Outcomes of 23 patients diagnosed with New Delhi metallo-beta-lactamase (NDM)-producing Klebsiella pneumoniae infection treated with ceftazidime/avibactam and aztreonam at a single center in Poland.

PURPOSE: Amongst all etiologic hospital-acquired infection factors, K. pneumoniae strains producing New Delhi metallo-ß-lactamase (KP-NDM) belong to pathogens with the most effective antibiotic resistance mechanisms. Clinical guidelines recommend using ceftazidime/avibactam with aztreonam (CZA + AT) as the preferred option for NDM-producing Enterobacterales. However, the number of observations on such treatment regimen is limited. This retrospective study reports the clinical and microbiological outcomes of 23 patients with KP-NDM hospital-acquired infection treated with CZA + AT at a single center in Poland. METHODS: The isolates were derived from the urine, lungs, blood, peritoneal cavity, wounds, and peritonsillar abscess. In microbiological analysis, mass spectrometry for pathogen identification, polymerase chain reaction, or an immunochromatographic assay for detection of carbapenemase, as well as VITEK-2 system, broth microdilution, and microdilution in agar method for antimicrobial susceptibility tests were used, depending of the pathogens' nature. CZA was administered intravenously (IV) at 2.5 g every eight hours in patients with normal kidney function, and aztreonam was administered at 2 g every eight hours IV. Such dosage was modified when renal function was reduced. RESULTS: KP-NDM was eradicated in all cases. Four patients (17.4%) died: three of them had a neoplastic disease, and one - a COVID-19 infection. CONCLUSION: The combination of CZA + AT is a safe and effective therapy for infections caused by KP-NDM, both at the clinical and microbiological levels. The synergistic action of all compounds resulted in a good agreement between the clinical efficacy of CZA + AT and the results of in vitro susceptibility testing.

Bacteraemia caused by Lactobacillus casei in a patient after cardiac surgery. A case report.

BACKGROUND: Bacteria of the Lactobacillus family are a part of the physiological flora of the oral cavity, gastrointestinal tract, and urinary tract. We have used them in the food industry as probiotics and supplements. In some settings, rod-shaped lactic acid bacteria may become pathogenic. It may occur in immunocompromised or heart disease patients after cardiac surgery, patients with disturbed intestinal wall permeability, or those treated with broad-spectrum antibiotics. CASE PRESENTATION: We present rare bacteraemia induced by the probiotic bacterium Lactobacillus casei in a 63-year-old patient after the attempted removal of ICD electrodes, complicated by acute regurgitation of the tricuspid valve. The patient underwent urgent cardiac surgery, the electrode elements were removed, and the tricuspid valve was replaced with a biological prosthesis. After surgery, the patient required intensive, multidisciplinary treatment with mechanical ventilation, continuous renal replacement therapy, broad-spectrum empirical antibiotic therapy, parenteral nutrition, and blood product transfusion because of multiple organ failure. On the 14th day of hospitalisation, the clinical symptoms of septic shock were observed. The microbiological investigation was performed, and Lactobacillus casei was cultured from a dialysis catheter sample. Dedicated antimicrobials were administered, and the patient was discharged home in good overall condition. CONCLUSIONS: The present case shows that the promoted use of probiotics must be cautiously administered to patients in severe conditions, especially when accompanied by reduced immune system efficiency symptoms.

Bloodstream Infections in the Intensive Care Unit: a Single-Center Retrospective Bacteriological Analysis Between 2007 and 2019.

