Carbapenemase-Producing Klebsiella pneumoniae Infections in Diabetic and Nondiabetic Hospitalized Patients.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has recently attracted widespread attention due to its limited treatment options and significant morbidity and mortality rates. This study aimed to examine the relationship between risk factors and antimicrobial resistance in individuals with and without diabetes for the development of carbapenemase-producing K. pneumoniae infections. METHODS: Between May 2019 and January 2021, a prospective study involving patients with and without diabetes who were infected with K. pneumonia, was carried out in a tertiary care hospital. Six hundred K. pneumoniae isolates were collected from various clinical samples, such as pus/wound samples, urine, respiratory samples, blood, and body fluids. An antimicrobial susceptibility test in K. pneumoniae was performed and compared between diabetics and nondiabetics. Univariate and multivariate logistic regression were used to identify independent risk factors for K. pneumoniae infections in the diabetic group and nondiabetic group separately. Multiplex PCR was used to detect genes that produce carbapenemase. RESULTS: A total of 600 patients were infected with K. pneumoniae, with 300 (50%) being diabetic and 300 (50%) being nondiabetic. We found that diabetics had higher antimicrobial resistance to numerous routinely used drugs for infection than the nondiabetic group. In the multivariate analysis of the variables, it was found that immunosuppressive therapy, prior antibiotic use, mechanical ventilation, and urinary catheter use were all significant risk factors influencing the development of K. pneumoniae infections in diabetic patients. Diabetics had a higher prevalence of carbapenemase-producing K. pneumoniae than nondiabetics. Outcome measures in K. pneumoniae patients revealed that the diabetic group had considerably higher infection-related mortality. CONCLUSION: We found that CRKP infection was associated with higher resistance to antibiotics in the diabetic group. Furthermore, the diabetic group had a higher prevalence of carbapenemase-producing K. pneumoniae than the nondiabetic group. Crucially, in order to lower mortality without worsening antibiotic resistance and metabolic damage, more focus has to be placed on sensible and efficient antibiotic and supportive care therapies.

A Study of Community-Acquired Pyodermas with Special Reference to Panton-Valentine Leukocidin (PVL)-Positive Methicillin-Resistant Staphylococcus Aureus.

Background: Community-acquired (CA) pyodermas are one of the most common infections encountered in the dermatology outpatient clinics. A significant number of these conditions are caused by Staphylococcus aureus. CA-methicillin-sensitive Staphylococcus aureus (MSSA) and CA-methicillin-resistant Staphylococcus aureus (MRSA) have specific virulence genes which are associated with these diseases, particularly the Panton-Valentine leukocidin (PVL) genes. The presence of the PVL gene as a virulence factor may be associated with recurrent and severe skin infections. Materials and Methods: A prospective study was conducted with 205 cases of CA pyodermas, of which five were discarded due to mixed isolates. Clinical details were taken and wound exudate was sent for bacteriological examination. Further, the molecular study was performed on all MRSA (7) isolates and 13 randomly selected MSSA isolates using polymerase chain reaction for mecA and PVL genes. Results: Staphylococcus aureus was the most common organism (90%) isolated from primary or secondary CA pyodermas. The prevalence of CA-MRSA among all pyodermas was 3.5% in our community. The PVL gene was not detected in all tested CA-MRSA and CA-MSSA isolates. Conclusion: While pyodermas are common, the prevalence of MRSA is low in the CA pyodermas in our region. PVL does not appear to be a virulence factor among the isolated MRSA. Larger, multicentric, and periodic studies are, however, required to further justify these claims.

POCUS increases successful placement of peripheral arterial lines in neonates by less experienced providers.

To assess success of peripheral arterial line (PAL) placement after implementing a point-of-care ultrasound (POCUS) program in a neonatal intensive care unit. This was a retrospective chart review of infants who underwent successful PAL placement from January 2019 to March 2021. Outcomes included first-attempt success and the number of attempts with and without the use of POCUS. Among 80 PALs, 36% were POCUS-guided. All POCUS-guided lines were placed by providers with < 5 years neonatology experience. Among infants ≥ 2.5 kg, the use of POCUS was associated with fewer attempts compared to non-POCUS PAL placement (1 vs. 2, p = 0.035).     Conclusions: Use of POCUS for PAL placement was associated with fewer attempts for successful placement in infants ≥ 2.5 kg by providers with less neonatology experience compared with traditional method. What is Known: • Arterial line placement in neonates has been traditionally done by palpation and can be technically challenging. • POCUS is an emerging tool in the NICU with increasing number of less clinically experienced providers in the NICU having access to ultrasound. What is New: • Use of POCUS by less experienced clinicians for arterial line placement resulted in fewer attempts compared to the traditional landmark-based approach in a cohort of neonates.

