Hospital-acquired infections, particularly in the critical care setting, are becoming increasingly common during the last decade, with Gram-negative bacterial infections presenting the highest ...incidence among them. Multi-drug-resistant (MDR) Gram-negative infections are associated with high morbidity and mortality, with significant direct and indirect costs resulting from long hospitalization due to antibiotic failure. As treatment options become limited, antimicrobial stewardship programs aim to optimize the appropriate use of currently available antimicrobial agents and decrease hospital costs.
,
and
are the most common resistant bacteria encountered in intensive care units (ICUs) and other wards. To establish preventive measures, it is important to know the prevalence of Gram-negative isolated bacteria and antibiotic resistance profiles in each ward separately, compared with ICUs. In our single centre study, we compared the resistance levels per antibiotic of
,
and
clinical strains between the ICU and other facilities during a 2-year period in one of the largest public tertiary hospitals in Greece. The analysis revealed a statistically significant higher antibiotic resistance of the three bacteria in the ICU isolates compared with those from other wards. ICU strains of
presented the highest resistance rates to gentamycin (57.97%) and cefepime (56.67%), followed by fluoroquinolones (55.11%) and carbapenems (55.02%), while a sensitivity rate of 97.41% was reported to colistin. A high resistance rate of over 80% of
isolates to most classes of antibiotics was identified in both the ICU environment and regular wards, with the lowest resistance rates reported to colistin (53.37% in ICU versus an average value of 31.40% in the wards). Statistically significant higher levels of resistance to most antibiotics were noted in ICU isolates of
compared with non-ICU isolates, with the highest difference-up to 48.86%-reported to carbapenems. The maximum overall antibiotic resistance in our ICU was reported for
spp. (93.00%), followed by
spp. (72.30%) and
spp. (49.03%).
In the era of increasing antimicrobial resistance, the need for early identification and prompt treatment of multi-drug-resistant infections is crucial for achieving favorable outcomes in critically ...ill patients. As traditional microbiological susceptibility testing requires at least 24 hours, automated machine learning (AutoML) techniques could be used as clinical decision support tools to predict antimicrobial resistance and select appropriate empirical antibiotic treatment.
An antimicrobial susceptibility dataset of 11,496 instances from 499 patients admitted to the internal medicine wards of a public hospital in Greece was processed by using Microsoft Azure AutoML to evaluate antibiotic susceptibility predictions using patients' simple demographic characteristics, as well as previous antibiotic susceptibility testing, without any concomitant clinical data. Furthermore, the balanced dataset was also processed using the same procedure. The datasets contained the attributes of sex, age, sample type, Gram stain, 44 antimicrobial substances, and the antibiotic susceptibility results.
The stack ensemble technique achieved the best results in the original and balanced dataset with an area under the curve-weighted metric of 0.822 and 0.850, respectively.
Implementation of AutoML for antimicrobial susceptibility data can provide clinicians useful information regarding possible antibiotic resistance and aid them in selecting appropriate empirical antibiotic therapy by taking into consideration the local antimicrobial resistance ecosystem.
Hospital-acquired infections, particularly in the critical care setting, have become increasingly common during the last decade, with Gram-negative bacterial infections presenting the highest ...incidence among them. Multi-drug-resistant (MDR) Gram-negative infections are associated with high morbidity and mortality with significant direct and indirect costs resulting from long hospitalization due to antibiotic failure. Time is critical to identifying bacteria and their resistance to antibiotics due to the critical health status of patients in the intensive care unit (ICU). As common antibiotic resistance tests require more than 24 h after the sample is collected to determine sensitivity in specific antibiotics, we suggest applying machine learning (ML) techniques to assist the clinician in determining whether bacteria are resistant to individual antimicrobials by knowing only a sample's Gram stain, site of infection, and patient demographics. In our single center study, we compared the performance of eight machine learning algorithms to assess antibiotic susceptibility predictions. The demographic characteristics of the patients are considered for this study, as well as data from cultures and susceptibility testing. Applying machine learning algorithms to patient antimicrobial susceptibility data, readily available, solely from the Microbiology Laboratory without any of the patient's clinical data, even in resource-limited hospital settings, can provide informative antibiotic susceptibility predictions to aid clinicians in selecting appropriate empirical antibiotic therapy. These strategies, when used as a decision support tool, have the potential to improve empiric therapy selection and reduce the antimicrobial resistance burden.
