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Background. The spread of Klebsiella pneumoniae (Kp) strains that produce K. pneumoniae carbapenemases (KPCs) has become a significant problem, and treatment of infections caused by these pathogens is a major challenge for clinicians. Methods. In this multicenter retrospective cohort study, conducted in 3 large Italian teaching hospitals, we examined 125 patients with bloodstream infections (BSIs) caused by KPC-producing Kp isolates (KPC-Kp) diagnosed between 1 January 2010 and 30 June 2011. The outcome measured was death within 30 days of the first positive blood culture. Survivor and nonsurvivor subgroups were compared to identify predictors of mortality. Results. The overall 30-day mortality rate was 41.6%. A significantly higher rate was observed among patients treated with monotherapy (54.3% vs 34.1% in those who received combined drug therapy; P = .02). In logistic regression analysis, 30-day mortality was independently associated with septic shock at BSI onset (odds ratio [OR]: 7.17; 95% confidence interval [CI]: 1.65–31.03; P = .008); inadequate initial antimicrobial therapy (OR: 4.17; 95% CI: 1.61–10.76; P = .003); and high APACHE III scores (OR: 1.04; 95% CI: 1.02–1.07; P < .001). Postantibiogram therapy with a combination of tigecycline, colistin, and meropenem was associated with lower mortality (OR: 0.11; 95% CI: .02–.69; P = .01). Conclusions. KPC-Kp BSIs are associated with high mortality. To improve survival, combined treatment with 2 or more drugs with in vitro activity against the isolate, especially those also including a carbapenem, may be more effective than active monotherapy.

We retrospectively studied patients diagnosed with P. aeruginosa bloodstream infections (BSIs) in two Italian university hospitals. Risk factors for the isolation of multidrug-resistant (MDR) or non-MDR P. aeruginosa in blood cultures were identified by a case-case-control study, and a cohort study evaluated the clinical outcomes of such infections. We identified 106 patients with P. aeruginosa BSI over the 2-year study period; 40 cases with MDR P. aeruginosa and 66 cases with non-MDR P. aeruginosa were compared to 212 controls. Independent risk factors for the isolation of MDR P. aeruginosa were: presence of central venous catheter (CVC), previous antibiotic therapy, and corticosteroid therapy. Independent risk factors for non-MDR P. aeruginosa were: previous BSI, neutrophil count <500/mm3, urinary catheterization, and presence of CVC. The 21-day mortality rate of all patients was 33·9%. The variables independently associated with 21-day mortality were presentation with septic shock, infection due to MDR P. aeruginosa, and inadequate initial antimicrobial therapy.

Introduction/Background*The purpose of this paper is to analyze data related to infections of patients suffering from gynecological malignancies, particularly after surgical procedures. Furthermore, we performed an economic analysis to provide an overview of HAIs-related costs.MethodologyWe retrospectively collected data of the culture samples, collected in the microbiology laboratory, of patients recovered in the Oncological Gynecology Department of the Fondazione Policlinico ”Agostino Gemelli” IRCCS, from 1st January 2017 to 31th December 2018. The data concerned both ordinary and emergency hospitalizations. For each patient, we collected data on germs responsible of infection and on the site of the infectionResult(s)*323 gynecological cancer patients with HAIs were identified. 249 patients had undergone surgery in the previous 30 days and 74 were on chemotherapy treatment or in the follow-up phase. The most common HAIs were urinary infections (57.9%), surgical wound infections were present in 42.1%. 14.5% had central venous catheter infection and 21.7% of patients blood stream infections. The median length of stay for patients with post-operative infection or with an infective event during chemotherapy was 25 days. After discharge, 22% of patients were readmitted to the hospital due to new infection and were hospitalized for 22 days on average. The total cost that our hospital paid for the treatment of infected patients was 4.598391 $.Abstract 633 Figure 1Conclusion*Bowel resection appears to be the procedure most associated with the development of HAIs. An important method of reducing the risk of infections is careful screening of patients and risk factors before admission.

