Epidemiology, risk factors, treatment and outcome of Candida bloodstream infections because of Candida albicans and Candida non-albicans in two district general hospitals in the United Kingdom.

INTRODUCTION: Bloodstream infections caused by Candida species, known as candidemia are on the rise because of increasing complexity of surgical procedures, patient's underlying co-morbidities and shift in patient's demographics. This study was conducted to evaluate the epidemiology, risk factors, co-morbidities, antifungal treatment and outcomes of candidemia in Candida albicans (C. albicans) and Candida non-albicans (C. non-albicans) in East Sussex Healthcare Trust (ESHT), England. MATERIAL AND METHODS: This retrospective and prospective study was performed during January 2006 to June 2017. RESULT: A total of 102 episodes of candidemia on 100 patients (55 males) were identified. C. non-albicans were predominant (55%). All isolates were sensitive to amphotericin B, caspofungin and voriconazole while one C. albicans and five C. non-albicans isolates were resistant to fluconazole. The risk factors in C. albicans and C. non-albicans groups were comparable which included intensive care unit (ICU) stay (15% vs 10%), the presence of intravascular line (35% vs 42%), previous antibiotic exposure (39% vs 49%), surgical intervention (19% vs 19%), mechanical ventilation (5% vs 8%), total parenteral nutrition (30% vs 27%) and urinary catheters (33 vs 38). The comorbidities in both groups (C. albicans and C. non-albicans) were solid organ cancer (15&14), haematology malignancy (1&3), steroid use (14&13), diabetes (9&7) and chemotherapy (2&4). Main sources of candidemia in C. albicans were line (12), respiratory (10) and urinary tracts (6) while line (26) and urinary tract (9) were predominant in C. non-albicans group. Only a small number of patients underwent echocardiography (30%) and ophthalmology reviews (20%). A total of 45 fatal cases were recorded (C. albicans 23). The highest mortality was seen in patients with C. albicans and among them the risk factors were elderly age group > 65 years (17/23), surgical intervention (9/23) and the history of ICU stay (7/23). CONCLUSION: C. albicans candidemia, >65 years of age and surgical procedure is associated with significant mortality, however, the use of fluconazole has shown the increased survival rate. This study suggests the surveillance of candidemia, and antifungal susceptibility pattern in current practice and the treatment.

Oral treatment options for patients with urinary tract infections caused by extended spectrum ßeta-lactamase (ESBL) producing Enterobacteriaceae.

INTRODUCTION: Frequent use of different antibiotics to treat urinary tract infections (UTIs) exerts a variety of selective pressure on pathogens which ultimately lead to the antimicrobial resistance. Extended Spectrum ßeta-Lactamase (ESBL) producing Enterobacteriacae causing UTIs, which are usually multidrug resistant organisms, pose a great therapeutic treatment challenge. Rediscovery of forgotten antibiotics such as pivmecillinam, fosfomycin, and nitrofurantoin may be helpful in this situation until the discovery of new agents. The main aim of present study was to determine the prevalence of ESBL producing Enterobacteriacae causing UTIs and their sensitivity profile to determine alternate effective oral treatment options. METHODS: This retrospective study was conducted to determine the prevalence of ESBL producing Enterobacteriacae from urine samples and their sensitivity profile (pivmecillinam, fosfomycin, nitrofurantoin, trimethoprim and ciprofloxacin) from September 2015 to September 2017. RESULTS: A total of 986 organisms were isolated from the urine samples of 680 patients. Approximately 77% isolates were obtained from female patients (526). Of 986 organisms, Escherichia coli was the most common isolated organism (889, 90%); followed by Klebsiella species (71, 7%) and other Enterobacteriacae (26, 3%). Of 889 E. coli, approximately 98%, 96%, and 93% were found to be sensitive to fosfomycin, pivmecillinam and nitrofurantoin respectively. On the other hand pivmecillinam was most effective against Klebsiella species (83%, 59); followed by fosfomycin (62%, 44) and nitrofurantoin (42%, 30). Of 26 other Enterobacteriacae, 23 (88%), and 22 (85%) were sensitive to pivmecillinam and fosfomycin while lower sensitivity rate (15%, 4) was noted against nitrofurantoin. More than 95% of all ESBL producing Enterobacteriacae were sensitive to pivmecillinam, fosfomycin and nitrofurantoin. Trimethoprim and ciprofloxacin were least effective. CONCLUSION: The emergence of multidrug resistant ESBL producing Enterobacteriacae restricts significantly the therapeutic options. This study shows higher sensitivity rates to pivmecillinam, fosfomycin and nitrofurantoin. We recommend their use to treat uncomplicated UTIs due to ESBL producing Enterobacteriacae.

