The increasing prevalence of colistin resistance (ColR) Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (Kp) is a matter of concern because of its unfavourable impact on mortality ...of KPC-Kp bloodstream infections (BSI) and the shortage of alternative therapeutic options. A matched case–control–control analysis was conducted. The primary study end point was to assess risk factors for ColR KPC-Kp BSI. The secondary end point was to describe mortality and clinical characteristics of these infections. To assess risk factors for ColR, 142 patients with ColR KPC-Kp BSI were compared to two controls groups: 284 controls without infections caused by KPC-Kp (control group A) and 284 controls with colistin-susceptible (ColS) KPC-Kp BSI (control group B). In the first multivariate analysis (cases vs. group A), previous colistin therapy, previous KPC-Kp colonization, ≥3 previous hospitalizations, Charlson score ≥3 and neutropenia were found to be associated with the development of ColR KPC-Kp BSI. In the second multivariate analysis (cases vs. group B), only previous colistin therapy, previous KPC-Kp colonization and Charlson score ≥3 were associated with ColR. Overall, ColR among KPC-Kp blood isolates increased more than threefold during the 4.5-year study period, and 30-day mortality of ColR KPC-Kp BSI was as high as 51%. Strict rules for the use of colistin are mandatory to staunch the dissemination of ColR in KPC-Kp-endemic hospitals.
Knowledge of carbapenem-resistant Klebsiella pneumoniae (CR-KP) colonization is important to prevent nosocomial spread but also to start prompt adequate antibiotic therapy in patients with suspicion ...of infection. However, few studies have examined the incidence and risk factors for CR-KP bloodstream infection (BSI) among rectal carriers. To identify risk factors for CR-KP BSI among carriers, we performed a multicentre prospective matched case–control study of all adult CR-KP rectal carriers hospitalized in five tertiary teaching hospitals in Italy over a 2-year period. Carriers who developed CR-KP BSI were compared with those who did not develop subsequent BSI. Overall, 143 CR-KP BSIs were compared with 572 controls without a documented infection during their hospitalization. Multivariate analysis revealed that admission to the Intensive Care Unit (ICU) (OR, 1.65; 95% CI, 1.05–2.59; p 0.03), abdominal invasive procedure (OR, 1.87; 95% CI, 1.16–3.04; p 0.01), chemotherapy/radiation therapy (OR, 3.07; 95% CI, 1.78–5.29; p <0.0001), and number of additional colonization sites (OR, 3.37 per site; 95% CI, 2.56–4.43; p <0.0001) were independent risk factors for CR-KP BSI development among CR-KP rectal carriers. A CR-KP BSI risk score ranging from 0 to 28 was developed based on these four independent variables. At a cut-off of ≥2 the model exhibited a sensitivity, specificity, positive predictive value and negative predictive value of 93%, 42%, 29% and 93%, respectively. Colonization at multiple sites with CR-KP was the strongest predictor of BSI development in our large cohort of CR-KP rectal carriers.
A central role in the general circulation of the atmosphere is played by planetary-scale inertial fluctuations with zonal wavenumber in the range k = 1-4. Geopotential variance in this range is ...markedly non-gaussian and a great fraction of it is non-propagating, in contrast with the normal distribution of amplitudes and the basically propagating character of fluctuations in the baroclinic range (3 < k < 15). While a wave dispersion relationship can be identified in the baroclinic range, no clear relationship between time and space scales emerges in the ultra-long regime (k < 5, period >10 days). We investigate the hypothesis that nonlinear self-interaction of planetary waves influences the mobility (and, therefore, the dispersion) of ultra-long planetary fluctuations. By means of a perturbation expansion of the barotropic vorticity equation we derive a minimal analytic description of the impact of self-nonlinearity on mobility and we show that this is responsible for a correction term to phase speed, with the prevalent effect of slowing down the propagation of waves. The intensity of nonlinear self-interaction is shown to increase with the complexity of the flow, depending on both its zonal and meridional modulations. Reanalysis data of geopotential height and zonal wind are analysed in order to test the effect of self-nonlinearity on observed planetary flows.
