Presence of hypervirulence-associated determinants in Klebsiella pneumoniae from hospitalised patients in Germany.

BACKGROUND: Klebsiella (K.) pneumoniae is a ubiquitous Gram-negative bacterium and a common coloniser of animals and humans. Today, K. pneumoniae is one of the most persistent nosocomial pathogens worldwide and poses a severe threat/burden to public health by causing urinary tract infections, pneumonia and bloodstream infections. Infections mainly affect immunocompromised individuals and hospitalised patients. In recent years, a new type of K. pneumoniae has emerged associated with community-acquired infections such as pyogenic liver abscess in otherwise healthy individuals and is therefore termed hypervirulent K. pneumoniae (hvKp). The aim of this study was the characterisation of K. pneumoniae isolates with properties of hypervirulence from Germany. METHODS: A set of 62 potentially hypervirulent K. pneumoniae isolates from human patients was compiled. Inclusion criteria were the presence of at least one determinant that has been previously associated with hypervirulence: (I) clinical manifestation, (II) a positive string test as a marker for hypermucoviscosity, and (III) presence of virulence associated genes rmpA and/or rmpA2 and/or magA. Phenotypic characterisation of the isolates included antimicrobial resistance testing by broth microdilution. Whole genome sequencing (WGS) was performed using Illumina® MiSeq/NextSeq to investigate the genetic repertoire such as multi-locus sequence types (ST), capsule types (K), further virulence associated genes and resistance genes of the collected isolates. For selected isolates long-read sequencing was applied and plasmid sequences with resistance and virulence determinants were compared. RESULTS: WGS analyses confirmed presence of several signature genes for hvKp. Among them, the most prevalent were the siderophore loci iuc and ybt and the capsule regulator genes rmpA and rmpA2. The most dominant ST among the hvKp isolates were ST395 capsule type K2 and ST395 capsule type K5; both have been described previously and were confirmed by our data as multidrug-resistant (MDR) isolates. ST23 capsule type K1 was the second most abundant ST in this study; this ST has been described as commonly associated with hypervirulence. In general, resistance to beta-lactams caused by the production of extended-spectrum beta-lactamases (ESBL) and carbapenemases was observed frequently in our isolates, confirming the threatening rise of MDR-hvKp strains. CONCLUSIONS: Our study results show that K. pneumoniae strains that carry several determinants of hypervirulence are present for many years in Germany. The detection of carbapenemase genes and hypervirulence associated genes on the same plasmid is highly problematic and requires intensified screening and molecular surveillance. However, the non-uniform definition of hvKp complicates their detection. Testing for hypermucoviscosity alone is not specific enough to identify hvKp. Thus, we suggest that the classification of hvKp should be applied to isolates that not only fulfil phenotypical criteria (severe clinical manifestations, hypermucoviscosity) but also (I) the presence of at least two virulence loci e.g. iuc and ybt, and (II) the presence of rmpA and/or rmpA2.

Bacterial Spectrum and Infective Foci in Patients Operated for Infective Endocarditis: Time to Rethink Strategies?

OBJECTIVE: The rising incidence of infective endocarditis (IE) accompanied by the de-escalation of antibiotic prophylaxis and the complexity of surgical treatment makes IE a daunting foe. We reviewed all patients who underwent cardiac surgery for IE at our institution with a focus on causative organisms and infective foci. METHODS: A review of 3,952 consecutive patients who underwent cardiac surgery at our institution between January 2013 and December 2017 revealed 160 patients (4%) who were operated for IE. RESULTS: The predominantly affected valves were the aortic (30%) and mitral valve (26.9%) as well as a combination of both (8.8%). A total of 28.8% of patients suffered from prosthetic valve endocarditis (PVE). The most frequently identified causative organisms were Staphylococcus (45.7%), Streptococcus (27.5%), and Enterococcus species (16.7%), which was predominantly associated with PVE (p = 0.050). In 13.1% of patients, a causative organism has not been detected. The most frequent infective foci were dental (15%), soft-tissue infections (15%), spondylodiscitis (10%), and infected intravascular implants (8.8%). Relevant predisposing factors were immunosuppression (9.4%) and intravenous drug abuse (4.4%). Septic cerebral infarctions were diagnosed in 28.8% of patients. Postoperative mortality was 22.5%. CONCLUSIONS: As the bacterial spectrum and the infective foci are still the "old acquaintances," and with regard to the increasing incidence of IE, current risk-benefit evaluations concerning antibiotic prophylaxis may need to be revisited.