Burkholderia Pseudomallei Causing Bone and Joint Infections: A Clinical Update.

Burkholderia pseudomallei (B. pseudomallei), a causative agent of an emerging infectious disease melioidosis, is endemic in the tropical regions of the world. Due to increased international travel, the infection is now also seen outside of the tropics. The majority of patients with identified risk factors such as diabetes mellitus, heavy alcohol use, malignancy, chronic lung and kidney disease, corticosteroid use, thalassemia, rheumatic heart disease, systemic lupus erythematosus and cardiac failure acquire this organism through percutaneous inoculation or inhalation. The clinical manifestations are variable, ranging from localized abscess formation to septicemia. Melioidotic bone and joint infections are rarely reported but are an established entity. The knee joint is the most commonly affected joint in melioidosis, followed by the ankle, hip and shoulder joints. Melioidosis should be in the differential diagnosis of bone and joint infections in residents or returning travelers from the endemic area. Melioidosis diagnosis is missed in many parts of the world due to the lack of awareness of this infection and limited laboratory training and diagnostic techniques. It also mimics other diseases such as tuberculosis. Delay in the diagnosis, or the initiation of appropriate and effective treatment against melioidosis, could worsen the outcome. Initial therapy with ceftazidime, or carbapenem with or without cotrimoxazole is recommended, followed by the oral eradication therapy (based on the antimicrobial susceptibility) with amoxicillin/clavulanic acid or cotrimoxazole. Surgical intervention remains important. This paper reviews current literature on the epidemiology, clinical features, diagnosis, and management of melioidotic bone and joint infections.

Group B Streptococcus infection: epidemiology, serotypes, and antimicrobial susceptibility of selected isolates in the population beyond infancy (excluding females with genital tract- and pregnancy-related isolates) at the University Malaya Medical Centre, Kuala Lumpur.

Group B Streptococcus (GBS) infection was studied in 49 patients collected at convenience (convenience sampling), excluding infants and women with genital tract- and pregnancy-related isolates, according to the availability of stocked isolates and easy accessibility to epidemiological data. The data were examined both prospectively and retrospectively from 2003-2005 at a tertiary-level multidisciplinary hospital in Kuala Lumpur, Malaysia. Skin and soft-tissue infections in 35 patients (71.4%) were the most common clinical presentation, while diabetes mellitus was the most common underlying condition (35 patients, 71.4%). All GBS isolates were sensitive to penicillin, and most isolates tested were sensitive to erythromycin (97.7%). Serotyping of 45 GBS isolates using a commercial serotyping kit revealed that the most common serotype was Ia (22.2%), followed by VI (17.8%), III and V (13.3% each). Others included Ib, II, IV, VIII, and VII; 13.3% were nontypeable. The findings of this pilot study are limited by the small sample size, the sampling method and the possibility that the cases are not wholly representative of the University Malaya Medical Centre population. Further studies from our hospital with larger numbers and using probabilistic sampling techniques are required to confirm the relatively high occurrence of serotype VI (the second most common serotype) in the population studied.

Cases of melioidosis in a university teaching hospital in Malaysia.

BACKGROUND AND PURPOSE: Melioidosis is an infectious disease caused by Burkholderia pseudomallei that is endemic in Southeast Asia and northern Australia and has also been reported from non-endemic areas of the world. Little is known about the antimicrobial susceptibility pattern and the demography of melioidosis patients in Malaysia. METHODS: This was a retrospective study of 83 patients with culture-proven B. pseudomallei infections from the University of Malaya Medical Centre, Kuala Lumpur, Malaysia from May 1995 to June 2005. Antimicrobial susceptibility of B. pseudomallei, age, gender and race of patients, nature of specimen, serological evidence and monthly distribution of cases were evaluated. RESULTS: All isolates were susceptible to piperacillin and piperacillin-tazobactam. The majority of strains were susceptible to imipenem (99%), ceftazidime (94%), amoxicillin-clavulanic acid (95%), ampicillin-sulbactam (94%), tetracycline (89%), chloramphenicol (94%), trimethoprim-sulfamethoxazole (70%), meropenem (88%) and ciprofloxacin (79%). Significant antimicrobial resistance was noted in aminoglycosides and ampicillin. The male-to-female ratio was 3.15:1, and mean age was 43.85 years. The majority of the patients were middle-aged (41-60 years). Malays and Indians made up 39% and 33% of affected patients, while Chinese and others comprised 25% and 3%, respectively. Of 83 patients, 67 were diagnosed by positive blood cultures, and 16 patients were non-bacteremic cases. There were 22 patients in whom B. pseudomallei grew in more than one clinical specimen, and there were 6 polymicrobial cases. CONCLUSION: Melioidosis is expanding in endemicity around the world. Control of the disease requires close monitoring, improved clinical laboratory standards and aggressive therapy.