Abstract
BACKGROUND AND AIMS
Standard haemodialysis (HD) with low-flux membranes does not provide adequate middle molecular weight (MMW) clearance of uraemic toxins 1 and on-line haemodiafiltration ...(OL-HDF) may not be easily applicable and cost effective in some centres. We investigated whether low-flux conventional HD combined with hemoperfusion (HP) may offer any benefit regarding serum beta-2 microglobulin (β2M) levels as a surrogate of middle molecules in patients haemodialyzed for many years and we compared the method-combination with OL-HDF.
METHOD
We studied 24 stable anuric patients during 6 months, under standard medical therapy, aged 69 years (46–90), M: F = 20:4, on chronic HD for 84 (65–286) months, who formed three groups: A (GrA), B (GrB) and C (GrC). Each group included 8 age- and HD vintage-matched patients respectively. In GrA patients, a type HA130 cartridge for HP was connected in parallel to the low-flux polysulfone dialyzer and this combination of standard HD with HP (HD + HP) was used once a week for the first month, once every 2 weeks for the second month and once a month for the next 4 months. GrB patients underwent only standard HD treatment with low-flux polysulfone membranes and GrC patients were treated with OL-HDF. In all three groups serum β2M levels were determined at months 0 (M0) and 6 (M6), before (pre-dialysis, preD) and after (post-dialysis, postD) the second weekly session.
RESULTS
Serum preD β2M levels were similar in GrA and GrB at M0 (44.1 ± 8.6 versus 34.6 ± 16.2 mg/L; P = NS) and at M6 (46.1 ± 7.6 versus 41.1 ± 18.9 mg/L; P = NS). In GrC, preD-β2M values were lower compared with GrA at both M0 (31.1 ± 4.2 mg/L; P = .008) and M6 (33.8 ± 6.82 mg/L; P = .02). In GrC, serum postD-β2M levels decreased significantly at both M0 (7.4 ± 1.9 mg/L; P < .001) and M6 (9.9 ± 3.8 mg/L; P<.001). The postD reduction was maintained, with no difference between M0 and M6. An improvement/decrease in β2M values was observed only in GrA between M0 and M6 (−5.8 ± 7.2 versus 1.8 ± 5mg/L; P = .03) but not in GBr.
CONCLUSION
OL-HDF is obviously the most effective method for elimination of MMW uraemic toxins and in particular β2M 2–3. Interestingly, the combination HD + HP seems to be more effective than low-flux HD alone 4 and it could be useful for specific patient cases in daily clinical practice in order to prevent or delay the onset and deterioration of symptomatic amyloidosis. Possible result improvement with a more frequent use of HD + HP needs further investigation.
Abstract
BACKGROUND AND AIMS
Haemodialysis (HD) patients have a great risk of severe infection from coronovirus 2(SARS-CoV-2). However, chronic kidney disease is often associated with ...immunodeficiency and other existing vaccines have reduced efficacy in HD patients 1. Humoral immune response to SARS-CoV-2 vaccination in chronic HD patients was investigated during a period of 7 months.
METHOD
A total of 39 patients, M/F = 34/5, aged 71 (47–90) years, dialyzed for 55(18–286) months, vaccinated with mRNA Comirnaty vaccine (BNT 162b2; BioNTech & Pfizer) were studied. Patients received two initial vaccine doses in March and April 2021, respectively, and 24 out of 39 patients received a third dose in October 2021. We analyzed the antibody response to the spike (S) antigen of SARS-CoV-2 at 0, 1, 4 and 7 months (November) after second vaccine dose in all patients. We also compared serum antibody titers at time-point 7 between the 24/39 patients and 20 healthy age-matched individuals, also vaccinated with three doses at the same months.