Hospital-acquired bloodstream infections are a severe worldwide problem associated with significant morbidity and mortality. This retrospective, single-center study aimed to analyze bloodstream infections in patients hospitalized in the intensive care unit of the Military Institute of Medicine, Poland. Data from the years 2007-2019 were analyzed. When the infection was suspected, blood samples were drawn and analyzed microbiologically. When bacterial growth was observed, an antimicrobial susceptibility/resistance analysis was performed. Among 12,619 analyzed samples, 1,509 were positive, and 1,557 pathogens were isolated. In 278/1,509 of the positive cases, a central line catheter infection was confirmed. Gram-negative bacteria were the most frequently (770/1,557) isolated, including Acinetobacter baumannii (312/770), Klebsiella pneumoniae (165/770; 67/165 were the isolates that expressed extended spectrum beta-lactamases (ESBL), 5/165 isolates produced the New Delhi metallo-ß-lactamases (NDM), 4/165 isolates expressed Klebsiella pneumoniae carbapenemase (KPC), and 1/165 isolate produced OXA48 carbapenemase), Pseudomonas aeruginosa (111/770; 2/111 isolates produced metallo-ß-lactamase (MBL), and Escherichia coli (69/770; 11/69 - ESBL). Most Gram-positive pathogens were staphylococci (545/733), mainly coagulase-negative (368/545). Among 545 isolates of the staphylococci, 58 represented methicillin-resistant Staphylococcus aureus (MRSA). Fungi were isolated from 3.5% of samples. All isolated MRSA and methicillin-resistant coagulase-negative Staphylococcus (MRCNS) strains were susceptible to vancomycin, methicillin-sensitive Staphylococcus aureus (MSSA) isolates - to isoxazolyl penicillins, and vancomycin-resistant Enterococcus (VRE) - to linezolid and tigecycline. However, colistin was the only therapeutic option in some infections caused by A. baumannii and KPC-producing K. pneumoniae. P. aeruginosa was still susceptible to cefepime and ceftazidime. Echinocandins were effective therapeutics in the treatment of fungal infections.

The Clinical Manifestation of SARS-CoV-2 in Critically Ill Patients with Klebsiella pneumoniae NDM Hospitalized in the ICU of a Modular Hospital during the Third Wave of the Pandemic in Poland-An Observational Cohort Study.

There is limited information on the clinical characteristics of critically ill patients infected with SARS-CoV-2 and Klebsiella pneumoniae NDM. The objective of this study was to describe such a group of patients hospitalised in the intensive care unit of a large academic hospital during the third wave of the COVID-19 pandemic in Poland. Between 1 March and 30 June 2021, 103 patients were hospitalised, of whom 23 (22.3%) were positive for K. pneumoniae NDM; 14 (61%) of those patients died. Their hospitalisation time varied between 9 and 47 days. Five of the 23 patients (21.7%) were otherwise healthy. In contrast, the others suffered from cardiovascular problems (11, 47.8%), obesity (6, 26.1%), diabetes (5, 21.7%), neurological problems (4, 17.4%), or kidney disease (1, 4.3%); 4 (17.4%) were heavy smokers, and 1 (4.3%) had a history of alcohol abuse. K. pneumoniae NDM was isolated from urine samples of all patients. In 17 patients (73.9%), it was also isolated from other sources: from the respiratory tract in 10 (43.8%), from the blood in 2 (8.7%), and the central venous catheter was contaminated in 1 case (4.3%). Fourteen of the patients (60.9%) were colonised K. pneumoniae NDM. In four patients (17.4%), bacterial and fungal coinfection occurred. In one case (4.4%), two fungal species, Candida albicans and Candida glabrata, were isolated simultaneously. The most frequently administered antimicrobial agent was colistin (60.9%), followed by meropenem (47.8%), vancomycin (47.8%), ceftriaxone (34.8%), linezolid (30.4%), piperacillin/tazobactam (30.4%), and trimethoprim/sulfamethoxazole (30.4%). Other less-frequently administered agents included amikacin, amoxicillin/clavulanate, tigecycline, ciprofloxacin, fosfomycin, clindamycin, and cloxacillin. Fluconazole was administered in 14 patients (60.7%) and micafungin was administered in 2 (8.7%).

Thrombotic activation before and after total hip arthroplasty. A prospective cohort study.

BACKGROUND: Total hip arthroplasty (THA) causes acute blood loss. It may lead to a deficiency in coagulation factors, which, in turn, may lead to increased bleeding during the postoperative period. METHODS: Thirty patients (18 women) with a mean age of 67 years (range: 63-72 years) participated in this prospective diagnostic study. THA was performed without tranexamic acid administration in the perioperative period. Activities of clotting factors II, VIII, X, and fibrinogen concentration were evaluated before surgery, 6 hours after the procedure, 2, 4, and 6 days after the operation. All laboratory tests were performed using ACL TOP 500 CTS analyzer. RESULTS: No thromboembolic complications were noted during hospitalization. Mean fibrinogen concentration was 366 mg/dL before surgery, which decreased to 311 mg/dL 6 hours after the operation and peaked at 827 mg/dL on the 4th day after the procedure. Activities of factors II and X decreased on the second and fourth days after surgery. Although the activity of factor VIII decreased after the procedure, it remained within the normal range. Increased baseline fibrinogen concentrations were observed in 6 out of 30 (20%) patients. Mean blood loss was 1332 mL (range, 183-2479 mL) and did not correlate with changes in clotting factor activities. CONCLUSIONS: In patients undergoing THA, fibrinogen acts as an acute-phase protein. Activities of clotting factors II and X normalize within 6 days, and although the activity of factor VIII decreases, it remains within the normal range. TRIAL REGISTRATION: The study was pre-registered May 1st, 2020 on ClinicalTrials.gov.