Diagnosis of mycobacterial skin infections.

The diagnosis of cutaneous mycobacterial infections may be challenging. Owing to the broad spectrum of their clinical presentations, mycobacterioses have to be considered as differential diagnoses to many inflammatory dermatoses. Diagnostic measures comprise histology including special staining, cultures and molecular microbiological examinations as well as the detection of cellular immune reactions of the patient by means of interferon-γ release assays and skin testing. Clinicians should know the appropriate use and combination of procedures to diagnose mycobacterioses quickly and correctly and to avoid costs and delays caused by unnecessary examinations. This mini review summarizes advantages, limitations, and pitfalls of diagnostic methods for mycobacterial skin infections.

Antimicrobial-Resistant Bacteria in Infected Wounds, Ghana, 20141.

Wound infections are an emerging medical problem worldwide, frequently neglected in under-resourced countries. Bacterial culture and antimicrobial drug resistance testing of infected wounds in patients in a rural hospital in Ghana identified no methicillin-resistant Staphylococcus aureus or carbapenem-resistant Enterobacteriaceae but identified high combined resistance of Enterobacteriaceae against third-generation cephalosporins and fluoroquinolones.

Intestinal Pneumatosis Associated with Tuberculosis after Allogeneic Hematopoietic Stem Cell Transplantation.

Pneumatosis intestinalis (PI), defined as intestinal intra- and extramural gas accumulation, is a rare radiographic finding in conditions of intestinal wall damage of varied etiology. Here, we report on a 56-year-old female with multiple myeloma who presented with undulating fever, fluctuating abdominal symptoms, and a distended abdomen 5 months after allogeneic hematopoietic stem cell transplantation (HSCT). Abdominal X-ray and CT scan documented PI with gas accumulation both in the intestinal and colonic bowel walls. Concurrently, thoracic CT revealed mediastinal and bihilar lymphadenopathy associated with bilateral pleural effusions. Microscopy of bronchoalveolar lavage fluid (BALF) revealed acid-fast bacilli, which were identified as Mycobacterium tuberculosis. Tuberculostatic treatment resulted in timely clinical improvement, a complete clearance of the radiological and clinical findings of PI, and the control of the tuberculosis (Tbc), determined by multiple negative BALF results. Taken together, PI occurred as the initial symptom of Tbc in an allogeneic stem cell recipient, achieving complete recovery by tuberculostatic treatment only.

High prevalence of human papillomaviruses in Ghanaian pregnant women.

Data about the prevalence of human papillomaviruses (HPV) in African women with normal and abnormal cervical cytology are still scarce. Current HPV vaccines contain HPV types, which mainly represent the HPV epidemiology of industrial countries. As further developments of HPV vaccines are going on, it is necessary to regard regional differences in HPV type prevalence to ensure optimal protection by the vaccine. Vaginal swabs of Ghanaian pregnant women, routinely collected before delivery to rule out bacterial infections causing early onset sepsis, were screened for 12 high-risk (HR), 13 probably/possibly (pHR), and 18 low-risk (LR) HPV types. Most pregnant women come for delivery to the hospital. This was considered as appropriate possibility to have an unselected group of women. HPV DNA were detected in 55/165 women (33.3, 95 % CI 26.3-41.1 %). Thirty-four out of fifty-five (61.8, 95 % CI 47.7-74.3 %) of HPV-positive women were infected with HR and/or pHR HPV types. The five most prevalent HR or pHR HPV types were HPV-52 and HPV-67 (7 women each, 4.2, 95 % CI 1.9-8.9 %), HPV-53 (six women, 3.6, 95 % CI 1.5-8.1 %), HPV-45 (five women, 3.0, 95 % CI 1.1-7.3 %), and HPV-18 (four women, 2.4, 95 % CI 0.8-6.5 %), respectively. HPV-16 was found in two women only (1.2, 95 % CI 0.2-4.8 %). Future HPV vaccine research may devote special interest to HPV-67 and HPV-53 provided further studies confirm their high prevalence in the general population of Sub-Saharan African countries. The true carcinogenic potential of HPV-67, which is a member of species alpha9 including HPV-16, and so far categorized as pHR, should be clarified.

