Efficacy and safety of a structured de-escalation from antipseudomonal ß-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial.

BACKGROUND: De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal ß-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia. METHODS: An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal ß-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal ß-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete. FINDINGS: 2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths. INTERPRETATION: De-escalation from an antipseudomonal ß-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting. FUNDING: Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.

Expression profile of microRNAs related with viral infectivity, inflammatory response, and immune activation in people living with HIV.

Objective: To evaluate the serum expression of microRNAs (miRNAs) with ability to modulate the human immunodeficiency (HIV) replication or inflammatory status in people living with HIV (PLWH). Methods: Forty healthy controls and two groups of PLWH were evaluated: (a) Group 1 (n = 30), patients with detectable viral load at inclusion, analyzed before receiving antiretroviral therapy (ART) and 12 months after initiating it; (b) Group 2 (n = 55), PLWH with prolonged undetectable viral load. Intestinal barrier disruption (I-FABP) and bacterial translocation (16S rDNA) markers, inflammatory markers such as interleukin (IL)-6 and sCD163, immune activation and expression of specific miRNAs were evaluated. Results: Serum concentrations of I-FABP, 16S rDNA, IL-6, sCD163 and activated T lymphocytes were increased in PLWH. Serum miR-34a was overexpressed at inclusion and remained elevated after ART. The expression of the remaining miRNAs that modulate HIV infectivity (miR-7, mir-29a, miR-150, and miR-223) was similar in PLWH and controls. Related to miRNAs implicated in inflammation (miR-21, miR-155, and miR-210), significant overexpression were observed in miR-21 and miR-210 levels in untreated PLWH, but levels were restored in those patients treated for a long period. Conclusion: A sustained overexpression of miR-34a was detected even after prolonged HIV controlled replication. miR-21 and miR-210 can be considered new markers of inflammation with high sensitivity to its modifications.

An Improved Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry Data Analysis Pipeline for the Identification of Carbapenemase-Producing Klebsiella pneumoniae.

The increasing emergence of carbapenemase-producing Klebsiella pneumoniae (CPK) isolates is a global health alarm. Rapid methods that require minimum sample preparation and rapid data analysis are urgently required. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has recently been used by clinical laboratories for identification of antibiotic-resistant bacteria; however, discrepancies have arisen regarding biological and technical issues. The aim of this study was to standardize an operating procedure and data analysis for identification of CPK by MALDI-TOF MS. To evaluate this approach, a series of 162 K. pneumoniae isolates (112 CPK and 50 non-CPK) were processed in the MALDI BioTyper system (Bruker Daltonik, Germany) following a standard operating procedure. The study was conducted in two stages; the first is denominated the "reproducibility stage" and the second "CPK identification." The first stage was designed to evaluate the biological and technical variation associated with the entire analysis of CPK and the second stage to assess the final accuracy of MALDI-TOF MS for the identification of CPK. Therefore, we present an improved MALDI-TOF MS data analysis pipeline using neural network analysis implemented in Clover MS Data Analysis Software (Clover Biosoft, Spain) that is designed to reduce variability, guarantee interlaboratory reproducibility, and maximize the information selected from the bacterial proteome. Using the random forest (RF) algorithm, 100% of CPK isolates were correctly identified when all the peaks in the spectra were selected as input features and total ion current (TIC) normalization was applied. Thus, we have demonstrated that real-time direct tracking of CPK is possible using MALDI-TOF MS.

Characteristics and Evolution of Renal Transplant Recipients Infected by Carbapenemase-Producing Klebsiella pneumoniae.

BACKGROUND: Renal transplant (RT) recipients are especially susceptible to carbapenem-resistant Klebsiella pneumoniae carbapenemase (KPC) infections. However, published experience is limited. OBJECTIVE: To analyze the characteristics and evolution of RT recipients with KPC infection in our hospital. METHODS: We performed a retrospective cohort study of all RT recipients with KPC infection in our hospital from December 1, 2017 (first case), to July 31, 2019. For each RT recipient infected with KPC, 3 controls were selected. RESULTS: During the study period, 8 RT recipients presented KPC infection. Seven were detected in the first year post-RT. The most common site of infection was urine. In 2 cases the germ was isolated in blood. The number of patients with diabetes was significantly higher in the group with KPC infection (P = .023), and urologic interventions were more frequent in those patients (P = .039). No differences were found in the immunosuppressive treatment. A total of 62.5 % of patients required readmission after the KPC infection. One patient died of septicemia by KPC. In all these cases, the clone of KPC isolated was KPC ST512. CONCLUSION: KPC infection is more frequent in the first months after the RT and causes an important number of hospital admissions. It can be cause of death in RT recipients, especially in those with isolation of the germ in blood. Diabetes and urologic interventions were more frequent in this population. The analysis by molecular typing suggests exposure to a common source, highlighting the importance of preventive isolation measures and surveillance for limiting the transmission of this bacteria.