Preliminary Results of an Astri/UWM EGNSS Receiver Antenna Calibration Facility.

In 2019, the University of Warmia and Mazury in Olsztyn, in cooperation with Astri Polska, started a European Space Agency (ESA) project. The purpose of the project is the development and implementation of a field calibration procedure for a multi-frequency and multi-system global navigation satellite system (GNSS). The methodology and algorithms proposed in the project are inspired by the "Hannover" concept of absolute field receiver antenna calibration; however, some innovations are introduced. In our approach, the antenna rotation point is close to the nominal mean phase center (MPC) of the antenna, although it does not coincide with it. Additionally, a National Marine Electronics Association local time zone (NMEA ZDA) message is used to synchronize the robot with the GNSS time. We also propose some modifications in robot arm movement scenarios. Our first test results demonstrate consistent performance for the calibration strategy and calibration procedure. For the global positioning system (GPS) L1 frequency, the calibration results show good agreement with the IGS-type mean values. For high satellite elevations (20°-90°), the differences do not exceed 1.5 mm. For low elevation angles (0°-20°), the consistency of the results is worse and the differences exceed a 3 mm level in some cases.

Space State Representation Product Evaluation in Satellite Position and Receiver Position Domain.

In Global Navigation Satellite Systems (GNSS) positioning, important terms in error budget are satellite orbits and satellite clocks correction errors. International services are developing and providing models and correction to minimize the influence of these errors both in post-processing and real-time applications. The International GNSS Service (IGS) Real-Time Service (RTS) provides real-time orbits and clock corrections for the broadcast ephemeris. Real-time products provided by IGS are generated by different analysis centres using different algorithms. In this paper, four RTS products-IGC01, CLK01, CLK50, and CLK90-were evaluated and analysed. To evaluate State Space Representation (SSR) products' GPS satellites, the analyses were made in three variants. In the first approach, geocentric real-time Satellite Vehicle (SV) coordinates and clock corrections were calculated. The obtained results were compared with the final IGS, ESA, GFZ, and GRG ephemerides. The second approach was to use the corrected satellite positions and clock corrections to determine the Precise Point Position (PPP) of the receiver. In the third analysis, the impact of SSR corrections on receiver Single Point Position (SPP) was evaluated. The first part of the research showed that accuracy of the satellite position is better than 10 cm (average 3 to 5 cm), while in the case of clock corrections, mean residuals range from 2 cm to 17 cm. It should be noted that the errors of the satellites positions obtained from one stream differ depending on the reference data used. This shows the need for an evaluation of correction streams in the domain of the receiver position. In the case of PPP in a kinematic mode, the tests allowed to determine the impact that the use of different streams has on the final positioning results. These studies showed differences between specific streams, which could not be seen in the first study. The best results (3D RMS at 0.13 m level) were obtained for the CLK90 stream, while for IGC01, the results were three times worse. The SPP tests clearly indicate that regardless of the selected SSR stream, one can see a significant improvement in positioning accuracy as compared to positioning results using only broadcast ephemeris.

Assessment of Centre National d'Études Spatiales Real-Time Ionosphere Maps in Instantaneous Precise Real-Time Kinematic Positioning over Medium and Long Baselines.