Point-of-care multiplex PCR promises short turnaround times for microbial testing in hospital-acquired pneumonia--an observational pilot study in critical ill patients.

BACKGROUND: The early beginning of an adequate antibiotic therapy is crucial in hospital-acquired pneumonia (HAP), but depends on the results of conventional microbiological diagnostics (cMD). It was the aim of this study to evaluate the performance and turnaround times of a new point-of-care multiplex polymerase chain reaction (mPCR) system for rapid identification of pathogens and antibiotic resistance markers. We assessed the applicability of the system under real-life conditions in critical ill patients with HAP. METHODS: We enrolled forty critical ill patients with clinical signs for HAP into an observational study. Two samples of respiratory secretions were collected during one course of aspiration and cMD and mPCR testing (Unyvero, Curetis AG, Holzgerlingen, Germany) were performed immediately. The mPCR device was operated as a point-of-care system at the intensive care unit. We compared turnaround times, results of pathogen identification and results of antibiotic resistance testing of both methods. RESULTS: Mean turnaround times (min-max) were 6.5 h (4.7-18.3 h) for multiplex PCR and 71 h (37.2-217.8 h) for conventional microbiology (final cMD results, incomplete results neglected). 60% (n = 24) of the mPCR tests were completely valid. Complete test failure occurred in 10% (n = 4) and partial test failure occurred in 30% (n = 12). We found concordant results in 45% (n = 18) and non-concordant results in 45% (n = 18) of all patients. 55% (n = 16) of the results were concordant in patients with a clinical pulmonary infection score (CPIS) > 5 (n = 29). Concordant results included three cases of multidrug resistant bacteria. MPCR frequently detected antibiotic resistance markers that were not found by cMD. CONCLUSIONS: Unyvero allowed point-of-care microbial testing with short turnaround times. The performance of the system was poor. However, an improved system with a more reliable performance and an extended microbial panel could be a useful addition to cMD in intensive care medicine. TRIAL REGISTRATION: ClinicalTrials.gov NCT01858974 (registered 16 May 2013).

Molecular detection of Campylobacter jejuni as a cause of culture-negative spondylodiscitis.

Spondylodiscitis caused by Campylobacter species is a rare disease which is most often caused by Campylobacter fetus. We report a case of culture-negative spondylodiscitis and a psoas abscess due to Campylobacter jejuni in a 68-year-old woman, as revealed by 16S rRNA gene and Campylobacter-specific PCRs from biopsied tissue.

Impact of routine bedside infectious diseases service on clinical management and prognosis of patients with Candida fungemia - an example for Antifungal Stewardship at university level in Germany.