Detection and Characterization of Extended-Spectrum Beta-Lactamases-Producing Escherichia coli in Animals.

The detection of multidrug-resistant bacteria is a growing problem; however, the role of domesticated animals in the propagation of antimicrobial resistance has barely been studied. The aim of this study was to identify extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli strains in domestic animal feces to assess their antimicrobial resistance profile and carry out molecular characterization of the ß-lactamases. A total of 325 samples were collected from eight animal species. Of these, 34 bacterial isolates were identified as E. coli. The antibiotic resistance profile of the E. coli strains was as follows: 100% resistant to amoxicillin, aztreonam, and cephalosporins; 58.8% resistant to nalidixic acid, ciprofloxacin, and trimethoprim/sulfamethoxazole; 41.2% resistant to gentamicin and tobramycin; 11.8% resistant and 32.4% intermediate to cefoxitin; 97.1% sensible and 2.9% intermediate to amoxicillin/clavulanate; and 100% sensible to ertapenem, minocycline, imipenem, meropenem, amikacin, nitrofurantoin, fosfomycin, and colistin. All 34 E. coli strains met criteria for ESBL production. In total, 46 ß-lactamase genes were detected: 43.5% blaTEM, 30.4% blaCTX-M (23.9% blaCTX-M-1 and 6.5% blaCTX-M-9), and 26.1% blaSHV (17.4% blaSHV-5 and 8.7% blaSHV-12). All the ß-lactamases were found in dogs except for four blaSHV found in falcons. No plasmidic AmpC genes were found. The high prevalence of ESBL-producing E. coli strains in animals could become a zoonotic transmission vector.

Urinary tract infection in the oldest old: a work overload for the microbiology laboratory / Infecciones del tracto urinario en los más mayores: una sobrecarga para el laboratorio de Microbiología

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Utilidad de la espectrometría de masas en el diagnóstico microbiológico de la candiduria / Utility of mass spectrometry in the microbiological diagnosis of candiduria

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Infecciones por Mycobacterium simiae / Infections due to Mycobacterium simiae

Mycobacterium simiae es una micobacteria ambiental de crecimiento lento, fotocromógena, descrita por primera vez en 1965. Se asocia raramente a infecciones humanas, posiblemente por su limitada patogenicidad, principalmente a infección pulmonar en pacientes inmunocompetentes de edad avanzada con enfermedad pulmonar subyacente, e infección diseminada en pacientes jóvenes inmunodeprimidos con sida. El cultivo microbiológico es necesario para confirmar la sospecha clínica, y las técnicas de secuenciación genética son indispensables para identificar la especie. El tratamiento de las infecciones por M. simiae es complicado por su multirresistencia a los fármacos antituberculosos y por la falta de correlación de los datos de sensibilidad in vitro con la respuesta in vivo. El tratamiento adecuado aún está por definir, pero debe incluir claritromicina asociada a otros antimicrobianos, como moxifloxacino y cotrimoxazol. Es posible que las infecciones por M. simiae estén infradiagnosticadas

Mycobacterium simiae is a slow-growing photochromogenic environmental mycobacterium, first described in 1965. Rarely associated with human infections, possibly due to its limited pathogenicity, it mainly produces lung infection in immunocompetent elderly patients with underlying lung disease, and in disseminated infections in immunosuppressed young patients with AIDS. A microbiological culture is needed to confirm the clinical suspicion, and genetic sequencing techniques are essential to correctly identify the species. Treating M. simiae infections is complicated, owing to the multiple resistance to tuberculous drugs and the lack of correlation between in vitro susceptibility data and in vivo response. Proper treatment is yet to be defined, but must include clarithromycin combined with other antimicrobials such as moxifloxacin and cotrimoxazole. It is possible that M. simiae infections are undiagnosed

Evaluación de la espectrometría de masas en la identificación de levaduras de interés clínico / Evaluation of mass spectrometry for the identification of clinically interesting yeasts

INTRODUCCIÓN: La identificación de levaduras se basa en el estudio de las características morfológicas, bioquímicas y nutricionales, y en la utilización de métodos moleculares. La espectrometría de masas matrix-assisted laser desorption ionization time-of-fligh (MALDI-TOF) constituye un nuevo método de identificación de microorganismos que ha demostrado gran utilidad. Nuestro objetivo ha sido evaluar este nuevo método en la identificación de levaduras. MÉTODOS: Ensayamos un total de 600 cepas aisladas de muestras clínicas pertenecientes a 9 géneros y 43 especies. La identificación se realizó mediante secuenciación de las regiones ITS del ADN ribosómico, asimilación de compuestos de carbono (ID 32C) y espectrometría de masas en un espectrómetro Microflex (Bruker Daltonics GmbH, Alemania). RESULTADOS: Un total de 569 cepas (94,8%) fueron identificadas a nivel de especie por ID 32C, y 580 (96,7%) por MALDI-TOF. La concordancia entre ambos métodos comprendió un total de 553 cepas (92,2%), elevándose al 100% en las especies de interés clínico: Candida albicans, C. glabrata, C. parapsilosis, C. tropicalis, y casi del 100% en C. krusei. MALDI-TOF identificó especies que precisan métodos moleculares: Candida dubliniensis, C. nivariensis, C. orthopsilosis y C. metapsilosis. Observamos cierta irregularidad en la identificación de levaduras formadoras de artroconidias y de basidiomicetos. CONCLUSIÓN: La espectrometría de masas MALDI-TOF es un método rápido, rentable y económico que permite la identificación de la mayoría de las levaduras aisladas en clínica, así como la diferenciación de especies estrechamente relacionadas. Sería conveniente la inclusión de más especies en su base de datos para ampliar su rentabilidad

