Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas.
To provide practical suggestion ...for physicians dealing with the management of KPC-KP infections in critically ill patients, based on expert opinions.
PubMed search for relevant publications related to the management of KPC-KP infections.
A panel of experts developed a list of 12 questions to be addressed. In view of the current lack of high-level evidence, they were asked to provide answers on the bases of their knowledge and experience in the field. The panel identified several key aspects to be addressed when dealing with KPC-KP in critically ill patients (preventing colonization in the patient, preventing infection in the colonized patient and colonization of his or her contacts, reducing mortality in the infected patient by rapidly diagnosing the causative agent and promptly adopting the best therapeutic strategy) and provided related suggestions that were based on the available observational literature and the experience of panel members.
Diagnostic technologies could speed up the diagnosis of KPC-KP infections. Combination treatment should be preferred to monotherapy in cases of severe infections. For non–critically ill patients without severe infections, results from randomized clinical trials are needed for ultimately weighing benefits and costs of using combinations rather than monotherapy. Multifaceted infection control interventions are needed to decrease the rates of colonization and cross-transmission of KPC-KP.
The occurrence of illicit drugs (cocaine, opioids, amphetamines and cannabis derivatives), some of their metabolites and 48 pharmaceuticals, was investigated in pool and source waters in ten Italian ...indoor swimming pools. The samples were analyzed by highperformance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS), after solid phase extraction (SPE). Cocaine and its metabolites were found in nine swimming pools, at concentrations from 0.3 to 4.2 ng/L for cocaine, 1.1 to 48.7 ng/L for norcocaine, 0.7 to 21.4 ng/L for benzoylecgonine and 0.1 to 7.3 ng/L for norbenzoylecgonine. Opioids, amphetamines and cannabis derivatives were never detected. The most frequent pharmaceuticals were anti-inflammatory drugs: ibuprofen was found in all the pool waters, with a maximum 197 ng/L and ketoprofen was detected in 9/10 samples (maximum 127 ng/L). Among anticonvulsants, carbamazepine and its metabolite, 10,11-dihydro-10,11dihydroxycarbamazepine, were frequent in swimming pool water (8/10 samples) at concentrations up to 62 ng/L. The cardiovascular drug valsartan was also found frequently (8/10 samples), but at lower concentrations (up to 9 ng/L). Other pharmaceuticals were detected occasionally and at lower concentrations (atenolol, enalapril, paracetamol, hydroclorothiazide, irbesartan and dehydro-erythromycin). Carbamazepine, irbesartan and dehydroerythromycin were detected at very low levels (up to 5 ng/L) in only one of the four source water samples. A quantitative risk assessment showed that the health risk for humans to these substance in swimming pool waters was generally negligible, even for vulnerable subpopulations such as children and adolescents.
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•Four illicit drugs and eleven pharmaceuticals were found in swimming pools.•Ibuprofen was found in all the investigated pool waters.•Human Risk Assessment (HRA) was performed for different classes of age•No health risk was found for humans via swimming pool waters
Although internal medicine wards (IMWs) represent a significant reservoir of patients with candidemia, few investigators have specifically addressed the epidemiological aspects of candidaemia in this ...population. Of all patients hospitalized during the study period with candidaemia, 133/348 (38%) were admitted to IMWs. Variables associated with IMWs included: antibiotic therapy prior to hospitalization, urinary or central venous catheter, parenteral nutrition, tumour and age >75 years. Overall, 30-day mortality in IMWs was significantly higher than that in other wards (51.1% vs. 38.2%, p <0.02). Multiple logistic regression analysis identified the administration of antifungal treatment 48 h after having the first positive BC as an independent determinant of hospital mortality. Patients with candidaemia in IMWs account for a substantial proportion of patients with candidaemia and have higher mortality compared with patients in other wards.
