Attributable mortality of infections caused by carbapenem-resistant Enterobacterales: results from a prospective, multinational case-control-control matched cohorts study (EURECA).

OBJECTIVES: To assess the mortality attributable to infections caused by carbapenem-resistant Enterobacterales (CRE) and to investigate the effect of clinical management on differences in observed outcomes in a multinational matched cohort study. METHODS: A prospective matched-cohorts study (NCT02709408) was performed in 50 European hospitals from March 2016 to November 2018. The main outcome was 30-day mortality with an active post-discharge follow-up when applied. The CRE cohort included patients with complicated urinary tract infections, complicated intra-abdominal infections, pneumonia, or bacteraemia from other sources because of CRE. Two control cohorts were selected: patients with infection caused by carbapenem-susceptible Enterobacterales (CSE) and patients without infection. Matching criteria included type of infection for the CSE group, hospital ward of CRE detection, and duration of hospital admission up to CRE detection. Multivariable and stratified Cox regression was applied. RESULTS: The cohorts included 235 patients with CRE infection, 235 patients with CSE infection, and 705 non-infected patients. The 30-day mortality (95% CI) was 23.8% (18.8-29.6), 10.6% (7.2-15.2), and 8.4% (6.5-10.6), respectively. The difference in 30-day mortality rates between patients with CRE infection when compared with patients with CSE infection was 13.2% (95% CI, 6.3-20.0), (HR, 2.57; 95% CI, 1.55-4.26; p < 0.001), and 15.4% (95% CI, 10.5-20.2) when compared with non-infected patients (HR, 3.85; 95% CI, 2.57-5.77; p < 0.001). The population attributable fraction for 30-day mortality for CRE vs. CSE was 19.28%, and for CRE vs. non-infected patients was 9.61%. After adjustment for baseline variables, the HRs for mortality were 1.87 (95% CI, 0.99-3.50; p 0.06) and 3.65 (95% CI, 2.29-5.82; p < 0.001), respectively. However, when treatment-related time-dependent variables were added, the HR of CRE vs. CSE reduced to 1.44 (95% CI, 0.78-2.67; p 0.24). DISCUSSION: CRE infections are associated with significant attributable mortality and increased adjusted hazard of mortality when compared with CSE infections or patients without infection. Underlying patient characteristics and a delay in appropriate treatment play an important role in the CRE mortality.

Anthrax meningoencephalitis complicated with brain abscess - A case report.

Bacillus anthracis is a sporulating gram-positive rod whose main route of entry into the human body is cutaneous. Anthrax meningitis is usually fulminant and fatal. We present here a successfully treated case of anthrax meningoencephalitis complicated with brain abscess. The patient was a shepherd, with disease onset 7 days prior to hospital admission with fever, chills, occipital headache, and vertigo, followed by right hemiplegia, motor aphasia, agitation and coma. He had cutaneous lesions with black eschar on the limbs, which was a clue (along with his occupation), for diagnosis suspicion. The polymerase chain reaction for B. anthracis DNA was positive in both cerebrospinal fluid and cutaneous lesions. The cerebrospinal fluid was compatible with bacterial meningitis without being haemorrhagic. Magnetic resonance imaging showed meningeal enhancement and multiple intraparenchymal heterogeneous lesions with an important haemorrhagic component in the left parietal lobe, surrounded by vasogenic oedema with maintenance, 22 days later, of the left parietal lobe lesion, having a ring contrast enhancement and a central diffusion restriction, compatible with an abscess. From admission, he was intensively treated with combined large-spectrum antibiotics; this could be the most valuable factor in the successful outcome.

Co-infections and co-morbidities among injecting drug users versus sexually infected patients in Bucharest.

