Homemade Hypertonic Saline: Essential Treatment Can Be Available and Affordable.

BACKGROUND: Nebulized hypertonic saline (HS) treatment is unavailable to large populations worldwide. OBJECTIVES: To determine the bacterial contamination and electrolyte concentrations in homemade (HM-HS) vs. pharmacy made (PM-HS). METHODS: We conducted three double-blind consecutive trials: 50 boiled-water homemade 3%-HS (B-HM-HS) bottles and 50 PM-HS. The bottles were cultured after 48 hours. Electrolyte concentrations were measured in 10 bottles (5 per group). Forty bottles (20 per group) were distributed to volunteers for simulation of realistic treatment by drawing 4 ml HS three times daily. From each bottle, 4 ml samples were cultured after 1, 5, and 7 days. Volunteers prepared 108 bottles containing 3%-HS, sterilizing them using a microwave oven (1100-1850W). These bottles were cultured 24 hours, 48 hours, and 1 month after preparation. RESULTS: Contamination rates of B-HM-HS and PM-HS after 48 hours were 56% and 14%, respectively (P = 0.008). Electrolyte concentrations were similar: 3.7% ± 0.4 and 3.5% ± 0.3, respectively (P = NS). Following a single day of simulation B-HM-HS bottles were significantly more contaminated than PM-HS bottles: 75% vs. 20%, respectively (P < 0.01). By day 7, 85% of PM-HS bottles and 100% of B-HM-HS bottles were contaminated (P = 0.23). All 108 microwave-oven prepared bottles (MICRO-HS) were sterile, which was significantly better than the contamination rate of B-HM-HS and PM-HS (P < 0.001). Calculated risk for a consecutive MICRO-HS to be infected was negligible. CONCLUSIONS: Microwave preparation provides sterile HS with adequate electrolyte concentrations, and is a cheap, fast, and widely available method to prepare HS.

The accuracy of Gram stain of respiratory specimens in excluding Staphylococcus aureus in ventilator-associated pneumonia.

OBJECTIVE: To evaluate the Gram stain of deep tracheal aspirate as a tool to direct empiric antibiotic therapy, and more specifically as a tool to exclude the need for empiric antibiotic coverage against Staphylococcus aureus in ventilator-associated pneumonia (VAP). DESIGN: A prospective, single-center, observational, cohort study. SETTING: All wards at a community hospital. PATIENTS: Adult patients requiring mechanical ventilation, identified as having VAP in a 54-month prospective surveillance database. INTERVENTIONS: Sampling of lower airway secretions by deep endotracheal aspiration was taken from each patient who developed VAP. Samples were sent immediately for Gram stain and qualitative bacterial cultures. Demographic and relevant clinical data were collected; Gram stain, culture, and antibiotic susceptibility results were documented; and outcome was followed prospectively. MEASUREMENTS AND MAIN RESULTS: The analysis included 114 consecutive patients with 115 episodes of VAP from June 2007 to January 2012. Sensitivity of Gram stain compared with culture was 90.47% for gram-positive cocci, 69.6% for gram-negative rods, and 50% for sterile cultures. Specificity was 82.5%, 77.8%, and 79%, respectively. Negative predictive value was high for gram-positive cocci (97%) and sterile cultures (96%) but low for gram-negative rods (20%). Acinetobacter baumanii (45%) and Pseudomonas aeruginosa (38 %) were the prevailing isolates. S aureus was found in 18.3% of the patients. Most isolates were multiresistant. CONCLUSIONS: Absence of gram-positive bacteria on Gram stain had a high negative predictive value. These data can be used to narrow the initial empiric antibiotic regimen and to avoid unnecessary exposure of patients to vancomycin and other antistaphyloccocal agents.

A cost-saving algorithm for rapid diagnosis of Staphylococcus aureus and susceptibility to oxacillin directly from positive blood culture bottles by combined testing with BinaxNOW® S. aureus and Xpert MRSA/SA Assay.