Invasive fungal infections (IFIs) represent a global issue and affect various patient populations. In recent years, resistant fungal isolates showing increased azole or echinocandin MICs have been ...reported, and their potential clinical impact has been investigated.
To provide an update on the epidemiology of resistance among fungi (e.g., Candida spp., Aspergillus spp., and Cryptococcus spp.) and to offer a critical appraisal of the relevant literature regarding the impact of MICs on clinical outcome in patients with IFI.
PubMed search with relevant keywords along with a personal collection of relevant publications.
Although antifungal resistance has been associated with a poorer response to antifungal therapy in various studies, other factors such as comorbidities, septic shock and source of infection appear to be key determinants affecting the clinical outcome of patients with IFI.
Future international collaborative studies are required to tease out the relative contribution of in vitro antifungal resistance on patient outcomes, thus enabling the optimization of IFI management.
Despite the occurrence of several earthquakes, only a few studies were conducted in Italy on the psychological impact in children and adolescents, with data mostly collected within one year after the ...disaster. This cross-sectional study aimed at exploring the prevalence of both post-traumatic stress disorder (PTSD) and emotional/behavioral difficulties, as well as at identifying their main predictors, among youths 2 years after the earthquake that hit Northern Italy in 2012. 682 children and adolescents (9–14 years) living in two districts (earthquake zone vs control zone) were administered an exposure questionnaire, the UCLA PTSD-Index for DSM-IV, and the Strengths and Difficulties Questionnaire (SDQ) and 1162 parents were assessed through the Symptom Checklist-90 (SCL-90). The prevalence of a likely PTSD in the earthquake zone was 1.9% (4.4% near the epicenter) and the total PTSD score in the affected area was significantly higher than in the control zone. 14.9% of youths living in the earthquake zone had a borderline/abnormal SDQ total difficulties score and 87.5% of youth with a likely PTSD also had a SDQ total score in the borderline/abnormal range. Regression analysis showed that the number of lifetime traumatic events (e.g., death of a relative) was the best predictor of children/adolescents psychological difficulties 2 years after the earthquake, followed by severity of exposure (personal injuries and losses) and parental psychopathology. Despite some limitations, this study highlights that youths may exhibit PTSD symptoms years after disasters, often in comorbidity with behavioral/emotional difficulties, stressing the need for long-term surveillance and interventions in exposed populations.
Objectives The increased incidence of nosocomial infections by multidrug-resistant organisms has motivated the re-introduction of colistin in combination with other antimicrobials in the treatment of ...infections. We describe the clinical and microbiological outcomes of patients infected with multidrug-resistant Acinetobacter baumannii who were treated with a combination of colistin and rifampicin. Patients and methods Critically ill patients with pneumonia and bacteraemia caused by A. baumannii resistant to all antibiotics except colistin in medical and surgical intensive care units were enrolled. Clinical and microbiological responses and safety were evaluated. Results Twenty-nine patients (47 ± 14 years and APACHE II score 17.03 ± 3.68), of whom 19 were cases of nosocomial pneumonia and 10 were cases of bacteraemia, were treated with intravenous colistin sulphomethate sodium (2 million IU three times a day) in addition to intravenous rifampicin (10 mg/kg every 12 h). All A. baumannii isolates were susceptible to colistin. The mean duration of treatment with intravenous colistin and rifampicin was 17.7 (±10.4) days (range 7–36). Clinical and microbiological responses were observed in 22 of 29 cases (76%) and the overall infection-related mortality was 21% (6/29). Three of the 29 evaluated patients (10%) developed nephrotoxicity when treated with colistin, all of whom had previous renal failure. No cases of renal failure were observed among patients with normal baseline renal function. No neurotoxicity was noted. Conclusions Colistin and rifampicin appears to be an effective and safe combination therapy for severe infections due to multidrug-resistant A. baumannii.
