiting patients with confirmed acute dengue infection who had prolonged fever (>5 days). Two sets of blood cultures were taken in such patients prior to institution of antibiotic therapy. Demographic, clinical, haematological and biochemical parameters were recorded. Development of ascites and pleural effusions were detected using ultrasonography., Results: Fourty patients (52.5% males) with a mean age of 29.8 years (SD 13.6) were studied. The average duration of fever was 7.9 days (SD 1.8). Ten patients (25%) had bacterial isolates in their blood cultures; Staphylococcus aureus (n=2), coliforms (n=3), pseudomonas (n=1) and 4 had mixed growths. The culture positive group had severe body aches at admission and higher fever, third space fluid accumulation, a significant drop in platelets and a higher CRP., Conclusions: A quarter of dengue patients with prolonged fever had a bacterial isolate. Culture positive patients appeared more ill with body aches and had higher degrees of fever during the latter part of the illness. Increased vascular permeability may predispose to bacterial seepage into blood. Although white cell count is not helpful in detecting bacteraemia, low platelet count and elevation of CRP seem to be helpful.

Objective: To limit the regulation of antibiotherapy in neonatal early infections by improving the tracking and the diagnosis of infected newborns., Patients and Method: First part: analysis of procalcitonin (PCT) in the cord. Method of tracking: 87 cases. Cut-off PCT=0.5 ng/mL. Measurement of CRP at 24 h if PCT>0.5 ng/mL. Second part: analysis of the PCT between 4 h and 6 h in the event of infectious risk; 47 cases over 6 months. Cut-off PCT=2 ng/mL. Measurement of CRP at 12 h and/or 24 h., Results: In 2012, there were 10 antibiotherapies prescribed per 1000 births versus 30/1000 in 2011. A reduction in two thirds of the indications was seen., Conclusion: Markers of inflammation, i.e., the PCT (good specificity and good negative predictive value from 0 to 6 h of life) and CRP (good sensitivity and good positive predictive value from 12 to 24 of life) should be combined in time., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

We collected and analyzed the time to detection (TTD) of blood cultures in the BacT/Alert automated system from 2002 to 2007. Among the 10,893 monomicrobial isolates from a total of 133,735 blood culture sets, the recoveries of aerobic bottles were compared with those of anaerobic bottles in this study. Significantly more Gram-positive cocci (except Staphylococcus aureus and enterococci), glucose nonfermentative Gram-negative bacteria, and yeast were recovered from aerobic bottles than from anaerobic bottles. The average TTD was 19.0 hr and 20.1 hr for the aerobic and anaerobic bottles, respectively, and 96.8% of the microorganisms were detected within the first 72 hr. Of the 5,489 microorganisms recovered from both of the blood culture bottle pair, microbial growth was significantly more often detected first in the anaerobic bottles than the aerobic bottles for Enterobacteriaceae except Serratia marcescens, while S. aureus, coagulase-negative staphylococci and Pseudomonas aeruginosa were more often detected first in the aerobic bottles. According to these data, we conclude that the earlier positivity of anaerobic bottles is a useful marker for rapid presumptive identification of Enterobacteriaceae infection., (© 2013 Wiley Periodicals, Inc.)