Epidemiology of hepatitis C virus infection in Pakistan.

Since the discovery of hepatitis C virus (HCV) in 1989 as the causative agent of post-transfusion non-A non-B hepatitis, the epidemiology, pattern of transmission, different genotypes and clinical consequences of the disease have been studied worldwide, but little is known about the epidemiology of HCV infection in Pakistan. This paper reviews the available evidence on the epidemiology of HCV infection in Pakistan obtained via MEDLINE search (1970-2005) of published articles with key words hepatitis C and Pakistan, and other sources including ongoing discussions within the medical community. Approximately 10 million people have been infected with HCV in Pakistan. The majority of patients have acquired their infection through unsafe injections, reuse of syringes and needles and community barber shops used for face and armpit shaving. More than two-thirds of HCV patients were 40 to 50 years old. Although at present a small proportion of those with chronic HCV infection develop liver failure or hepatocellular carcinoma, it is estimated that the incidence of these advanced disease complications will increase over the coming years.

Etiology of blood culture isolates among patients in a multidisciplinary teaching hospital in Kuala Lumpur.

BACKGROUND AND PURPOSE: Bloodstream infections are an important cause of morbidity and mortality among hospitalized patients and the surveillance of etiological agents in these infections is important for their prevention and treatment. Data on common organisms isolated from blood cultures from Malaysia are limited, and our aim was to identify the common bloodstream isolates in hospitalized patients at the University of Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia. METHODS: A retrospective analysis was conducted over a 1-year period from January to December 2004 by reviewing laboratory reports of patients from the UMMC. The clinical significance of the isolates was not analyzed. RESULTS: Coagulase-negative staphylococci were the most common organisms isolated, accounting for 33.0% of the total blood culture isolates, followed by Staphylococcus aureus (10.4%) and Escherichia coli (9.7%). The incidence of methicillin-resistant S. aureus, and extended-spectrum beta-lactamase-producing E. coli and Klebsiella spp. bacteremia was low (2.3% and 1.8% of total isolates, respectively). Non-albicans Candida were the most common fungal isolates. CONCLUSIONS: The high number of coagulase-negative staphylococci should motivate clinicians and microbiologists to re-examine blood culture techniques in our institution. We recommend that further studies be carried out to establish the true significance of this organism among blood culture isolates.

Evaluation of the routine use of the anaerobic bottle when using the BACTEC blood culture system.

The established practice of sending blood cultures in an aerobic-anaerobic pair of bottles has been questioned in recent years, and this study was conducted to evaluate the routine use of an anaerobic bottle in the BACTEC blood culture set at the University of Malaya Medical Centre, Kuala Lumpur, from January to December 2004. A total of 11,663 paired blood culture sets were received, of which 3326 were from pediatric patients and 8337 were from adult patients. The overall positive isolation rate was 15%; the positive isolation rate on excluding the anaerobic bottles was 13%. Overall, there were significantly more organisms isolated from the aerobic bottle (p<0.05); however, the best yield was obtained on using the paired aerobic-anaerobic bottles. Among the positive blood culture sets, organisms were isolated from the anaerobic bottle alone in 15.2% of the pediatric sets and in 18.1% of the adult sets. Organisms that grew more frequently in the anaerobic bottle were anaerobes and some facultative anaerobes; however, the difference was not statistically significant except for anaerobes in the adult sets. We recommend that when culturing blood, an aerobic-anaerobic pair of bottles be used rather than an aerobic-aerobic pair, to optimize the recovery of a wider spectrum of organisms, including obligatory anaerobes.

Melioidotic septic arthritis: a case report and literature review.

Burkholderia pseudomallei, the causative agent of melioidosis, is endemic in southeast Asia and northern Australia. In recent years, the incidence of melioidosis has increased worldwide. Septic arthritis is a rare but well-recognized manifestation of melioidosis. Patients with underlying medical conditions, such as diabetes mellitus, renal impairment, cirrhosis, and malignancy are at greater risk. The presentations of melioidotic septic arthritis often mimic other disease processes and patients may not always be clinically septic. We present a case of septic arthritis due to B. pseudomallei in a 66-year-old male with diabetes mellitus presenting with a history of fever and ankle swelling. Follow-up ankle X-ray showed soft tissue swelling. Synovial fluid and blood samples grew B. pseudomallei. The patient improved gradually after parenteral administration of ceftazidime (2 g 8-hourly) and cotrimoxazole (1440 mg 8-hourly). He was discharged on oral cotrimoxazole (1440 mg 12-hourly), doxycycline (100 mg 12-hourly), and chloramphenicol (500 mg 6-hourly) for 6 months. This case highlights the possible occurrence of melioidotic septic arthritis, and the importance of prompt initiation of appropriate antimicrobials to achieve good outcomes.