Clinical and Molecular Profile of Carbapenem Resistant Klebsiella pneumoniae Infections in a Tertiary Care Hospital -Mangalore.

Purpose: Carbapenemase producing Klebsiella pneumoniae infection has increased in recent years, leading to limitations in treatment options. The present study was undertaken to detect the Carbapenemase-producing genes in K. pneumoniae, the risk factors for acquiring them, and their impact on clinical outcomes. Patients and Methods: This prospective study included 786 clinically significant K. pneumoniae isolates. Antimicrobial susceptibility testing was done by conventional method, carbapenem-resistant isolates were screened by carba NP test, and positive isolates were further evaluated by multiplex PCR method. The patient's clinical and demographic details, co morbidity, and mortality were collected. Multivariate analysis was performed to check risk factors for acquiring CRKP infection. Results: The results of our study showed high prevalence of CRKP (68%). The variables subjected to the multivariate analysis found that diabetes, hypertension, cardiovascular disease, COPD, use of immunosuppressants, previous hospitalization history, previous surgery, and parenteral nutrition are found to be significantly associated with carbapenem resistant K. pneumoniae infection. Clinical outcomes revealed that patients in the CRKP group had higher risk of mortality and were discharged against medical advice, and they also had higher rate of septic shock. Most of the isolates carried blaNDM-1 and blaOXA-48 carbapenemase genes. Additionally, the co-existence of blaNDM-1 and blaOXA-48 was found in our isolates. Conclusion: The prevalence of CRKP was alarmingly high in our hospital with the limited choice of antibiotics. This was associated with high mortality and morbidity with the increase in health care burden. While this information is important to treat critically ill patients with higher antibiotics, strict infection control practices need to be in place to prevent the spread of these infections in the hospital. Clinicians need to be aware of this infection to use appropriate antibiotics to save the lives of critically ill patients with the infection.

Synthesis, characterization, and evaluation of quaternary ammonium-based polymerizable antimicrobial monomers for prosthodontic applications.

The present study aims to synthesize and characterize two quaternary ammonium (QAM) based monomers such as - dimethyl-hexadecyl-methacryloxyethyl-ammonium iodide (DHMAI) and 2-dimethyl-2-dodecyl-1-methacryloxyethyl ammonium iodine (DDMAI) and assess their cytotoxicity and antimicrobial properties. The study also aims to incorporate the optimized concentration of these monomers as copolymerizing monomers into conventional Polymethyl methacrylate (PMMA) denture base resin and evaluate their suitability for prosthetic applications. DHMAI and DDMAI monomers were synthesized through a Menschutkin reaction and their chemical structure was characterized using FT-IR and 1H-NMR spectroscopy. Cytotoxicity was determined using Methyl Thiazolyl Tetrazolium (MTT) assay whereas antimicrobial activity was assessed using the agar-disc diffusion method. Subsequently, optimized concentrations of DHMAI or DDMAI, based on the cytotoxicity results, were added to conventional PMMA resin. Antimicrobial activity, cytotoxicity, surface hardness, and water sorption of PMMA denture base rein incorporated with DHMAI or DDMAI were evaluated. FT-IR and 1H-NMR results confirmed the structure of monomers and copolymerization of DHMAI and DDMAI with PMMA resin. DHMAI and DDMAI monomers were found to be cytocompatible with mouse fibroblast cells up to a concentration of 5 µg/mL and 20 µg/mL respectively. In addition, incorporation of DHMAI or DDMAI at 5 µg/mL and 20 µg/mL respectively into PMMA denture base material did not affect their cytocompatibility. PMMA denture base resin incorporated with DHMAI or DDMAI significantly reduced the adhesion of microbes. Further, an increase in the surface hardness and a reduction in the water sorption was observed. Hence DHMAI and DDMAI can be considered as potential candidates for imparting antimicrobial activity to polymeric denture base materials.

