Melioidosis Manifesting as Chronic Femoral Osteomyelitis in Patient from Ghana.

A 33-year-old man from Ghana who had diabetes had chronic osteomyelitis of the femoral shaft develop. Tissue samples from surgical debridement grew Burkholderia pseudomallei. He received meropenem, followed by oral trimethoprim/sulfamethoxazole and doxycycline, and fully recovered without complications. Our case report extends the range of countries in Africa as sources of culture-confirmed melioidosis.

Compassionate use of cefiderocol for carbapenem-resistant Acinetobacter baumannii prosthetic joint infection.

BACKGROUND: Cefiderocol is a recently licensed novel siderophore-conjugated cephalosporin stable to hydrolysis by serine and MBLs. It has been successfully used to treat Enterobacterales infections and is approved for the treatment of infections due to aerobic Gram-negative organisms in adults with limited treatment options. OBJECTIVES: To describe the compassionate use of cefiderocol and clinical outcome in a case of prosthetic joint infection due to MDR Acinetobacter baumannii. PATIENTS AND METHODS: This case study follows a 66-year-old woman who sustained an open fracture of the left distal humerus in Pakistan. She underwent open reduction and internal fixation and on return to the UK presented to hospital with a discharging surgical wound. RESULTS: Debridement of her wound cultured NDM carbapenemase-producing A. baumannii susceptible to colistin, tobramycin and tigecycline only. She developed vomiting with acute kidney injury with colistin and tigecycline. Antimicrobial efficacy of cefiderocol was predicted from in vitro and in vivo susceptibility tests. A successful request was made to Shionogi for compassionate use of cefiderocol, which was added to tigecycline. Cefiderocol was well tolerated with no toxicity and improved renal function. In total she received 25 days of cefiderocol and continued on tigecycline for a further 6 weeks in the community. She has well-healed wounds and good range of elbow movement. CONCLUSIONS: Cefiderocol's novel mode of cell entry is effective against MDR Gram-negative bacteria with reduced toxicity compared with other last line antibiotics. Our case demonstrates that cefiderocol may be useful as therapy for patients with limited treatment options due to antimicrobial resistance.

Performance of Gram Stains and 3 Culture Methods in the Analysis of Peritoneal Dialysis Fluid.

Microbiological diagnosis of peritoneal dialysis (PD)-related peritonitis includes PD fluid cell count, Gram stain, and culture, as recommended by the International Society for Peritoneal Dialysis. In this retrospective study, we examined the utility of Gram stains and compared 3 culture methods.We examined a laboratory cohort (samples sent to the laboratory for any reason; n = 251) and a clinical cohort (samples sent from patients felt clinically to have peritonitis; n = 264). Culture positivity rates were higher in the clinical cohort (39.4%) than the laboratory cohort (21.5%), with no difference in the distribution of organisms between the cohorts; cell counts were significantly higher in culture-positive samples in both cohorts.Rates of positivity in the laboratory and clinical cohorts, respectively, were as follows: Gram stains 1.9% and 7.7%; direct plate culture 13% and 30.8% and "bedside" inoculated blood culture bottles 82.1% and 92.8%. Enrichment culture was never negative when another method was positive.Our data indicate that enrichment culture can be used as a single culture methodology for analyzing PD fluid without loss of sensitivity. They also suggest that Gram stains are of relatively low yield; consideration could be given to ceasing their routine performance provided that broad antimicrobial therapy is administered pending culture results.

Clinical Value of Screening Peritoneal Dialysis Patients for Bacterial Colonization or Contamination.

INTRODUCTION: The adoption of the International Society for Peritoneal Dialysis guideline of using mupirocin ointment has been limited by fear of developing mupirocin-resistant organisms. We performed a surveillance program of a large peritoneal dialysis (PD) unit. METHODS: We performed 1,175 surveillance swabs from anterior nares, PD catheter exit site, groin, and axilla, from 240 patients. The mean interval between swabs was 3.3 months. RESULTS: Colonization by Staphylococcus aureus (S. aureus) or Pseudomonas species was 9.5% and 10.9%, respectively. Despite adopting a universal policy of applying mupirocin to PD catheter exit sites in 2001, no instances of mupirocin-resistant S. aureus were identified. Moreover, patients who grew S. aureus from surveillance swabs did not experience higher peritonitis rates than those with "no growth." This was in contrast to patients who grew Pseudomonas or enteric organisms. There were no differences in patient demographics for those who grew S. aureus, Pseudomonas, or enteric organisms (compared with "no-growth" patients). CONCLUSION: Our results suggest that the application of mupirocin ointment appeared to minimize peritonitis of patients colonized with S. aureus. The use of mupirocin in this patient cohort has not led to mupirocin resistance. The increased peritonitis rate of patients who grew Pseudomonas or enteric organisms is of interest. We propose that greater attention to hygiene and catheter care in these patients is warranted. The increasing use of paid healthcare workers attending patients daily to help perform PD (assisted PD) gives an opportunity for us to address these wider issues.