BACKGROUND: Candidemia is rare and has a high mortality rate. This study analyses the impact of bedside antifungal stewardship (AFS) on clinical management and prognosis of patients with candidemia at a university hospital in Germany. METHODS: All patients with at least one positive blood culture with Candida species between 2014 and 2016 received bedside AFS with standardized recommendations. Medical records were retrospectively analyzed. Results from the intervention period from 2014-2016 (n=109), with focus on 2016 (n=39), were compared with those from the pre-intervention period in 2013 (n=30). RESULTS: Bedside AFS was performed in 24/35 (69%) surviving patients in 2016 within the first 3 days after diagnosis of candidemia. All surviving patients (n=35) in 2016 received antifungal treatment compared with 24/28 (86%) in 2013 (p=0.0344). Follow-up blood cultures were performed in 25/35 (71%) in 2016 compared with 10/25 (40%) in 2013 (p=0.0046). Survival in the intervention compared with the pre-intervention group did not differ significantly (p=0.58) one year after the diagnosis of candidemia was made. However, patients with candidemia often have multiple serious comorbidities. CONCLUSIONS: Individualized bedside AFS significantly improves adherence to recommendations for patients with Candida fungemia, especially guideline-oriented diagnostics and therapy. Improving the prognosis of patients with candidemia remains a huge challenge for AFS.

Emerging Antimicrobial Drug Resistance in Africa and Latin America: Search for Reasons.

Medicine quality and methods for its assessment play a major role in the effectiveness of therapies and the treatment of many infectious diseases. However, poor-quality and/or falsified products are circulating in huge amounts in many low- and middle-income countries and are one of the major reasons why more and more resistant bacteria emerge. The development of resistance is additionally triggered by a plethora of antibiotic medicines which is easily available through pharmacies and unofficial sources. The uncontrolled overuse of these products is a huge problem not only in single countries but worldwide. In this review, we aim to demonstrate the factors which are involved in an emerging resistance development and how strong regulatory authorities, routine quality control by means of proficiency testing, and post-marketing surveillance as well as training personnel and patients can be combined to curb the problem.

Epidemiology and Prevalence of Oral Candidiasis in HIV Patients From Chad in the Post-HAART Era.

Oral candidiasis remains a common problem in HIV-infected individuals, especially in sub-Saharan Africa. Here, we performed the first study in Chad on the prevalence of oral yeasts carriage and oral candidiasis in HIV-positive subjects from southern Chad and analyzed the influence of HAART, CD4+ T-cell numbers, and antimycotics in 589 patients. These patients were recruited from a specialized medical center for HIV patients in Sarh and from a rural medical health dispensary in the vicinity, including a total of 384 HIV-positive and 205 HIV-negative individuals. Yeasts obtained from oral specimen were identified by MALDI-TOF MS and their antifungal susceptibility profiles determined. The overall prevalence of yeast colonization and symptomatic oral candidiasis in HIV-infected patients was 25.1%. The prevalence of oral candidiasis was higher in untreated than in HAART-treated HIV-positive patients (16% vs. 2%; p < 0.01). Oral candidiasis was furthermore associated with high fungal burdens of Candida albicans and a CD4+ T-cell number <200/µl. A shift toward non-albicans Candida species was observed under nucleoside-based HAART therapy. Azole antifungal drug resistance was only observed for the intrinsically resistant species Candida krusei and Candida glabrata. Prevalence of oral candidiasis in the studied area was very low. The species distribution was similar to other countries around the world, with C. albicans being dominant. Candida dubliniensis was not isolated. Nucleoside-based HAART therapy significantly reduced oral colonization as well as occurrence of oral candidiasis caused by C. albicans and led to a species shift toward non-albicans species. Antifungal resistance was not yet a concern in Chad.

Travel-related Streptococcal toxic shock syndrome caused by emm type 78 Streptococcus pyogenes.

Streptococcal toxic shock syndrome is a serious health problem in developed and developing countries. We here report a case of severe protracted disease after a minor skin infection in a young traveler returning from West Malaysia which was caused by an unusual emm-type strain harboring speG and smeZ superantigen genes.

Rickettsia typhi infection with interstitial pneumonia in a traveler treated with moxifloxacin.

Rickettsial diseases may play an important part in the differential diagnosis of fever in returned travelers. The initial empirical treatment needs to take Rickettsia species into consideration to avoid the development of life-threatening courses. Here, we present a case of interstitial pneumonia associated with Rickettsia typhi infection treated with moxifloxacin.