Implementation of a Bedside Point-of-Care Ultrasound Program in a Large Academic Neonatal Intensive Care Unit.

OBJECTIVE: In the adult and pediatric critical care population, point-of-care ultrasound (POCUS) can aid in diagnosis, patient management, and procedural accuracy. For neonatal providers, training in ultrasound and the use of ultrasound for diagnosis and management is increasing, but use in the neonatal intensive care unit (NICU) is still uncommon compared with other critical care fields. Our objective was to describe the process of implementing a POCUS program in a large academic NICU and evaluate the role of ultrasound in neonatal care during early adaption of this program. STUDY DESIGN: A POCUS program established in December 2018 included regular bedside scanning, educational sessions, and quality assurance, in collaboration with members of the cardiology, radiology, and pediatric critical care divisions. Core applications were determined, and protocols outlined guidelines for image acquisition. An online database included images and descriptive logs for each ultrasound. RESULTS: A total of 508 bedside ultrasounds (76.8% diagnostic and 23.2% procedural) were performed by 23 providers from December 2018 to December 2020 in five core diagnostic applications: umbilical line visualization, cardiac, lung, abdomen (including bladder), and cranial as well as procedural applications. POCUS guided therapy and influenced clinical management in all applications: umbilical line assessment (26%), cardiac (33%), lung (14%), abdomen (53%), and cranial (43%). With regard to procedural ultrasound, 74% of ultrasound-guided arterial access and 89% of ultrasound-guided lumbar punctures were successful. CONCLUSIONS: Implementation of a POCUS program is feasible in a large academic NICU and can benefit from a team approach. Establishing a program in any NICU requires didactic opportunities, a defined scope of practice, and imaging review with quality assurance. Bedside clinician performed ultrasound findings can provide valuable information in the NICU and impact clinical management. KEY POINTS: · Use of point-of-care ultrasound is increasing in neonatology and has been shown to improve patient care.. · Implementation of a point-of-care ultrasound program requires the definition of scope of practice and can benefit from the support of other critical care and imaging departments and providers.. · Opportunities for point-of-care ultrasound didactics, imaging review, and quality assurance can enhance the utilization of bedside ultrasound..

A descriptive analysis of antimicrobial resistance patterns of WHO priority pathogens isolated in children from a tertiary care hospital in India.

The World Health Organization (WHO) has articulated a priority pathogens list (PPL) to provide strategic direction to research and develop new antimicrobials. Antimicrobial resistance (AMR) patterns of WHO PPL in a tertiary health care facility in Southern India were explored to understand the local priority pathogens. Culture reports of laboratory specimens collected between 1st January 2014 and 31st October 2019 from paediatric patients were extracted. The antimicrobial susceptibility patterns for selected antimicrobials on the WHO PPL were analysed and reported. Of 12,256 culture specimens screened, 2335 (19%) showed culture positivity, of which 1556 (66.6%) were organisms from the WHO-PPL. E. coli was the most common organism isolated (37%), followed by Staphylococcus aureus (16%). Total of 72% of E. coli were extended-spectrum beta-lactamases (ESBL) producers, 55% of Enterobacteriaceae were resistant to 3rd generation cephalosporins due to ESBL, and 53% of Staph. aureus were Methicillin-resistant. The analysis showed AMR trends and prevalence patterns in the study setting and the WHO-PPL document are not fully comparable. This kind of local priority difference needs to be recognised in local policies and practices.

Factors associated with follow-up of infants with hypoxic-ischemic encephalopathy in a high-risk infant clinic in California.

OBJECTIVE: To determine the rates of high-risk infant follow-up (HRIF) attendance and the characteristics associated with follow-up among infants with hypoxic-ischemic encephalopathy (HIE) in California. STUDY DESIGN: Using population-based datasets, 1314 infants with HIE born in 2010-2016 were evaluated. The characteristics associated with follow-up were identified through multivariable logistic regression. RESULTS: 73.9% of infants attended HRIF by age 1. Follow-up rates increased and variation in follow-up by clinic decreased over time. Female infants; those born to African-American, single, less than college-educated, or publicly insured caregivers; and those referred to high-volume or regional programs had lower follow-up rates. In multivariable analysis, Asian and Pacific Islander race/ethnicity had lower odds of follow-up; infants with college- or graduate school-educated caregivers or referred to mid-volume HRIF programs had greater odds. CONCLUSION: Sociodemographic and program-level characteristics were associated with lack of follow-up among HIE infants. Understanding these characteristics may improve the post-discharge care of HIE infants.