INTRODUCTION: The aim of the study was to analyze the incidence, management and cost associated to hematological and dermatological adverse effects (AE) in chronic hepatitis C patients on triple therapy (TT) with telaprevir (TVR) or boceprevir (BOC). METHODS: An analysis was made on the data recorded on patients who started treatment with TVR or BOC associated with peginterferon alfa and ribavirin in a 12-week follow-up period. RESULTS: Fifty-three patients were included (TVR n = 36; BOC n = 17). Thrombocytopenia (83% TVR vs. 88% BOC) followed by neutropenia (89% TVR vs. 82% BOC) were the most common AE. Dermatological AE were observed in 32% of patients. Eleven patients required treatment discontinuation (all of them received TVR), and toxicity was the main reason for discontinuation (64%). The percentage of patients who required supportive treatment for management of AE was 66%. The most used supportive treatment was erythropoietin. Eight patients required emergency health care, and 2 were hospitalized due to AE. Total cost of additional supportive resources was 32,522 Euros (625 [SD = 876] Euros/patient) (TVR 759 [SD = 1,022] Euros/patient vs. BOC 349 [SD = 327] Euros/patient; P > .05). Patients with grade iii-iv toxicity required greater supportive care with higher costs, compared to patients with grade i-ii toxicity (849 [SD = 1,143] Euros/patient vs. 387 [SD = 397] Euros/patient; P = .053). CONCLUSION: The addition of new protease inhibitors to conventional treatment leads to a higher incidence of hematological AE in our study, compared to data described in clinical trials. The elevated incidence of AE involves the use of supportive care, increasing total costs of therapy

Diferenciación de especies del complejo Mycobacterium fortuitum mediante espectrometría de masas / Differentiation of Mycobacterium fortuitum complex species using mass spectrometry

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[Infections due to Mycobacterium simiae]. / Infecciones por Mycobacterium simiae.

Mycobacterium simiae is a slow-growing photochromogenic environmental mycobacterium, first described in 1965. Rarely associated with human infections, possibly due to its limited pathogenicity, it mainly produces lung infection in immunocompetent elderly patients with underlying lung disease, and in disseminated infections in immunosuppressed young patients with AIDS. A microbiological culture is needed to confirm the clinical suspicion, and genetic sequencing techniques are essential to correctly identify the species. Treating M. simiae infections is complicated, owing to the multiple resistance to tuberculous drugs and the lack of correlation between in vitro susceptibility data and in vivo response. Proper treatment is yet to be defined, but must include clarithromycin combined with other antimicrobials such as moxifloxacin and cotrimoxazole. It is possible that M. simiae infections are undiagnosed.

[Evaluation of mass spectrometry for the identification of clinically interesting yeasts]. / Evaluación de la espectrometría de masas en la identificación de levaduras de interés clínico.

INTRODUCTION: Identification of yeasts is based on morphological, biochemical and nutritional characteristics, and using molecular methods. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry, a new method for the identification of microorganisms, has demonstrated to be very useful. The aim of this study is to evaluate this new method in the identification of yeasts. METHODS: A total of 600 strains of yeasts isolated from clinical specimens belonging to 9 genera and 43 species were tested. Identification was made by sequencing of the ITS regions of ribosomal DNA, assimilation of carbon compounds (ID 32C), and mass spectrometry on a Microflex spectrometer (Bruker Daltonics GmbH, Germany). RESULTS: A total of 569 strains (94.8%) were identified to species level by ID 32C, and 580 (96.7%) by MALDI-TOF. Concordance between both methods was observed for 553 strains (92.2%), with 100% in clinically relevant species: C. albicans, C. glabrata, C. parapsilosis, C. tropicalis, and almost 100% in C. krusei. MALDI-TOF identified species requiring molecular methods: Candida dubliniensis, C. nivariensis, C. metapsilosis and C. orthopsilosis. Some irregularities were observed in the identification of arthroconidia yeast and basidiomycetes. CONCLUSION: MALDI-TOF is a rapid, effective and economic method, which enables the identification of most clinically important yeasts and the differentiation of closely related species. It would be desirable to include more species in its database to expand its performance.