INTRODUCTION: After the 2008 introduction of new psychoactive substances (NPS) in Romania, the number of newly diagnosed HIV infections showed significant increase among injecting drug users (IDUs). Our objective was to analyze the differences between co-infections related to the HIV infection, based on the way of transmission (IDUs versus sexually infected). MATERIALS AND METHODS: A retrospective transversal study was carried out, analyzing 245 adult HIV-positive patients, diagnosed between January 2013 and December 2013 in our hospital. We collected socio-demographic, epidemiological and laboratory data at the diagnosis and analyzed them using SPSS version 20. RESULTS: Most patients (71%, 174/245) were men and the median age was 32 years (IQR: 26-38). 91 patients (37%) were former/active IDUs (most of them injecting both opioids and NPS), while 154 patients (63%) were sexually infected, with 84% being heterosexuals and 16% men having sex with men (MSM). The median CD4 count, at the moment of diagnosis, was 294 cells/mm(3) (IQR: 119-483). CONCLUSION: Heterosexual transmission was the most common way of HIV transmission in 2013 in contrast with EU/CEE, where MSM accounted for the majority of cases of HIV epidemics in 2012 [1]. Sexually transmitted HIV infection was associated with late presentation, stage C and syphilis. We noted a high percentage of IDU transmission, which was associated with stage A and hepatitis C infection.

Characteristics of late presenters in Bucharest.

INTRODUCTION: Late presentation is associated with increased healthcare costs, rates of HIV transmission and poor outcome. In Romania, in 2012, one third of individuals with new HIV diagnosis were late presenters (LP). OBJECTIVE: The aim of the study was to evaluate the epidemiological and clinical characteristics associated with late presentation. METHODS: We retrospectively studied patients over 18 years old, notified in our institution between January 2012 and December 2013, including 499 out of 727 newly diagnosed patients in Bucharest. LP were defined as patients presenting with CD4 T-cell count below 350 cells/mm(3) or with an AIDS defining event. Patients with advanced HIV disease (AHD) were defined as persons with a CD4 T-cell count below 200 cells/mm(3). Differences between groups were analyzed using the Mann-Whitney U test for continuous variables and the chi-square test for dichotomous variables. Multivariable analysis was performed using binary logistic regression. RESULTS: Out of 499 patients included, 362 (72%) were male. The median age was 30 (IQR 26-36). A total of 302 (61%) were LP and 184 (37%) were patients with AHD. A total of 170 (34%) were asymptomatic and 114 (23%) presented with an AIDS-defining event. The median CD4 count was 293 cells/mm(3) (IQR 125-471) and the median HIV viral load was 100,191 copies/mL (IQR 34,560-272,936). Characteristics of LP compared with non-LP are shown in Table 1. Stage C disease has been shown by multivariable analysis to be associated with LP (p<0.001, OR=11.56, 95% CI 4.94-27.03). CONCLUSIONS: More than half of newly HIV diagnosed patients in Bucharest were LP. The proportion of LP was highest among heterosexually acquired cases. Although most our patients were young, late presentation was associated with age over 35 years. The lower proportion of LP among IVDU compared with those heterosexually infected could be explained by a higher proportion of HIV screening tests among IVDU.

Occurrence of Clostridium difficile infections due to PCR ribotype 027 in Bucharest, Romania.

INTRODUCTION: Little is known about prevailing ribotypes of Clostridium difficile infection in Romania where CDI is not a mandatory notifiable disease. METHODOLOGY: We studied 64 non-duplicate C. difficile isolates from patients hospitalised at the National Institute of Infectious Diseases, Bucharest, Romania between March 2011 and March 2012. RESULTS: Sixty-three of the 64 C. difficile isolates produced toxins A and B whereas 44 (69%) isolates produced a binary toxin. Ribotype 027 accounted for 43 (68%) of the 63 toxigenic strains. The remaining 20 isolates belonged to ribotypes 018 (n = 9), 012 (n = 3), and, with one isolate each, 014, 031, 081, 416, 433, 500, 507 and PR03035 (new ribotype). Information on hospital mortality was available for 62 of the 64 patients; among these 62 cases, 4 (6.4%) ended fatal. Recurrence was documented for 11 (18.3%) of the 60 patients for whom this information was available. Multilocus variable-number tandem repeat analysis of the 43 isolates of ribotype 027 yielded a unique cluster for the Romanian isolates when compared to Austrian or Italian isolates. CONCLUSION: Our findings sustain the hypothesis of a recent emerged outbreak of C. difficile PCR ribotype 027 infections in the area of Bucharest.