How to Minimize Patient Anxiety From Screening Mammography.

Anxiety has been portrayed by the media and some organizations and societies as one of the harms of mammography. However, one experiences anxiety in multiple different medical tests that are undertaken, including screening examinations; it is not unique to mammography. Some may argue that because this anxiety is transient, the so-called harm is potentially overstated, but for some women the anxiety is significant. Anxiety can increase or decrease the likelihood of obtaining a screening mammogram. There are multiple ways that anxiety associated with screening mammography can be diminished, including before, during, and after the examination. These include simple measures such as patient education, improved communication, being aware of the patient's potential discomfort and addressing it, validating the patient's anxiety as well as providing the patient with positive factual data that can easily be implemented in every breast center. More complex interventions include altering the breast center environment with multisensory stimulation, reorganization of patient flow to minimize wait times, and relaxation techniques including complementary and alternative medicine. In this article we will review the literature on measures that can be taken to minimize anxiety that would maximize the likelihood of a woman obtaining an annual screening mammogram.

Racial/ethnic disparities and human milk use in necrotizing enterocolitis.

BACKGROUND: The impact of human milk use on racial/ethnic disparities in necrotizing enterocolitis (NEC) incidence is unknown. METHODS: Trends in NEC incidence and human milk use at discharge were evaluated by race/ethnicity among 47,112 very low birth weight infants born in California from 2008 to 2017. We interrogated the association between race/ethnicity and NEC using multilevel regression analysis, and evaluated the effect of human milk use at discharge on the relationship between race/ethnicity and NEC using mediation analysis. RESULTS: Annual NEC incidence declined across all racial/ethnic groups from an aggregate average of 4.8% in 2008 to 2.6% in 2017. Human milk use at discharge increased over the time period across all racial groups, and non-Hispanic (NH) black infants received the least human milk each year. In multivariable analyses, Hispanic ethnicity (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.02-1.57) and Asian or Pacific Islander race (OR 1.35, 95% CI 1.01-1.80) were each associated with higher odds of NEC, while the association of NH black race with NEC was attenuated after adding human milk use at discharge to the model. Mediation analysis revealed that human milk use at discharge accounted for 22% of the total risk of NEC in non-white vs. white infants, and 44% in black vs. white infants. CONCLUSIONS: Although NEC incidence has declined substantially over the past decade, a sizable racial/ethnic disparity persists. Quality improvement initiatives augmenting human milk use may further reduce the incidence of NEC in vulnerable populations.

Clinical deterioration during neonatal transport in California.

OBJECTIVE: Identify clinical factors, transport characteristics and transport time intervals associated with clinical deterioration during neonatal transport in California. STUDY DESIGN: Population-based database was used to evaluate 47,794 infants transported before 7 days after birth from 2007 to 2016. Log binomial regression was used to estimate relative risks. RESULTS: 30.8% of infants had clinical deterioration. Clinical deterioration was associated with prematurity, delivery room resuscitation, severe birth defects, emergent transports, transports by helicopter and requests for delivery room attendance. When evaluating transport time intervals, time required for evaluation by the transport team was associated with increased risk of clinical deterioration. Modifiable transport intervals were not associated with increased risk. CONCLUSION: Our results suggest that high-risk infants are more likely to be unstable during transport. Coordination and timing of neonatal transport in California appears to be effective and does not seem to contribute to clinical deterioration despite variation in the duration of these processes.

Improved Referral of Very Low Birthweight Infants to High-Risk Infant Follow-Up in California.