Antimicrobial stewardship programs are implemented to optimize the use of antibiotics and control the spread of antibiotic resistance. Many antimicrobial stewardship interventions have demonstrated significant efficacy in reducing unnecessary prescriptions of antibiotics, the duration of antimicrobial therapy, and mortality. We evaluated the benefits of a combination of rapid diagnostic tests and an active re-evaluation of antibiotic therapy 72 h after the onset of bloodstream infection (BSI). All patients with BSI from November 2015 to November 2016 in a 1100-bed university hospital in Rome, where an Infectious Disease Consultancy Unit (Unità di Consulenza Infettivologica, UDCI) is available, were re-evaluated at the bedside 72 h after starting antimicrobial therapy and compared to two pre-intervention periods: the UDCI was called by the ward physician for patients with BSI and the UDCI was called directly by the microbiologist immediately after a pathogen was isolated from blood cultures. Recommendations for antibiotic de-escalation or discontinuation significantly increased (54%) from the two pre-intervention periods (32% and 27.2%, p < 0.0001). Appropriate escalation also significantly increased (22.5%) from the pre-intervention periods (8.1% and 8.2%, p < 0.0001). The total duration of antibiotic therapy decreased with intervention (from 21.9 days [standard deviation, SD 15.4] in period 1 to 19.3 days [SD 13.3] in period 2 to 17.7 days in period 3 [SD 11.5]; p = 0.002) and the length of stay was significantly shorter (from 29.7 days [SD 29.3] in period 1 to 26.8 days [SD 24.7] in period 2 to 24.2 days in period 3 [SD 20.7]; p = 0.04) than in the two pre-intervention periods. Mortality was similar among the study periods (31 patients died in period 1 (15.7%), 39 (16.7%) in period 2, and 48 (15.3%) in period 3; p = 0.90). Rapid diagnostic tests and 72 h re-evaluation of empirical therapy for BSI significantly correlated with an improved rate of optimal antibiotic therapy and decreased duration of antibiotic therapy and length of stay.

Introduction/BackgroundStudy aim was to determine whether sepsis organ failure assessment (SOFA) score is a useful diagnostic tool in patients with an underlying gynecologic malignancy and if other parameters could be used as bloodstream infection predictors.MethodologyBetween July 2016 and December 2017, 68 patients accessing the Emergency Ward with an underlying gynecologic malignancy were recruited. Variables concerning underlying disease, invasive procedures, laboratory and SOFA score parameters were analyzed. Patients were divided in 3 groups based on their blood and urine specimens. Risk factors for surgical site infections (SSIs), recent (<30 days) surgery and chemotherapy were studied separately.ResultsParameters included in the SOFA score and SOFA score itself were not significant predictors of bloodstream infection. Patients who had been treated with chemotherapy were at a higher risk of developing bloodstream infection (p=0.04; OR=7.9). In a rough model, C reactive protein (CRP), bilirubin and oxygen saturation (SO2) were significantly different between patients with an underlying infection and those who had not. Only CRP maintained its significance in a complex model, with a cutoff of 180 mg/L (linear regression, p=0.03; OR=4).ConclusionSOFA score does not seem reliable in diagnosing bloodstream infections in patients with an underlying malignancy, but other criteria may help an early diagnosis.DisclosureNothing to disclose.

Phenotypic variants of Staphylococcus aureus may be misidentified by routine microbiological methods, and they may also respond poorly to antibacterial treatment. Using molecular methods, we identified small-colony variants of methicillin-resistant S. aureus (which were misidentified by 3 widely used automated identification systems as methicillin-susceptible coagulase-negative staphylococci) as the cause of recurrent ventriculoperitoneal shunt—related meningitis.

Background Recent reports have suggested the efficacy of a double carbapenem (DC) combination, including ertapenem, for the treatment of carbapenem-resistant Klebsiella pneumoniae (CR- Kp ) infections. We aimed to evaluate the clinical impact of such a regimen in critically ill patients. Methods This case–control (1:2), observational, two-center study involved critically ill adults with a microbiologically documented CR- Kp invasive infection treated with the DC regimen matched with those receiving a standard treatment (ST) (i.e., colistin, tigecycline, or gentamicin). Results The primary end point was 28-day mortality. Secondary outcomes were clinical cure, microbiological eradication, duration of mechanical ventilation and of vasopressors, and 90-day mortality. Forty-eight patients treated with DC were matched with 96 controls. Occurrence of septic shock at infection and high procalcitonin levels were significantly more frequent in patients receiving DC treatment ( p  < 0.01). The 28-day mortality was significantly higher in patients receiving ST compared with the DC group (47.9% vs 29.2%, p  = 0.04). Similarly, clinical cure and microbiological eradication were significantly higher when DC was used in patients infected with CR- Kp strains resistant to colistin (13/20 (65%) vs 10/32 (31.3%), p  = 0.03 and 11/19 (57.9%) vs 7/27 (25.9%), p  = 0.04, respectively). In the logistic regression and multivariate Cox-regression models, the DC regimen was associated with a reduction in 28-day mortality (OR 0.33, 95% CI 0.13–0.87 and OR 0.43, 95% CI 0.23–0.79, respectively). Conclusions Improved 28-day mortality was associated with the DC regimen compared with ST for severe CR- Kp infections. A randomized trial is needed to confirm these observational results. Trial registration ClinicalTrials.gov NCT03094494 . Registered 28 March 2017.