Capturing agricultural heterogeneity through the analysis of farm typologies is key with regard to the design of sustainable policies and to the adoptability of new technologies. An optimal balance ...needs to be found between, on the one hand, the requirement to consider local stakeholder and expert knowledge for typology identification, and on the other hand, the need to identify typologies that transcend the local boundaries of single studies and can be used for comparisons. In this paper, we propose a method that supports expert-driven identification of farm typologies, while at the same time keeping the characteristics of objectivity and reproducibility of statistical tools. The method uses a range of multivariate analysis techniques and it is based on a protocol that favours the use of stakeholder and expert knowledge in the process of typology identification by means of visualization of farm groups and relevant statistics. Results of two studies in Zimbabwe and Kenya are shown. Findings obtained with the method proposed are contrasted with those obtained through a parametric method based on latent class analysis. The method is compared to alternative approaches with regard to stakeholder-orientation and statistical reliability.
▶ Seven farm types were defined for the vegetable farming systems of South Uruguay. ▶ An innovative quantitative method for farm typology identification was developed. ▶ The method facilitates the ...inclusion of expert knowledge. ▶ The method is applicable to support a qualitative up-scaling of model results.
The effectiveness of quantitative system approaches, aimed at exploring options for sustainable development, can be improved by integrating farm typologies and participatory methods. An innovative method of quantitative identification and characterization of farm typologies was developed, whose advantages are the straightforward communication of results to stakeholders and rapid graphical selection of representative farms. The method is presented through an application to a large census dataset of specialized vegetable production systems of South Uruguay. Seven farm types were characterized that mainly differed for availability of off-farm labour, mechanization endowment and irrigation. Farm types can be used to complement a model-based exploration aimed at designing options for sustainable development of the farming systems. The potential of the method to support the up-scaling of farm level results to study the impact of different livelihood strategies at the regional level is discussed.
Pneumocystis jiroveci
pneumonia in non-HIV patients is infrequent and characterized by atypical presentations and increased severity. Although hematogenous dissemination from the lungs can lead to ...extrapulmonary infections, isolation of oocysts from blood in human subjects has not been documented. We report a case of
P. jiroveci
pneumonia with persistent isolation of oocysts from blood and positivity of
P. jiroveci
polymerase chain reaction. The patient presented with bilateral diffuse pulmonary nodules and received prolonged treatment with trimethoprim/sulfamethoxazole.
The posology of tacrolimus (TAC) is usually guided by its therapeutic drug monitoring. Some patients reach target concentrations (CTs) quickly, others more slowly. In a retrospective study, 20 kidney ...transplant recipients were included (mean age, 50.7 ± 14.1 years; weight 64.0 ± 14.2 kg; patients clinically stable for over a year). We studied cytochrome CYP3A5 genotype, in particular CYP3A5 6986A>G, the most important polymorphism related to the metabolism of TAC (wild genotype CYP3A5 *1 genotype, and CYP3A5 *3 variants). One year after transplantation, the CTs were 5.0 to 8.0 ng/mL. The patients were divided into group A (TAC doses < 6.0 mg/d) and group B (TAC doses > 6.0 mg/d). All were tested for the CYP3A5 gene sequence to characterize their polymorphism. Patients with CYP3A5 *1/*1 and *1/*3 were extensive metabolizers, and those with CYP3A5 *3/*3 were poor metabolizers. In group A and group B, the average TAC doses at the time of therapeutic drug monitoring were 3.0 ± 1.4 ng/mL (0.05 ± 0.03 mg/kg) and 12.8 ± 3.7 ng/mL (0.2 ± 0.1 mg/kg), respectively (P < .001). Group A was the poor metabolizers genotype, while in group B, the extensive metabolizers genotype was present. Patients with the CYP3A5 *1/*1 or *1/*3 genotype required 1.5 to 2 times higher doses than patients *3/*3 to reach CT. This genetic test allows clinicians to know, before the kidney transplant, the patient's TAC metabolism pattern and then to optimize the drug exposure.
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