Introduction: the purpose of this retrospective multicenter study was to assess whether the risk of developing bloodstream infections (BSI) due to carbapenem-resistant
Klebsiella pneumoniae
(CRKP) in ...colonized patients is influenced by the occurrence of BSI due to other pathogens. Methods: from January 2012 to March 2014, all patients with at least one rectal swab positive for CRKP and at least 30 days of previous hospital stay were included in the study. The primary outcome measure was CRKP BSI, defined as a time-to-event endpoint. The role of potential predictors was evaluated through univariable and multivariable Cox regression analyses, considering previous BSI as a time-dependent variable. Results: during the study period, 353 patients met the inclusion criteria. Thirty-seven developed a CRKP BSI (11%). A higher incidence of CRKP BSI was observed in presence rather than in absence of previous BSI. In the final multivariable model of risk factors for CRKP BSI, multisite colonization (hazard ratio HR 13.73, 95% confidence intervals CI 3.29–57.32,
p
< 0.001), ICU stay (HR 3.14, 95% CI 1.19–8.31,
p
= 0.021), and previous BSI (
p
= 0.026, with the overall effect being mainly due to
Enterococcus
spp. BSI vs absence of BSI, HR 6.62, 95% CI 2.11–20.79) were associated with the development of CRKP BSI, while an inverse association was observed for age (HR 0.98, 95% CI 0.95–1.00,
p
= 0.027). Conclusions: previous BSI due to other pathogens were associated with an increased risk of CRKP BSI that was independent of other factors in colonized patients with prolonged hospital exposure.
To evaluate the aetiology of neonatal invasive diseases (positive cultures from blood or cerebrospinal fluid, CSF) due to bacteria other than coagulase-negative staphylococci in a large tertiary care ...centre and compare with results of surveillance cultures.
Retrospective analysis of microbiological data of children admitted in neonatal intensive care unit (NICU) of a large tertiary care centre from 2005 to 2018.
230 bacterial strains, 223 from blood and 7 from CSF, respectively, were detected as cause of invasive infections, while 152 were detected in surveillance cultures. Methicillin-susceptible Staphylococcus aureus (MSSA) was the most frequently isolated pathogen both in invasive infections (18%) and colonizations (23%) followed by Escherichia coli (16% on invasive disease and 20% of colonizations). Other common bacteria include Enterococcus faecalis and Streptococcus agalactiae for invasive disease and methicillin-resistant Staphylococcus aureus in colonizations. Invasive infection was due to a pathogen detected in surveillance cultures in 33% of cases. In more than 50% of invasive diseases the identified pathogen was not present in surveillance cultures.
The high percentage of invasive infections due to bacteria not previously identified in surveillance cultures raises doubts about the efficiency of this procedure and highlights the need to search for alternative infection sources. This finding and the high prevalence of invasive infections due to nosocomial pathogens such as Staphylococcus aureus could be the result of horizontal transmission between patients through the hands of health care professionals, emphasizing once again the importance of applying stringent hand hygiene procedures and isolation standards.
Cirrhosis for biliary atresia (BA) is associated with risk of gastrointestinal bleeding (GB) from gastroesophageal varices due to portal hypertension. Primary prophylaxis of GB is controversial in ...children who are candidates for liver transplantation (LT). The aim of the study was to define the management of gastroesophageal varices and to identify the benefit of primary prophylaxis for GB in BA children waiting for LT.
A retrospective single-center study including all BA children listed for LT in 2008–2016. Clinical, endoscopical, and biochemical data were analyzed.
Of 82 children, 50 (61%) did not receive primary prophylaxis and did not present any episode of bleeding, 16 (19.5%) underwent primary prophylaxis, and 16 (19.5%) presented spontaneous GB and received secondary prophylaxis. Children without primary prophylaxis and GB were younger than patients with primary prophylaxis and those with GB (7.7 years range, 4.1–37.9 years vs 11.2 years range, 5.1–43 years; P = .03 vs 10.7 years range, 6.9–39.9 years, respectively; P = .004). Seventy-five percent of GB occurred in children older than 8 months. Fifteen (93.8%) children with GB presented esophageal varices (grade III = 10 62.5%) and 10 (62.5%) required endoscopic treatments, consisting mainly of sclerotherapy. Median time to LT was similar for children with or without bleeding (2 months range, 0–17.7 months vs 2.2 months 0–17.9 months, respectively; P = .89). After 45.5 months (range, 13.7–105.5 months) of follow-up, the overall patient survival was 97.6%. At the intention-to-treat analysis, the survival rate was 100% for patients without bleeding episode and 87.5% for children with GB (P = .16).