OBJECTIVE: To examine changes in referral rates of very low birthweight (birthweight <1500 g) infants to high-risk infant follow-up in California and identify factors associated with referral before and after implementation of a statewide initiative in 2013 to address disparities in referral. STUDY DESIGN: We included very low birthweight infants born 2010-2016 in the population-based California Perinatal Quality Care Collaborative who survived to discharge home. We used multivariable logistic regression to examine factors associated with referral and derive risk-adjusted referral rates by neonatal intensive care unit (NICU) and region. RESULTS: Referral rate improved from 83.0% (preinitiative period) to 94.9% (postinitiative period); yielding an OR of 1.48 (95% CI, 1.26-1.72) for referral in the postinitiative period after adjustment for year. Referral rates improved the most (≥15%) for infants born at ≥33 weeks of gestation, with a birthweight of 1251-1500 g, and born in intermediate and lower volume NICUs. After the initiative, Hispanic ethnicity, small for gestational age status, congenital anomalies, and major morbidities were no longer associated with a decreased odds of referral. Lower birthweight, outborn status, and higher NICU volume were no longer associated with increased odds of referral. African American race was associated with lower odds of referral, and higher NICU level with a higher odds of referral during both time periods. Referral improved in many previously poor-performing NICUs and regions. CONCLUSIONS: High-risk infant follow-up referral of very low birthweight infants improved substantially across all sociodemographic, perinatal, and clinical variables after the statewide initiative, although disparities remain. Our results demonstrate the benefit of a targeted initiative in California, which may be applicable to other quality collaboratives.

Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage.

Since 1990, breast cancer mortality has decreased by 40% in white women but only 26% in African American women. The age at diagnosis of breast cancer is younger in black women. Breast cancer diagnosed before age 50 represents 23% of all breast cancers in African American women but only 16% of all breast cancers in white women. White women have a higher incidence of breast cancer over the age of 60. Tumor subtypes also vary among racial and ethnic groups. The triple-negative (TN) subtype, which has a poorer outcome and occurs at a younger age, represents 21% of invasive breast cancers in black women but only 10% of invasive breast cancers in white women. The hormone receptor-positive subtype, which is more common in older women and has the best outcome, has a higher incidence in white women (70%) than in black women (61%). The BRCA2 mutation is also more common in black women than in white women (other than those who are of Ashkenazi Jewish ancestry). There are also many barriers to screening. Major ones include the lack of contact with a primary health care provider as well as a decreased perceived risk of having breast cancer in the African American population. Given the younger age of onset and the higher incidence of the TN molecular subtype, following breast cancer screening guidelines that do not support screening before the age of 50 may disadvantage black women.

Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives.

Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

Maternal body mass index and risk of intraventricular hemorrhage in preterm infants.

BackgroundIntraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.MethodsPopulation-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.ResultsAmong 20,927 infants, 4,818 (23%) had any IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% confidence interval (CI) 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P<0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).ConclusionPre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand the contributing maternal factors.

Does the use of pretreatment MRI change the management of patients with newly diagnosed breast cancer?

Breast MRI plays a critical role in the diagnosis and management of breast cancer. The purpose of this study is to evaluate the effect of preoperative breast MRI on the management of a large cohort of breast cancer patients at our institution. This study is a retrospective chart review of all newly diagnosed breast cancer patients who underwent preoperative breast MRI at our institution between January 1, 2004 and December 31, 2009. 1352 patients comprised the study population. 241 (17.8%) patients underwent a change in surgical management as a result of preoperative MRI. Patients with tumors in the lower inner quadrant and the central breast and those with pathology of invasive lobular carcinoma were significantly more likely to have their management changed by preoperative MRI. There was also a significant trend for larger tumors to be associated with a change in surgical management. No statistically significant association was found between breast density and change in management. This study supports the recommendation for the use of preoperative breast MRI in the majority of newly diagnosed breast cancer patients, especially those with larger tumors, pathology of invasive lobular carcinoma, and tumors in the lower inner quadrant. Preoperative breast MRI is a useful tool for the evaluation of additional disease that led to a change in the surgical management of 17.8% of patients.

Refractory Chylous Ascites Secondary to Neuroblastoma.

BACKGROUND: Neonatal ascites is a complex condition that often poses a diagnostic dilemma for the clinician. We present a case of neonatal ascites secondary to neuroblastoma. CASE PRESENTATION: Our neonatal patient had congenital and recurrent chylous ascites despite multiple postnatal paracenteses, which resolved with complete resection of a retroperitoneal neoplasm. CONCLUSION: Congenital neuroblastoma may present with chylous ascites, probably due to disruption of the lymphatic vasculature.