Precise real-time kinematic (RTK) Global Navigation Satellite System (GNSS) positioning requires fixing integer ambiguities after a short initialization time. Originally, it was assumed that it was only possible at a relatively short distance from a reference station (<10 km), because otherwise the atmospheric effects prevent effective ambiguity fixing. Nowadays, through the use of VRS, MAC, or FKP corrections, the distances to the closest reference station have been increased to around 35 km. However, the baselines resolved in real time are not as far as in the case of static positioning. Further extension of the baseline requires the use of an ionosphere-weighted model with ionospheric delay corrections available in real time. This solution is now possible thanks to the Radio Technical Commission for Maritime (RTCM) stream of SSR corrections from, for example, Centre National d'Études Spatiales (CNES), the first analysis center to provide it in the context of the International GNSS Service. Then, ionospheric delays are treated as pseudo-observations that have a priori values from the CLK RTCM stream. Additionally, satellite orbit and clock errors are properly considered using space-state representation (SSR) real-time radial, along-track, and cross-track corrections. The following paper presents the initial results of such RTK positioning. Measurements were performed in various field conditions reflecting realistic scenarios that could have been experienced by actual RTK users. We have shown that the assumed methodology was suitable for single-epoch RTK positioning with up to 82 km baseline in solar minimum (30 March 2019) mid and high latitude (Olsztyn, Poland) conditions. We also confirmed that it is possible to obtain a rover position at the level of a few centimeters of precision. Finally, the possibility of using other newer experimental IGS RT Global Ionospheric Maps (GIMs), from Chinese Academy of Sciences (CAS) and Universitat Politècnica de Catalunya (UPC) among CNES, is discussed in terms of their recent performance in the ionospheric delay domain.

High-Altitude Decompression Sickness Treated with Hyperbaric Therapy and Extracorporeal Oxygenation.

BACKGROUND: High-altitude decompression sickness (HADCS) is a rare condition that has been associated with aircraft accidents. To the best of our knowledge, the present paper is the first case report of a patient treated for severe HADCS using recompression therapy and veno-venous extracorporeal oxygenation (VV-ECMO) with a complete recovery.CASE REPORT: After depressurization of a cabin, the 51-yr-old jet pilot was admitted to the Military Institute of Medicine with a life-threatening HADCS approximately 6 h after landing from a high-altitude flight, in a dynamically deteriorating condition, with progressing dyspnea and edema, reporting increasing limb paresthesia, fluctuating consciousness, and right-sided paresis. Hyperbaric oxygen therapy in the intensive care mode was initiated. A therapeutic recompression with U.S. Navy Treatment Table 6 was performed with neurological improvement. Due to cardiovascular collapse, sedation, mechanical ventilation, and significant doses of catecholamines were started, followed by continuous veno-venous hemodialysis. In the face of disturbances in oxygenation, during the second day of treatment the patient was commenced on veno-venous extracorporeal oxygenation. Over the next 6 d, the patient's condition slowly improved. On day 7, VV-ECMO was discontinued. On day 19, the patient was discharged with no neurological deficits.DISCUSSION: We observed two distinct stages during the acute phase of the disease. During the first stage, signs of hypoperfusion, neurological symptoms, and marbled skin were observed. During the second stage, multiple organ dysfunction dominated, including heart failure, pulmonary edema, acute kidney injury, and fluid overload, all of which can be attributed to extensive endothelial damage.Siewiera J, Szalanski P, Tomaszewski D, Kot J. High-altitude decompression sickness treated with hyperbaric therapy and extracorporeal oxygenation. Aerosp Med Hum Perform. 2020; 91(2):106-109.

The Prediction of Geocentric Corrections during Communication Link Outages in PPP.

The International GNSS Service (IGS) real-time service (RTS) provides access to real-time precise products. State-Space Representation (SSR) products are disseminated through the Internet using the Networked Transport of the RTCM (Radio Technical Commission for Maritime Services) via the Internet Protocol (NTRIP). However, communication outages caused by a loss of the communication link during ephemeris changes can occur. Unfortunately, any break in providing orbit and clock corrections affects the possibility to perform precise point positioning. To eliminate this problem, various methods have been developed and presented in the literature. The solution proposed by the authors is to directly predict geocentric corrections. This manuscript presents the results and analysis of geocentric correction predictions under two scenarios: the first between the IODE (issue of data ephemeris) value change and the second where prediction must be done for epochs containing a change in IODE ephemeris. In this case, the prediction uses data from a previous message. The Root Mean Square (RMS) values calculated based on the differences between the true correction values and the predicted geocentric corrections using a linear function, a second-degree polynomial and a constant value do not differ significantly. The numerical results show that, in most cases, maintaining the constant value of the last registered SSR correction is the best option.

Space State Representation Corrections as an Aid in Pseudolite Positioning.