We studied an algorithm combining 2 rapid methods to detect Staphylococcus aureus and its susceptibility to oxacillin directly from positive blood cultures; our goal was to reduce the cost of the procedure, while maintaining accuracy and a short turnaround time. A total of 581 blood cultures containing gram-positive cocci in clusters were tested by BinaxNOW® Staphylococcus aureus Test. Positive samples were further assessed by the Xpert MRSA/SA BC Assay. Phenotypic methods have identified coagulase-negative staphylococci in 505 samples and S. aureus in 76 samples, of which 51 were oxacillin sensitive and 25 were oxacillin resistant. Sensitivity and specificity of the BinaxNOW® Test were 92% and 99%, respectively, compared to the phenotypic method. The Xpert MRSA/SA BC Assay showed complete concordance with phenotypic identification and antimicrobial susceptibility results. The combined rapid assays produced results within 2 hours and reduced the cost by 75% compared with the Xpert MRSA/SA BC Assay if used alone on all blood bottles.

Invasive pediatric Kingella kingae Infections: a nationwide collaborative study.

BACKGROUND: Kingella kingae is a gram-negative coccobacillus, increasingly recognized as an invasive pediatric pathogen. To date, only few small series of invasive K. kingae infections have been published, mostly from single medical centers. A nationwide multicenter study was performed to investigate the epidemiologic, clinical, and laboratory features of children with culture-proven K. kingae infections. METHODS: Clinical microbiology laboratories serving all 22 medical centers in Israel were contacted in a search for children aged 0 to 18 years from whom K. kingae was isolated from a normally sterile site, dating from as far back as possible until December 31, 2007. Medical records of identified patients were reviewed using uniform case definitions. RESULTS: A total of 322 episodes of infection were identified in 321 children, of which 96% occurred before the age of 36 months. The annual incidence in children aged <4 years was 9.4 per 100,000. Infections showed a seasonal nadir between February and April. Skeletal system infections occurred in 169 (52.6%) children and included septic arthritis, osteomyelitis, and tenosynovitis. Occult bacteremia occurred in 140 children (43.6%), endocarditis in 8 (2.5%), and pneumonia in 4 (1.2%). With the exception of endocarditis cases, patients usually appeared only mildly ill. About one-quarter of children had a body temperature <38 degrees C, 57.1% had a blood white blood cell count <15,000/mm, 22.0% had normal C-reactive protein values, and 31.8% had nonelevated erythrocyte sedimentation rate. CONCLUSIONS: K. kingae infections usually occur in otherwise healthy children aged 6 to 36 months, mainly causing skeletal system infections and bacteremia, and occasionally endocarditis and pneumonia. Clinical presentation is usually mild, except for endocarditis, necessitating a high index of suspicion.

First national surveillance of susceptibility of extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella spp. to antimicrobials in Israel.

In this 1st national surveillance study, the susceptibility pattern of 1011 consecutive isolates of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella spp. isolated from patients hospitalized in Israel hospitals, covering 62.3% of all general hospital beds in the country, was investigated. Proportion of susceptibilities (range among institutions, MIC(50)/MIC(90) in micrograms per milliliter) were to ertapenem 95.0% (88.8-100%, 0.19/0.75), imipenem 98.8% (88.8-100%, 0.25/0.38), meropenem 98.2% (90.0-100%, 0.06/0.19), piperacillin-tazobactam 59.1% (42.6-77.0%, 16/256), ciprofloxacin 17.2% (9.0-24.6%, 32/32), levofloxacin 17.8% (9.0-24.6%, 32/32), amikacin 74.5% (63.8-98.0%, 6/32), and gentamicin 19.3% (12.3-28.5%, 96/256). Coresistance, cross-resistance, and variability between institutions were high. Only carbapenems retain predicted activity against ESBL-producing E. coli and Klebsiella spp. across Israeli hospitals.