Despite the risk of GB being not clinically predictable in children with BA waiting for LT, our experience suggests that primary prophylaxis of GB might be unnecessary in children younger than 6 months, while it should be considered in older children. Thus, the occurrence of GB does not delay the timing of transplantation.
•Risk of gastrointestinal bleeding is not clinically predictable in biliary atresia.•Esophageal varices screening in children younger than 6 months who are waiting for liver transplant is unnecessary.•Primary prophylaxis should be always considered in selected children older than 6 months.•Occurrence of gastrointestinal bleeding does not delay the time of transplantation.
Abstract Background We evaluated the clinical impact of donor biliary anatomy discrepancies (DBAD) achieved by comparing pre-operative evaluation obtained with magnetic resonance (MR)/magnetic ...resonance cholangiopancreatography (MRCP) imaging, with intra-operative cholangiography (IOC) on the living related liver donor (LDLT) and recipient. Methods This single-center, retrospective study included 97 consecutive adult-to-adult (A2A) LDLT performed in our hospital in the last 12 years. Donor sex and age, living donors with biliary and/or vascular anomalies, recipient age, sex, primary etiology, re-transplantation, Model of End-Stage Liver Disease score, co-morbidities, arterial and biliary recipient complications assessed on the basis of clinical follow-up were collected and analyzed for significance through the use of a multivariate linear regression model. Results Biliary complications in the donor (DBC) were detected in 8 (8.2%) cases. Biliary complications in the recipients (RBC) were detected in 38 (39%) cases. DBADs were found in 32 (33%) cases and resulted strictly related to RBC ( P = .05). Conclusions After adjusting for co-variables, results of the linear regression analysis confirmed that DBAD is an independent predictor of RBC, but it is not significantly associated with vascular complications or patient survival. We showed that RBCs after LDLT were influenced by DBAD.
Abstract Background Liver transplantation (OLT) is the gold standard therapy for patients with cirrhosis complicated by hepatocellular carcinoma (HCC) within Milan Criteria (MC). We evaluated the ...impact of the etiology of the underlying liver disease on long-term outcomes of patients undergoing OLT for HCC within MC having a Model for End-stage Liver Disease (MELD) score < 15. Methods From November 2002 to December 2009, we performed 203 primary OLTs from brain-dead donors in recipients with HCC and cirrhosis with biochemical MELD scores below 15. We excluded 31 patients outside MC on the explant pathology of the native liver. The remaining 172 were divided into 3 groups according to the etiology of the underlying cirrhosis: hepatitis C virus-positive (HCV+; n = 78; 45%), hepatitis B virus-positive (HBV+; n = 65; 38%) and other indications ( n = 29; 17%). The groups were compared for donor and recipient features, donor-recipient match, and transplant variables. The study endpoint was long-term patient survival. Results The groups were similar, except for a greater prevalence of hepatitis B core antibody-positive grafts in the HBV+ group and less frequent HCC bridging procedures in the other indications group. After a median follow-up of 72 months, HCC recurrence was observed in 8 (4.7%) patients (6 HCV+, 2 other indications), 5 of whom died. Overall 5-year patient survival of 82%, revealed significant differences among groups: 98.3% in HBV+, 67.1% in HCV+, and 85.8% in other indications (HBV+ vs other indications: P = .01; HBV+ vs HCV+: P = .0001; HCV+ vs other indications: P = NS). In the HCV+ group, recurrent HCV hepatitis was the most frequent cause of death. Upon multivariate analysis, HBV positivity in the recipient was an independent predictor of better patient survival (hazard ratio = 0.10, 95% confidence interval 0.02–0.64, P = .013). Conclusions Etiology of the underlying cirrhosis significantly influenced the long-term survival after OLT of patients with HCC within MC and MELD < 15. It should be taken into account in estimation of survival benefit.
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