High Prevalence of Carbapenemase-Producing Acinetobacter baumannii in Wound Infections, Ghana, 2017/2018.

Three years after a prospective study on wound infections in a rural hospital in Ghana revealed no emergence of carbapenem-resistant bacteria we initiated a new study to assess the prevalence of multidrug-resistant pathogens. Three hundred and one samples of patients with wound infections were analysed for the presence of resistant bacteria in the period August 2017 till March 2018. Carbapenem-resistant Acinetobacter (A.) baumannii were further characterized by resistance gene sequencing, PCR-based bacterial strain typing, pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST "Oxford scheme"). A. baumanni was detected in wound infections of 45 patients (15%); 22 isolates were carbapenem-resistant. Carbapenemases NDM-1 and/or OXA-23 were detected in all isolates; two isolates harboured additionally OXA-420. PFGE and MLST analyses confirmed the presence of one A. baumannii strain in 17 patients that was assigned to the worldwide spread sequence type ST231 and carried NDM-1 and OXA-23. Furthermore, two new A. baumannii STs (ST2145 and ST2146) were detected in two and three patients, respectively. Within three years the prevalence of carbapenem-resistant A. baumannii increased dramatically in the hospital. The early detection of multidrug-resistant bacteria and prevention of their further spread are only possible if continuous surveillance and molecular typing will be implemented.

Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy.

BACKGROUND: The use of highly active antiretroviral therapy (HAART) may change the incidence of, and the risk and prognostic factors for, invasive pneumococcal disease in patients with human immunodeficiency virus (HIV). METHODS: We prospectively studied 142 episodes of pneumococcal bacteremia in 122 HIV-infected adults. Eighty-five episodes occurred in the pre-HAART era (1986-1996) and 57 in the HAART era (1997-2002). A case-control study was conducted to identify risk factors for pneumococcal bacteremia in the HAART era. RESULTS: The incidence of pneumococcal bacteremia dropped from 24.1 episodes per 1000 patient-years in the pre-HAART era to 8.2 episodes per 1000 patient-years in the HAART era (P = .01). Compared with patients in the pre-HAART era, patients in the HAART era had more associated comorbidity (42% vs 26%; P = .04), fewer recurrences of bacteremia (4% vs 15%; P = .04), and a higher 30-day mortality rate (26% vs 8%; P=.004). High antibiotic resistance rates were observed in both periods. By multivariate analysis, the major risk factors for pneumococcal bacteremia in the HAART era were associated comorbidity (adjusted odds ratio [OR], 3.36), alcohol abuse (adjusted OR, 5.28), prior hospitalization (adjusted OR, 3.38), current smoking (adjusted OR, 5.19), and CD4 cell count lower than 100 cells/muL (adjusted OR, 2.38); while use of HAART (adjusted OR, 0.37) and pneumococcal vaccine (adjusted OR, 0.39) were protective factors. CONCLUSIONS: The widespread use of HAART and pneumococcal vaccine may decrease the incidence of invasive pneumococcal disease in HIV-infected patients. Risk factors and prognosis of pneumococcal bacteremia in the HAART era are more similar to those reported in non-HIV-infected individuals.

The effect of cephalosporin resistance on mortality in adult patients with nonmeningeal systemic pneumococcal infections.