In the presented study, the authors deal with the problem of transmission of pseudolite coordinates to the receiver. Nowadays, there is no uniquely specified method that would provide data about the position of the pseudolite to the GNSS receiver. There is also no technical standard that defines the explicit way of performing such transmission. Solutions presented in the literature are usually tailored to the described system, which is then suited to the specific situation. The article shows that the universal methods, involving the modification of transmitted broadcast ephemeris data, cannot be universally used. The modifications could not have been introduced due to the low resolution of the quantities that are transmitted in the ephemeris data, in relation to the values that would have to be sent by the pseudolite. To overcome the implementation problems, the authors propose two solutions. The first solution presented is the modification of the RTCM SSR frame. This approach allows replacing one of the existing satellites in space with the pseudolite, while the second method involves the use of new RTCM frame for sending the pseudolite position. Finally, a numerical example of the proposed solutions is presented. At the end of the manuscript, their advantages and implementation possibilities are discussed.

The Polish Prevalence of Infection in Intensive Care (PPIC): A one-day point prevalence multicenter study.

BACKGROUND: Infections in critically ill patients are the main reasons for a lack of therapeutic success and increased mortality in intensive care units (ICUs). There have been many analyses of the incidence of infections in ICUs; however, no large studies of this kind have been conducted either in Poland or in Eastern and Central Europe. OBJECTIVES: The aim of the research was to undertake a one-day study of the prevalence of infections in ICUs in Warszawa and the Mazovian region of Poland. MATERIAL AND METHODS: A prospective questionnaire survey analysis - a one-day prevalence study of infections - was carried out on June 25, 2014, in 28 ICUs in Poland. RESULTS: Among 205 ICU patients (193 adults and 12 children), 134 infections were found in 101 patients (99/193 adults (51.30%) and 2/12 children (16.70%)), and bacterial colonization in 19/205 (9.3%) patients. In 66.42% of the cases, more than 1 site of infection was diagnosed. On the day of the study, 75.40% of the diagnosed infections had positive microbiological results. The most frequent were respiratory tract infections (53.73%), wound infections (18.65%) and bloodstream infections (14.92%). Most of the infections (64.10%) were caused by Gram-negative bacteria (GN), followed by Gram-positive bacteria (GP; 31.80%) and fungi (4.10%). The most frequently reported GN microorganisms were Enterobacteriaceae (44.7%). Methicillin-resistant Staphylococcus aureus (MRSA) infections were found in 8.80% of the patients. Antibiotics were administered to 75.60% of the adult patients, in 69.20% as targeted treatment. Mechanical ventilation, central vein catheterization and urinary bladder catheterization were used in 67.80%, 85.85% and 94.63% of the patients, respectively. CONCLUSIONS: On the day of the study, more than half of the patients had infections, mostly from GN bacteria. Respiratory tract infections were the main type found. In about 2/3 of the patients, antibiotics were administered, mainly as targeted therapy.

Regional Cerebral Oxygen Saturation Decreases During Primary Hip Arthroplasty: An Analysis of Perioperative Regional Cerebral Oxygenation (rSO2), S100 Calcium-Binding Protein B (S100B) and Glial Fibrillary Acidic Protein (GFAP) Values. A Pilot Study.

BACKGROUND The incidence of postoperative cognitive dysfunction (POCD) after major joint arthroplasty is high. In the etiology of POCD, many factors have been cited, including thromboembolic complications. The incidence of cerebral embolization after lower extremity arthroplasty may be as high as 40-60%. The potential events of cerebral embolization could lead to a decrease in the regional cerebral oxygenation (rSO2) and increased serum levels of biochemical markers of brain damage. The objective of the study was to test whether there are any changes in the rSO2 values and serum markers of brain damage in patients who underwent total hip arthroplasty. MATERIAL AND METHODS Fifteen patients who underwent primary hip arthroplasty under spinal anesthesia were analyzed. The rSO2 was monitored using infrared spectroscopy. Biochemical analyses of S100 calcium-binding protein B (S100B) protein and fibrillary acidic protein (GFAP) serum concentrations were performed using immunoassay methods. RESULTS The values of rSO2 decreased during the surgery, but this was not related to mean arterial pressure variations or hemoglobin saturation. The concentration of S100B was increased compared to its preoperative values, and there were no changes in GFAP values. The changes in rSO2 readings correlated with the biomarkers' levels just after the surgery. CONCLUSIONS Our results suggest that S100B may be a more specific marker of astroglial damage in patients after primary total hip arthroplasty. The decrease in rSO2 readings may be due to micro-thromboembolic events that occurred during the surgery. However, the results of this study are preliminary, and further studies are needed to establish its clinical efficacy.

Withholding and withdrawing life-sustaining treatment: Experiences in limiting futile therapy from three Polish intensive care departments.