RESULTS
At time-point 0, titers of S protein-targeting antibodies(S-Abs) were 5 ± 1 AU/mL. At 1 month S-Abs were < 50 AU/mL in 2 patients (5.15%), between 51 and 100 AU/mL in 2/39 patients (5.15%), between 101 and 1000(528 ± 292) AU/mL in 19/39 patients (48.7%) and between 1001 and 10 000 (4486 ± 2547) AU/mL in 13/39 patients(33.3%). S-Abs were higher than 10 000(14 516 ± 3062) AU/mL in 3/39 patients (7.7%) after previous infection. In the 36/39 patients not infected, at 4 months there was a significant titer decrease compared with values at 1 month: from 3108 ± 4361 to 1442 ± 4357 AU/mL; P < 0.001. At 7 months, the 24/39 patients vaccinated with the third dose showed increased titers in comparison with values at 1 and 4 months, respectively (9285 ± 11 202 versus 1957 ± 2763 AU/mL; P < 0.001 and versus 584 ± 669 AU/mL; P < 0.001, respectively). Among 15/39 patients who did not receive the third dose, 4/15 with an average titer of 739 AU/mL died from other causes, 3/15 with an average titer of 25 468 AU/mL were hospitalized for COVID-19 and discharged and 8/15 showed further titer decrease (2117 ± 4887 to 950 ± 1855 AU/mL; P = 0.031). After the third dose higher S-Abs were observed in healthy controls compared with HD patients (18 050 ± 15 374 versus 9285 ± 11 202 AU/mL; P = 0.032).
CONCLUSION
Healthy controls showed a better humoral immune response compared with patients. Two doses of mRNA BNT162b2 vaccine induced an initial satisfactory humoral response in HD patients but S-Abs significantly declined subsequently 2. Humoral response was significantly better after the third dose and booster immunization seems necessary 3.
Abstract
BACKGROUND AND AIMS
Conventional haemodialysis (HD) with low-flux membranes does not provide adequate middle molecular weight (MMW) clearance of uremic toxins 1. The potential for better ...removal of parathyroid hormone (PTH) and β2-microglobulin (β2M) was investigated using a combination of low-flux HD and haemoperfusion (HP) (HD + HP).
METHOD
A total of 16 stable HD male patients, free of infections, malignancies or haematological disorders, under usual medications for anaemia and hyperparathyroidism, treated with low-flux polysulfone membranes, were randomized into two groups: group A (GA) included eight patients under HD + HP and group B (GΒ) included eight patients under HD only. In GA patients, a type HA130 HP cartridge was connected in parallel to the dialyzer, once a week for the first month, once every 2 weeks for the second month and once a month for the next 4 months. A third group C (GC) was also studied, consisting of eight males undergoing online haemodiafiltration (OL-HDF). In all three groups, serum β2M and iPTH levels were determined at months 0 and 6, before (preD) and after (postD) the mid-week session.
RESULTS
Serum preD-β2M levels were similar in groups A and B at month 0 (44.1 ± 8.6 versus 34.6 ± 16.2 mg/L; P = NS) and at month 6 (46.1 ± 7.6 versus 41.1 ± 18.9 mg/L; P = NS). In GC, preD–β2M values were lower compared with GA at month 0 (31.1 ± 4.2 mg/L; P = .008) and at month 6 (33.8 ± 6.82 mg/L; P = .02), and postD–β2M values decreased significantly at month 0 (7.4 ± 1.9 mg/L; P < .001) and at month 6 (9.9 ± 3.8 mg/L; P < 0.001). The reduction was maintained, with no difference between month 0 and month 6. An improvement/decrease in β2M values was observed between month 0 and month 6 only in GA (–5.8 ± 7. 2 versus 1.8 ± 5 mg/L; P = .03) but not in GB. PreD–iPTH values did not differ between groups A, B and C at month 0 (623 ± 432 versus 434 ± 350 versus 710 ± 286 pg/mL, respectively; P = NS) and at month 6 (758 ± 550 versus 383 ± 186 versus 559 ± 296 pg/mL, respectively; P = NS). PostD–iPTH values showed a decrease at month 6 in GA (from 758 ± 550 to 514 ± 474 pg/mL; P = .04) but not in GB and a mild decrease in GC (from 559 ± 296 to 363 ± 295 pg/mL; P = .05), with a marginal reduction improvement between month 0 and month 6 in GC (41 ± 55 versus 196 ± 87 pg/mL; P = .046).
