Retrospective Tertiary Care-Based Cohort Study on Clinical Characteristics and Outcomes of Ceftazidime-Avibactam-Resistant Carbapenem-Resistant Klebsiella pneumoniae Infections.

Introduction: The advent of ceftazidime-avibactam (CAZ-AVI)-resistant carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates has been steadily documented in recent years. We aimed to identify risk factors of CAZ-AVI-resistant CRKP infection and assess clinical outcomes of patients. Methods: The study retrospectively examined the clinical and microbiological data of patients with ceftazidime avibactam susceptible and ceftazidime avibactam-resistant Klebsiella pneumonia carbapenem-resistant enterobacteriaceae infection to identify risk factors, clinical features, and outcomes using multivariate logistic regression analysis. Results: A total of 152 patients with CRKP infection were enrolled in this study. Patients with CAZ-AVI-resistant CRKP isolates (20/34 = 58.8%) had prior exposure to carbapenems (p=0.003) and had more tracheostomies (16/34 = 47.1%) (p=0.001). Only 8/28 (28.6%) patients with CAZ-AVI susceptible CRKP isolates died amongst those administered ceftazidime-avibactam compared to 49/90 (54.4%) who did not receive the same (p=0.016). 1/9 (11.1%) patients with CAZ-AVI-resistant CRKP isolates who received colistin died compared to 13/25 (52%) who did not receive colistin (p=0.03). There was no association between presence of CAZ-AVI-resistant CRKP isolates and overall mortality (odds ratio: 0.7; 95% CI: 0.3, 1.6), and no independent predictors of risk factors to overall mortality in the group with CAZ-AVI-resistant CRKP isolates were noted. Conclusion: Early advent of CAZ-AVI resistance in CRE isolates highlights the dynamic necessity of routine CAZ-AVI resistance laboratory testing and antimicrobial stewardship programmes focusing on the utilization of all antibiotics. Consolidating the hospital infection control of tracheostomies may help to prevent CAZ resistance in CRKP. Colistin may aid in decreasing of mortality rates among patients with CAZ-AVI CRKP isolates.

A Systematic Review of Arterial Dissections in COVID-19 Patients.

INTRODUCTION: COVID-19 is often seen presenting with a myriad of signs and symptoms of multiorgan dysfunction including arterial dissection. METHODS: Various theories have been proposed such as endothelial dysfunction triggered by hyperinflammatory response that results in rupture of atherosclerotic plaque and subsequent dissection. RESULTS: However, the exact incidence is unknown and only case reports and case series have been published till date. CONCLUSION: Here we carried out a systematic analysis of published case reports/series related to dissection of the aorta, coronary, cerebral, vertebral, cervical, renal, and splanchnic arteries.

Evaluation of the Association between Single Nucleotide Polymorphisms of Metabolizing Enzymes with the Serum Concentration of Paracetamol and Its Metabolites.

Intravenous paracetamol is a commonly administered analgesic and antipyretic in inpatient settings. Paracetamol is metabolized by cytochrome P450 (CYP) enzymes followed by conjugating enzymes to mainly glucuronide but to a lesser extent, sulphate metabolites, and oxidative metabolites. Single nucleotide polymorphisms (SNPs) in the CYP enzymes result in modified enzymatic activity. The present study was carried out to evaluate the prevalence of SNPs related to paracetamol metabolism and principal metabolites in critically ill patients, and those with chronic kidney disease. The present study is a cross-sectional study carried out in adults (>21 years) requiring intravenous paracetamol as part of their standard of care. Details regarding their demographics, and renal and liver function tests were collected. Blood was withdrawn for the analysis of paracetamol and their metabolites, and the SNPs of key CYP enzymes. Paracetamol/paracetamol glucuronide (P/PG), paracetamol/paracetamol sulphate (P/PS) and PG/PS were estimated. Acute liver injury (ALI) and renal dysfunction were defined using standard definitions. We observed a significant prevalence of SNPs in CYP1A2*1C, CYP3A4*3, CYP1A2*1K, CYP1A2*6, CYP2D6*10, and CYP2E1*2 amongst the 150 study participants. Those with CYP1A2*6 (CC genotype) were observed with significantly lower PG and PS concentrations, and a higher P/PS ratio; CYP2D6*10 (1/1 genotype) with a significantly lower PG concentration and a higher P/PG ratio; and CYP1A2*1K (CC genotype) was observed with a significantly higher PG/PS ratio. Good predictive accuracies were observed for determining the SNPs with the cut-off concentration of 0.29 µM for PS in determining CYP1A2*1K, 0.39 µM for PG and 0.32 µM for PS in determining CYP1A2*6 genotype, and 0.29 µM for PG in determining the CYP2D6*10 genotype. Patients with renal dysfunction were observed with significantly greater concentrations of paracetamol, PG and P/PS, and PG/PS ratios, with a lower concentration of PS. No significant differences were observed in any of the metabolites or metabolite ratios in patients with ALI. We have elucidated the prevalence of key CYP enzymes involved in acetaminophen metabolism in our population. Alterations in the metabolite concentrations and metabolic ratios were observed with SNPs, and in patients with renal dysfunction. Population toxicokinetic studies elucidating the dose-response relationship are essential to understand the optimized dose in this sub-population.