BACKGROUND: In intensive care units (ICUs), a patient's vital functions may be maintained, regardless of the patient's chances of survival. A key issue is how to precisely determine the moment in which life-support treatment should be withheld. In many countries, the decision-making process is regulated by the guidelines of scientific societies. However, heuristic errors may influence this process. OBJECTIVES: The objective of this study was to assess factors involved in decisions to implement or withhold treatment in general ICUs in Poland. MATERIAL AND METHODS: The medical records of patients treated in 3 clinical ICUs of general, cardiosurgical and neurosurgical profile were retrospectively analyzed. Patients with a diagnosis of brain death were finally excluded from the study. RESULTS: The records of 1,449 patients hospitalized between January 1, 2014 and December 31, 2014 were analyzed. Of these, 226 patient cases were evaluated. There were no correlations between the placement of restrictions on resuscitation in specific cases, use of noradrenaline, frequency of blood gas testing, and patients' age. There was a relationship between these factors and the duration of hospitalization in the ICU. There was a direct relation between a "do not resuscitate" (DNR) order in a patient's record and the frequency of both resuscitation procedures and withholding catecholamine treatment in the hours preceding a patient's death. CONCLUSIONS: Treatment was withheld in about 20% of cases involving dying patients in analyzed ICUs, regardless of age. Placing a limit on treatment consisted of either withholding new procedures or withdrawing existing therapy. The length of stay in the ICU affected the decisions to limit treatment.

In vitro analysis of the minimal inhibitory concentration values of different generations of anti-methicillin-resistant Staphylococcus aureus antibiotics.

Methicillin-resistant Staphylococcus aureus (MRSA) resistance to antimicrobials may result in the increased risk of treatment failure. The objective of the study was to analyse in vitro MRSA susceptibility to vancomycin, linezolid, daptomycin, tigecycline, ceftaroline, dalbavancin, clindamycin, ciprofloxacin and trimethoprim/sulfamethoxazole. All MRSA strains isolated from hospitalised patients were analysed according to the current microbiological recommendations. Finally, a total of 124 MRSA strains were analysed; all were susceptible to tested antibiotics. Dalbavancin had the lowest minimum inhibitory concentration (MIC), and vancomycin the highest MIC value. There were 28/124 strains of MRSA susceptible for clindamycin, 36/124 for ciprofloxacin and 121/124 for trimethoprim/sulfamethoxazole. Dalbavancin was the most effective antimicrobial in our study.

Non-instrumental clinical monitoring does not guarantee an adequate course of general anesthesia. A prospective clinical study.

BACKGROUND: Clinical monitoring is the most common method of adjusting the appropriate level of general anesthesia. However, episodes of intraoperative awareness (AWR) are still reported, suggesting that clinical observations may not be sufficient in some cases. The objective of this study was to compare the efficacy of clinical and instrumental neuromonitoring with auditory evoked potentials (AEP) in an intraoperative analysis of the proper level of general anesthesia. METHODS: Patients scheduled for elective surgery were randomly divided into two groups. Subjects in the first group underwent intravenous, in the second group volatile anesthesia. The adequacy of anesthesia was analyzed using clinical parameters. All the participants were instrumentally monitored with the autoregressive AEP index (AAI). After the anesthesia, patients filled out a questionnaire on possible AWR. RESULTS: Data of 208 patients (87 in the first, and 121 in the second group) were analyzed. Before surgery there were no changes in AAI values between groups (80 vs. 78, P=0.5192). The mean values of clinical parameters changed, but five minutes after the nociceptive stimuli. The mean values of AAI at analyzed time points were specific for general anesthesia. In patients under intravenous anesthesia, we found more episodes of too low (46/608 vs.15/847, P<0.000) anesthesia. One case of AWR was found in the TIVA group. CONCLUSIONS: AAI index is good indicator of patients' level of consciousness during general anesthesia. Standard clinical monitoring provides appropriate level of the procedure. However, it is insufficient during TIVA and does not prevent episodes of AWR.

Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report.