Purpose Clinical application of an antibiotic’s pharmacokinetic/pharmacodynamic (PK/PD) properties may improve the outcome of severe infections. No data are available on the use of linezolid (LNZ) continuous infusion in critically ill obese patients affected by ventilator-associated pneumonia (VAP). Methods We conducted a prospective randomized controlled trial to compare LNZ concentrations in plasma and epithelial lining fluid (ELF), when administered by intermittent and continuous infusion (II, CI), in obese critically ill patients affected by VAP. Results Twenty-two critically ill obese patients were enrolled. At the steady state, in the II group, mean ± SD total and unbound maximum–minimum concentrations ( C max / C max,u  −  C min /C min,u ) were 10 ± 3.7/6.8 ± 2.6 mg/L and 1.7 ± 1.1/1.2 ± 0.8 mg/L, respectively. In the CI group, the mean ± SD total and unbound plasma concentrations ( C ss and C ss,u ) were 6.2 ± 2.3 and 4.3 ± 1.6 mg/L, respectively. Within a minimum inhibitory concentration (MIC) range of 1–4 mg/L, the median (IQR) time LNZ plasma concentration persisted above MIC (% T  > MIC) was significantly higher in the CI than the II group [100 (100–100) vs 100 (89–100), p  = 0.05; 100 (100–100) vs 82 (54.8–98.8), p  = 0.009; 100 (74.2–100) vs 33 (30.2–78.5), p  = 0.005; respectively]. Pulmonary penetration (%) was higher in the CI group, as confirmed by a Monte Carlo simulation [98.8 (IQR 93.8–104.3) vs 87.1 (IQR 78.7–95.4); p  < 0.001]. Conclusions In critically ill obese patients affected by VAP, LNZ CI may overcome the limits of standard administration but these advantages are less evident with difficult to treat pathogens (MIC = 4 mg/L). These data support the usefulness of LNZ continuous infusion, combined with therapeutic drug monitoring (TDM), in selected critically ill populations.

Background Central Line-Associated BloodStream Infections (CLABSIs) are emerging challenge in Respiratory semi-Intensive Care Units (RICUs). We evaluated efficacy of educational interventions on rate of CLABSIs and effects of port protector as adjuvant tool. Methods Study lasted 18 months (9 months of observation and 9 of intervention). We enrolled patients with central venous catheter (CVC): 1) placed during hospitalization in RICU; 2) already placed without signs of systemic inflammatory response syndrome (SIRS) within 48 h after the admission; 3) already placed without evidence of microbiologic contamination of blood cultures. During interventional period we randomized patients into two groups: 1) educational intervention (Group 1) and 2) educational intervention plus port protector (Group 2). We focused on CVC-related sepsis as primary outcome. Secondary outcomes were the rate of CVC colonization and CVC contamination. Results Eighty seven CVCs were included during observational period. CLABSIs rate was 8.4/1000 [10 sepsis (9 CLABSIs)]. We observed 17 CVC colonizations and 6 contaminations. Forty six CVCs were included during interventional period. CLABSIs rate was 1.4/1000. 21/46 CVCs were included into Group 2, in which no CLABSIs or contaminations were reported, while 2 CVC colonizations were found. Conclusions Our study clearly shows that both kinds of interventions significantly reduce the rate of CLABSIs. In particular, the use of port protector combined to educational interventions gave zero CLABSIs rate. Trial registration NCT03486093 [ ClinicalTrials.gov Identifier], retrospectively registered.