CONCLUSION
OL-HDF is obviously the most effective method for the elimination of MMW uremic toxins 2. Interestingly, the combination HD + HP seems to be more effective than low-flux HD alone 3, and it could be useful for specific patient cases in daily clinical practice.
Strongyloidiasis is a disease characterized by a diverse spectrum of unspecific manifestations that complicate its diagnosis. Although, the course of its chronic form is usually benign, in cases of ...immunosuppression, iatrogenic or not, it can evolve to a hyperifection syndrome with even fatal complications. Herein, we report a case of Strongyloides stercoralis hyperinfection in a Greek patient receiving corticosteroid treatment for chronic eosinophilia and angioedema. The case represents an extremely rare case of autochthonous strongyloidiasis in Greece and underlines the importance of the early diagnosis of the disease's uncomplicated forms in order to prevent its severe sequelae.
Community-acquired pleural infection (CAPI) is a growing health problem worldwide. Although most CAPI patients recover with antibiotics and pleural drainage, 20% require surgical intervention. The ...use of inappropriate antibiotics is a common cause of treatment failure. Awareness of the common causative bacteria along with their patterns of antibiotic resistance is critical in the selection of antibiotics in CAPI-patients. This study aimed to define CAPI bacteriology from the positive pleural fluid cultures, determine effective antibiotic regimens and investigate for associations between clinical features and risk for death or antibiotic-resistance, in order to advocate with more invasive techniques in the optimal timing.
We examined 158 patients with culture positive, CAPI collected both retrospectively (2012-2013) and prospectively (2014-2018). Culture-positive, CAPI patients hospitalized in six tertiary hospitals in Greece were prospectively recruited (N=113). Bacteriological data from retrospectively detected patients were also used (N=45). Logistic regression analysis was performed to identify clinical features related to mortality, presence of certain bacteria and antibiotic resistance.
Streptococci, especially the non-pneumococcal ones, were the most common bacteria among the isolates, which were mostly sensitive to commonly used antibiotic combinations. RAPID score (i.e., clinical score for the stratification of mortality risk in patients with pleural infection; parameters: renal, age, purulence, infection source, and dietary factors), diabetes and CRP were independent predictors of mortality while several patient co-morbidities (e.g., diabetes, malignancy, chronic renal failure, etc.) were related to the presence of certain bacteria or antibiotic resistance.
The dominance of streptococci among pleural fluid isolates from culture-positive, CAPI patients was demonstrated. Common antibiotic regimens were found highly effective in CAPI treatment. The predictive strength of RAPID score for CAPI mortality was confirmed while additional risk factors for mortality and antibiotic resistance were detected.
Candida auris was sporadically detected in Greece until 2019. Thereupon, there has been an increase in isolations among inpatients of healthcare facilities.
We aim to report active surveillance data ...on MALDI-TOF confirmed Candida auris cases and outbreaks, from November 2019 to September 2021.
A retrospective study on hospital-based Candida auris data, over a 23-month period was conducted, involving 11 hospitals within Attica region. Antifungal susceptibility testing and genotyping were conducted. Case mortality and fatality rates were calculated and p-values less than 0.05 were considered statistically significant. Infection control measures were enforced and enhanced.
Twenty cases with invasive infection and 25 colonized were identified (median age: 72 years), all admitted to hospitals for reasons other than fungal infections. Median hospitalisation time until diagnosis was 26 days. Common risk factors among cases were the presence of indwelling devices (91.1 %), concurrent bacterial infections during hospitalisation (60.0 %), multiple antimicrobial drug treatment courses prior to hospitalisation (57.8 %), and admission in the ICU (44.4 %). Overall mortality rate was 53 %, after a median of 41.5 hospitalisation days. Resistance to fluconazole and amphotericin B was identified in 100 % and 3 % of tested clinical isolates, respectively. All isolates belonged to South Asian clade I. Outbreaks were identified in six hospitals, while remaining hospitals detected sporadic C. auris cases.
Candida auris has proven its ability to rapidly spread and persist among inpatients and environment of healthcare facilities. Surveillance focused on the presence of risk factors and local epidemiology, and implementation of strict infection control measures remain the most useful interventions.
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