Evaluation of a Rapid Diagnostic Test for Detection of Burkholderia pseudomallei in the Lao People's Democratic Republic.

Burkholderia pseudomallei causes significant global morbidity and mortality, with the highest disease burden in parts of Asia where culture-based diagnosis is often not available. We prospectively evaluated the Active Melioidosis Detect (AMD; InBios International, USA) lateral flow immunoassay (LFI) for rapid detection of B. pseudomallei in turbid blood cultures, pus, sputum, sterile fluid, urine, and sera. The performance of this test was compared to that of B. pseudomallei detection using monoclonal antibody latex agglutination (LA) and immunofluorescence assays (IFA), with culture as the gold standard. AMD was 99% (99/100; 95% confidence interval, 94.6 to 100%) sensitive and 100% (308/308; 98.8 to 100%) specific on turbid blood culture bottles, with no difference from LA or IFA. AMD specificity was 100% on pus (122/122; 97.0 to 100%), sputum (20/20; 83.2 to 100%), and sterile fluid (44/44; 92 to 100%). Sensitivity on these samples was as follows: pus, 47.1% (8/17; 23.0 to 72.2%); sputum, 33.3% (1/3; 0.84 to 90.6%); and sterile fluid, 0% (0/2; 0 to 84.2%). For urine samples, AMD had a positive predictive value of 94% (32/34; 79.7 to 98.5%) for diagnosing melioidosis in our cohort. AMD sensitivity on stored sera, collected prospectively from melioidosis cases during this study, was 13.9% (5/36; 4.7% to 29.5%) compared to blood culture samples taken on the same day. In conclusion, AMD is an excellent tool for rapid diagnosis of melioidosis from turbid blood cultures and maintains specificity across all sample types. It is a promising tool for urinary antigen detection, which could revolutionize diagnosis of melioidosis in resource-limited settings. Further work is required to improve sensitivity on nonblood culture samples.

Epidemiology and clinical features of imported malaria in East London.

BACKGROUND: Malaria is the most common imported tropical disease in the United Kingdom (UK). The overall mortality is low but inter-regional differences have been observed. METHODS: We conducted a 2-year retrospective review of clinical and laboratory records of patients with malaria attending three acute hospitals in East London from 1 April 2013 through 31 March 2015. Epidemiological and clinical characteristics of imported malaria were described and risk factors associated with severe falciparum malaria were explored. RESULTS: In total, 133 patients with laboratory-confirmed malaria were identified including three requiring critical care admission but no deaths. The median age at presentation was 41 years (IQR 30-50). The majority of patients were males (64.7%, 86/133) and had Black or Black British ethnicity (67.5%, 79/117). West Africa was the most frequent region of travel (70.4%, 76/108). Chemoprophylaxis use was poor (25.3%, 20/79). The interval between arriving in the UK and presenting to hospital was short (median 10 days; IQR 5-15.5, n = 84). July-September was the peak season of presentation (34.6%, 46/133). Plasmodium falciparum was the commonest species (76.7%, 102/133) and 31.4% (32/102) of these patients had parasitaemia >2%. Severe falciparum malaria was documented in 36.3% (37/102) of patients and the October-March season presentation was associated with an increased risk of severity (OR 3.00; 95% CI 1.30-6.93). Black patients appeared to have reduced risk of severe falciparum malaria (OR 0.46; 95% CI 0.16-1.35) but this was not statistically significant. HIV sero-status was determined in only 27.1% (36/133) of cases. Only 8.5% (10/117) of all malaria patients were treated as outpatients. CONCLUSION: Clinicians need to raise awareness on malaria prevention strategies, improve rates of HIV testing in tropical travellers, and familiarise themselves with ambulatory management of malaria. The relationship between season of presentation, ethnicity and severity of falciparum malaria should be explored further.