BACKGROUND: A deep sternal wound infection (DSWI) can become a severe complication after cardiac surgery, with in-hospital mortality rates reaching up to 35%. Staphylococci, particularly methicillin resistant Staphylococcus aureus (MRSA), play important roles in its etiology. CASE PRESENTATION: This case report presents a patient who underwent coronary artery bypass surgery, and suffered postoperatively from a DSWI caused by MRSA. The pathogen was susceptible to vancomycin and rifampicin in vitro; however, this therapy was clinically ineffective. Both clinical improvement and MRSA eradication were achieved after surgical debridement of the wound and the intravenous administration of dalbavancin. CONCLUSIONS: We decided to administer dalbavancin because of its convenient pharmacological profile. The patient's tolerance of the antimicrobial was good, the biochemical markers of inflammation returned to the normal ranges, and the microbiological results one week after the dalbavancin administration were negative. A good clinical outcome was achieved with both the surgery and antimicrobial administration. In this case, dalbavancin was more effective in the treatment of the sternal and surrounding tissue infections caused by MRSA, when compared to vancomycin.

Changes in bacterial flora and antibiotic resistance in clinical samples isolated from patients hospitalized in the Military Institute of Medicine in Warsaw, Poland, between 2005-2012

BACKGROUND: Hospital infections have become an important problem. Knowledge of microbiological situations both helps in ensuring that the optimal choice of antibacterial treatment is made, and in improving the results of the selected therapy. OBJECTIVE: In this paper, both the changes in the bacterial flora of patients hospitalized in the Military Institute of Medicine, and the bacterial resistance to antimicrobials were analyzed. MATERIAL AND METHODS: Data were collected between 2005 and 2012. The identification and testing of pathogens, susceptibility tests, and analysis of bacterial resistance mechanisms to antibiotics were performed according to current guidelines. RESULTS: A total number of 28,066 bacterial strains were isolated. The most frequently isolated pathogens were Gram-negative bacteria (n=18,021; 64% of all isolated bacteria), including Enterobacteriaceae (71%) and non-Enterobacteriaceae (29%). The total number of isolated Gram-positive bacteria (n=10,045; 36% of all isolates) included Staphylococcus spp. (65%) and Enterococcus spp. (35%). The highest increase in the number of infections was caused by Enterobacteriaceae. The number of Staphylococcus aureus and coagulase negative Staphylococcus resistant to methicillin decreased. Analyzed alert pathogens with resistance phenotypes were highly susceptible to a single type of antibiotic. All multidrug resistant Gram-negative bacteria (except those naturally resistant to colistin) were susceptible to colistin. All methicillin resistant S. aureus and methicillin resistant coagulase negative Staphylococci were susceptible to vancomycin and linezolid. All MSSA strains were susceptible to cloxacillin, all Enterococcus faecium strains to ampicillin, and all VRE strains were susceptible to linezolid and tigecycline.

Malignant triton tumor of the lung, infiltrating the left atrium and left ventricle, with metastasis to the small intestine.

Malignant triton tumors are a rare subtype of malignant peripheral nerve sheath tumors showing rhabdomyosarcomatous differentiation. We report the case of a 33-year-old patient who underwent an excision of such a tumor by thoracic and cardiac surgery. He was reoperated on 1 month later because of a tumor of the small intestine and received adjuvant radiation.

Etomidate, but not thiopental, decreases serum cortisol concentration in morbidly obese patients. A randomized controlled trial.

BACKGROUND: The effect of etomidate administration on the adrenal cortex in obese patients is still unclear. The objective of the study was to determine the influence of a single dose of etomidate on cortisol secretion in the morbidly obese. METHODS: 127 healthy patients were enrolled into the study. Data from 82 patients scheduled for elective laparoscopic surgery were analyzed. 62 of them were morbidly obese, while 20 had normal body mass. The participants were divided equally into etomidate and thiopental groups, depending on the kind of intravenous anaesthetic used for the induction of anaesthesia. Each patient's serum cortisol concentration was measured five times: on the day before surgery (sample A), two hours after the induction of anaesthesia (sample B), after a short tetracosactide test (sample C), 24 hours after the induction of anaesthesia (sample D), and after a second short stimulation test (sample E). RESULTS: The mean cortisol concentration in obese patients in the etomidate group was lower two hours after the induction of anaesthesia (sample B, P < 0.001), and 30 minutes after the first tetracosactide test (sample C, P < 0.001) compared to obese patients in the thiopental group. There were no differences between the groups in sample A (P = 0.833), D (P = 0.614) and E (P = 0.769). We found no changes in haemodynamic parameters between both groups. CONCLUSIONS: Etomidate decreased serum cortisol concentration and decreased reactivity to tetracosactide both in morbidly obese and in normal weight patients. This effect was reversible within 24 hours.