Acute respiratory distress syndrome secondary to COVID-19 mRNA vaccine administration in a pregnant woman: A case report.

Healthcare professionals monitoring vaccine-related adverse responses should be aware of COVID-19 vaccine-related acute respiratory distress syndrome to enable expeditious diagnosis and treatment. We report the first case of acute respiratory distress syndrome in a young pregnant woman, occurring immediately after a second dose of the Pfizer-BioNTech BNT16B2b2 mRNA COVID-19 vaccine and requiring a brief period of mechanical ventilation, with a good response to a two-week steroid course. She had recovered from mild COVID-19 infection requiring home isolation nine months prior to the current vaccination dose. Without depreciating the colossal benefit of the COVID-19 vaccine, vaccine-related acute respiratory distress syndrome should be listed as a possible adverse reaction.

Staphylococcous epidermidis, Staphylococcous schleiferi Infections: Are CoNS Cons?

Coagulase-negative Staphylococcus (CoNS) represents one of the major nosocomial pathogen in multimorbid, immunosuppressed patients, especially with device-associated infections, often presenting with a diagnostic dilemma and aggressive antibiotic resistance. We report a case of a healthy young man with no comorbidities who succumbed to an extensive abdominal infection with Staphylococcus epidermidis and Staphylococcus schleiferi after an uneventful diagnostic procedure, despite aggressive antibiotic therapy and surgical source control. Early identification, diagnosis, and aggressive management of CoNS species is warranted depending on clinical scenario and should not be viewed as mere skin contaminants or physiological colonization. HOW TO CITE THIS ARTICLE: Abraham B, Gokhale AU, Mohsin J, Prakash S. Staphylococcous epidermidis, Staphylococcous schleiferi Infections: Are CoNS Cons? Indian J Crit Care Med 2020;24(8):716-718.

Dextrocardia and ventricular septal defect with situs inversus: Anesthetic implications and management.

The patients with complicated congenital heart diseases are reaching adulthood with advances in corrective surgeries and medical management. Impact of anesthetic agents on complex cardiac and extra cardiac anomalies and presence of previous palliative procedures can be a challenge for the anesthesiologist perioperatively, while these patients present for cardiac/noncardiac surgeries. We report the perioperative management of a patient with ventricular septal defect, dextrocardia, pulmonary hypertension, and situs inversus who underwent a successful hernioplasty and hydrocelectomy with a combined spinal epidural anesthesia. This discussion relates to the anesthetic management in such conditions with a special reference to Kartagener's syndrome.

Magnitude and quality of antibody response to a combination hepatitis A and hepatitis B vaccine.

Interference between antibodies generated by a combination hepatitis A and B vaccine was investigated by evaluating the quantity and quality of anti-hepatitis A virus (HAV) and anti-hepatitis B surface antigen (HBs) antibodies generated by Twinrix (Hepatitis A Inactivated and Hepatitis B (Recombinant) Vaccine). The magnitude of the immune response was determined by a retrospective analysis of eight clinical trials, completed during stepwise development of Twinrix. The functionality of anti-HAV was evaluated by comparison of routine ELISA results with neutralization assays and was further characterized by defining the epitope-specificity of binding. Functionality of the anti-HBs response was not tested because a validated assay was not developed at the time this study was conducted. Results of all analyses demonstrated that the combination vaccine induced high antibody titers against hepatitis A and B and a functional anti-HAV response, with no evidence of immune interference to either viral antigen.