PURPOSE: To evaluate the clinical relevance of cephalosporin (ceftriaxone/cefotaxime) resistance among patients with nonmeningeal systemic pneumococcal infection. SUBJECTS AND METHODS: From January 1994 to October 2000, we prospectively studied 522 episodes of nonmeningeal systemic pneumococcal infections (448 pneumonias) in 499 adults who were treated according to hospital guidelines. In vitro antibiotic susceptibility, as the minimum inhibitory concentration (MIC), was determined by microdilution method. The MIC methods and breakpoints (cutoffs) were established by the National Committee for Clinical Laboratory Standards. RESULTS: Of the 522 pneumococcal strains, 413 strains (79%) were susceptible to ceftriaxone/cefotaxime, MIC < or =0.5 microg/mL; 79 (15%) were intermediate, MIC = 1 microg/mL; and 30 (6%) were resistant, MIC = 2 microg/mL. After adjusting for several variables, including pneumococcal serogroups/serotypes, infections due to nonsusceptible (intermediate and resistant) pneumococcal strains were independently associated with prior antibiotic therapy, with an odds ratio of 5.9 (95% confidence interval: 2.6 to 13.6). Thirty-day mortality among the 185 patients who were treated with ceftriaxone (1 g/d) or cefotaxime (1.5 g every 8 hours) did not differ by cephalosporin susceptibility: 18% (26/148) among those with susceptible organisms, 13% (3/24) with intermediate organisms, and 15% (2/13) in resistant cases (P = 0.81). CONCLUSION: Ceftriaxone or cefotaxime were effective in treating patients with nonmeningeal systemic pneumococcal infections caused by strains with MIC < or =2 microg/mL. These results support the newly established ceftriaxone/cefotaxime MIC breakpoints (cutoffs) for nonmeningeal pneumococcal infections.

Severe Leptospira interrogans serovar Icterohaemorrhagiae infection with hepato-renal-pulmonary involvement treated with corticosteroids.

KEY CLINICAL MESSAGE: The traditional concept of immediate antibiotic treatment in suspected leptospirosis seems to be especially important for patients up to day 4 of clinical illness. As immune mechanisms probably play a crucial role in advanced leptospirosis with presumed pulmonary hemorrhages, patients might benefit from corticosteroids or other immunosuppressive agents beside antibiotics.

Smoking and alcohol abuse are the most preventable risk factors for invasive pneumonia and other pneumococcal infections.

OBJECTIVES: To determine the prevalence of smoking and alcohol abuse among patients with invasive pneumococcal disease (IPD) in order to promote prevention strategies. METHODS: We prospectively studied all culture-proven IPD cases in patients aged ≥ 18 years during the period 1997-2011. The habits of smoking and alcohol abuse were evaluated. Pneumococcal serotyping was performed. RESULTS: There were 1378 IPD cases, with a mean age of 61 ± 17 years; 65% were males. Compared to the general population aged 18-64 years, patients with IPD of the same age group were more often current smokers (57% vs. 35%, p < 0.001) and alcohol abusers (21% vs. 6%, p < 0.001). Among patients with IPD, young adults (aged 18-49 vs. 50-64 vs. ≥ 65 years) were more commonly current smokers (71% vs. 40% vs.14%, p < 0.001) and alcohol abusers (23% vs. 18% vs. 6%, p < 0.001). Males were more frequently smokers and alcohol abusers than females. Smokers and alcohol abusers more often had underlying diseases such as HIV infection and chronic liver disease. Pneumonia was more common in smokers and peritonitis in alcohol abusers. Alcohol abuse conferred higher mortality. Certain pneumococcal serotypes, such as serotypes 1, 8, and 23F, more frequently caused IPD in smokers, and serotypes 4, 11A, and 19F in alcohol abusers. CONCLUSIONS: Smoking and alcohol abuse are the most preventable risk factors for IPD. Implementing smoking and alcohol abuse cessation programs and a pneumococcal vaccination schedule are essential to diminish the burden of pneumonia and other pneumococcal infections.

Panton-Valentine leukocidin-positive Staphylococcus aureus infections in returning travelers.

Skin and soft tissue infections caused by Panton-Valentine leukocidin-producing strains of Staphylococcus aureus are emerging among travelers returning from the tropics. Here, we here present data on 15 affected individuals. Intrafamiliar spread was documented in one case, and occupational transmission was assumed in another. Spa typing of the strains revealed a broad spectrum of variants, but some were clonally related. Methicillin-resistant Staphylococcus aureus (MRSA) was found in three cases.