Microbiology of diabetic foot infections in a teaching hospital in Malaysia: a retrospective study of 194 cases.

BACKGROUND AND PURPOSE: Diabetes mellitus is a progressive disease with chronic complications. Foot infections are a major complication of diabetes and eventually lead to development of gangrene and lower extremity amputation. The microbiological characteristics of diabetic foot infections have not been extensively studied in Malaysia. This study investigated the microbiology of diabetic foot infections and their resistance to antibiotics in patients with diabetic foot infections treated at University of Malaya Medical Centre in Kuala Lumpur, Malaysia. METHODS: A retrospective analysis was conducted of clinical specimens taken from patients with diabetic foot infections over a 12-month period from July 1, 2004 to June 30, 2005. A total of 194 patients with positive clinical specimens were identified. The clinical specimens were cultured using standard aerobic and anaerobic microbiological techniques. Antibiotic sensitivity testing to different antimicrobial agents was carried out using the disk diffusion method. RESULTS: 287 pathogens were isolated from 194 patients, an average of 1.47 organisms per lesion. The most frequently isolated pathogens were Gram-negative bacteria (52%), including Proteus spp. (28%), Pseudomonas aeruginosa (25%), Klebsiella pneumoniae (15%) and Escherichia coli (9%). Gram-positive bacteria accounted for 45% of all bacterial isolates. Staphylococcus aureus was predominant (44%) among Gram-positive bacteria, followed by Group B streptococci (25%) and Enterococcus spp. (9%). Antimicrobial susceptibility results showed that Gram-negative bacterial isolates were sensitive to imipenem and amikacin while vancomycin showed good activity against Gram-positive bacteria. CONCLUSION: The antibiogram results of this study suggest that pathogens remain sensitive to a number of widely used agents. Imipenem was equally effective against Gram-negative bacilli and Gram-positive cocci.

Antimicrobial susceptibility pattern of clinical isolates of Pseudomonas aeruginosa in a tertiary care hospital.

BACKGROUND AND PURPOSE: Pseudomonas aeruginosa is an important cause of morbidity and mortality in hospitalized, critically ill patients and patients with underlying medical conditions such as cystic fibrosis, neutropenia, and iatrogenic immunosuppression. The prevalence of multiresistant P. aeruginosa isolates has been increasing. The aim of this study was to determine the antimicrobial susceptibility patterns in P. aeruginosa strains isolated at a university teaching hospital in Kuala Lumpur, Malaysia. METHODS: The Laboratory Information System of the microbiology department was retrospectively reviewed to determine the susceptibility patterns of P. aeruginosa isolates to anti-pseudomonal antibiotics, from January to June 2005. Disk diffusion methods were employed and results were interpreted according to National Committee for Clinical Laboratory Standards guidelines. RESULTS: 505 clinical isolates of P. aeruginosa were tested. Major sources of these isolates included respiratory tract, wound, urine and blood. The rates of antimicrobial resistance of isolates were 6.73% to amikacin, 12.9% to gentamicin, 10.1% to netilmicin, 10.9% to ceftazidime, 11.3% to ciprofloxacin, 9.9% to imipenem, 10.8% to piperacillin, 9.4% to piperacillin-tazobactam and 0% to polymyxin B. Of the 505 isolates, 29 (5.74%) were found to be multidrug-resistant; these were most commonly isolated from respiratory tract specimens of patients in surgical units, followed by respiratory tract specimens in patients in medical units. CONCLUSIONS: The data in this study showed low rates of antibiotic resistance among P. aeruginosa isolates. Combinations of aminoglycosides plus beta-lactams or quinolones should be the appropriate choice for empirical therapy in P. aeruginosa infections. Active antibiotic susceptibility testing and surveillance should be continued in order to curtail the problem of antibiotic resistance.

Disseminated invasive aspergillosis in an apparently immunocompetent host.

Aspergillosis is a spectrum of diseases caused by members of the genus Aspergillus that continues to pose a significant threat to immunocompromised, organ transplant, neutropenic and cancer patients. In view of increasing risk factors leading to invasive aspergillosis, it is imperative for clinicians to be familiar with the clinical presentation, diagnostic methods and management of the disease. We describe a 34-year-old immunocompetent male patient receiving chemotherapy for Aspergillus fumigatus infection that had disseminated to lung, liver and spleen. A computed tomogram of thorax and abdomen showed thick-walled cavities of different sizes with air fluid levels, consolidation in both lungs and involvement of liver and spleen. His broncheoalveolar lavage and sputum specimens yielded A. fumigatus. Successful treatment of this infection was achieved with amphotericin B and itraconazole.