Diversity, virulence, and antimicrobial resistance of the KPC-producing Klebsiella pneumoniae ST307 clone.

The global spread of Klebsiella pneumoniae producing Klebsiella pneumoniae carbapenemase (KPC) has been mainly associated with the dissemination of high-risk clones. In the last decade, hospital outbreaks involving KPC-producing K. pneumoniae have been predominantly attributed to isolates belonging to clonal group (CG) 258. However, results of recent epidemiological analysis indicate that KPC-producing sequence type (ST) 307, is emerging in different parts of the world and is a candidate to become a prevalent high-risk clone in the near future. Here we show that the ST307 genome encodes genetic features that may provide an advantage in adaptation to the hospital environment and the human host. Sequence analysis revealed novel plasmid-located virulence factors, including a cluster for glycogen synthesis. Glycogen production is considered to be one of the possible adaptive responses to long-term survival and growth in environments outside the host. Chromosomally-encoded virulence traits in the clone comprised fimbriae, an integrative conjugative element carrying the yersiniabactin siderophore, and two different capsular loci. Compared with the ST258 clone, capsulated ST307 isolates showed higher resistance to complement-mediated killing. The acquired genetic features identified in the genome of this new emerging clone may contribute to increased persistence of ST307 in the hospital environment and shed light on its potential epidemiological success.

Influenza like Illness among Medical Residents Anticipates Influenza Diffusion in General Population: Data from a National Survey among Italian Medical Residents.

The aim of this multicentre study was to assess incidence of influenza like illness (ILI) among Italian medical residents (MRs) during 2011-2012 influenza season, to detect variables associated with ILI and to compare estimated ILI incidence among MRs and general population. A cross-sectional survey was carried out throughout an anonymous questionnaire administered to all MRs attending the post-graduate medical schools of 18 Italian Universities. At the same time an analysis of the ILI incidence in the Italian general population was conducted through the Italian Influenza Surveillance Network. Of a total of 2,506 MRs, 1,191 (47.5%) reported at least one ILI episode. A higher proportion of ILIs was reported by MRs of Central (25.0% with ILI vs 20.2% without ILI) and Southern Italy (40.2% with ILI vs. 36.4 without ILI) compared to Northern Italy (34.8% with ILI vs. 43.4% without ILI) (p<0.001). Italian MRs had a higher cumulative incidence of ILIs (546.7 episodes per 1,000 vs. 75.9 episodes per 1,000) and an earlier peak (January 2012 vs. February 2012), compared to general population due to higher number of contacts in hospital setting. MRs reported a high rate of ILI infection probably in association with their working activities. These data suggest the need to offer an earlier influenza vaccination to HCWs than general population with the aim to both prevent ILI and its transmission to patients.

Staphylococcal cassette chromosome mec typing and mecA sequencing in methicillin-resistant staphylococci from Algeria: a highly diversified element with new mutations in mecA.

Genetic mechanisms of methicillin resistance are still relevant in staphylococci. The aims of this study are to assess the possible exchanges of staphylococcal cassette chromosome mec (SCCmec) among isolates of methicillin-resistant staphylococci (MRS) and to check for known or new mutations in mecA DNA. A total of 35 MRS non-repetitive isolates were recovered, including 20 Staphylococcushaemolyticus, 7 Staphylococcusaureus, 4 Staphylococcussciuri, 2 Staphylococcussaprophyticus and 1 isolate each of Staphylococcusxylosus and Staphylococcuslentus. Only 16 of the 35 strains were assigned to known SCCmec types: 7 SCCmec VII, 6 SCCmec IV and 3 SCCmec III, with possible horizontal transfer of the SCCmec VII from methicillin-resistant S. haemolyticus to methicillin-susceptible S. aureus. mecA gene sequencing in ten selected isolates allowed description of nine punctual mutations, seven of which were reported for the first time. The most frequent mutation was G246E, identified in isolates of methicillin-resistant S. aureus, S. sciuri, S. saprophyticus and S. lentus. These results emphasized the high degree of genetic diversity of SCCmec element in MRS and describe new missense mutations in mecA, which might be important in understanding the evolution of methicillin and new ß-lactam resistance.

Evidence for Human Adaptation and Foodborne Transmission of Livestock-Associated Methicillin-Resistant Staphylococcus aureus.

We investigated the evolution and epidemiology of a novel livestock-associated methicillin-resistant Staphylococcus aureus strain, which colonizes and infects urban-dwelling Danes even without a Danish animal reservoir. Genetic evidence suggests both poultry and human adaptation, with poultry meat implicated as a probable source.

Use of Cepheid Xpert Carba-R® for Rapid Detection of Carbapenemase-Producing Bacteria in Abdominal Septic Patients Admitted to Intensive Care Unit.

Early institution of effective antibiotic therapy and source control are pivotal to improve survival of abdominal septic patients. Xpert® Carba-R is a real time polymerase chain reaction assay for rapid detection and differentiation of five genes (blaKPC, blaVIM, blaOXA-48, blaIMP-1, blaNDM) responsible for carbapenem resistance. We performed an observational study investigating the clinical usefulness and applicability of Xpert® Carba-R to detect carbapenem resistance in abdominal septic patients admitted to intensive care unit. We compared the results of Xpert® Carba-R with standard microbiological culture. We collected a set of two rectal/stomia swabs and two swabs from abdominal drainage fluid for each patient. We included 20 patients for a total of 45 comparisons between the two methods. In our clinical setting, the overall performance of Xpert® Carba-R for detection of carbapenem resistance in the presence of genes detectable and non-detectable by the method was: sensitivity 50% (95% CI 24.6-75.3); specificity 93.1% (95% CI 77.2-99.1); positive predictive value (PPV) 80% (95% CI 44.4-97.5); negative predictive value (NPV) 77.1% (95% CI 56.9-89.6). The inter-rater agreement was 0.47 (SE 0.14; 95% CI 0.20-0.74). When considering the only 5 mechanisms of resistance detected by both methods, the overall diagnostic performance was: sensitivity 100% (95% CI 69.1-100), specificity 94.2 (95% CI 80.8-99.3), PPV 83.3 (95% CI 59.6-97.9) and NPV 100% (95% CI 89.4-100). The inter-rater agreement was 0.88 (SE 0.08; 95% CI 0.71-1). Xpert® Carba-R may be considered an additional diagnostic tool for early diagnosis of carbapenem resistance in abdominal septic patients. Clinicians should be aware of their epidemiology before its introduction in the diagnostic protocol of their intensive care units.

Molecular characterisation of quinolone-resistant Shigella strains isolated in Tehran, Iran.

Over the past few years, the number of Shigella strains resistant to nalidixic acid has increased and has made the selection of effective antimicrobial therapy more difficult. The purpose of this study was to investigate the molecular mechanism of quinolone resistance in Shigella strains. Shigella strains isolated from 1100 diarrhoeal patients in Tehran, Iran, were assessed for their susceptibility to nalidixic acid prior to PCR-RFLP and sequence analysis of their quinolone resistance genes. Among 73 Shigella strains isolated, 23 (31.5%) were resistant to nalidixic acid. The most common Shigella spp. was Shigella sonnei (54; 74.0%). Of the 23 quinolone-resistant isolates, 4 (17.4%) (including 2 Shigella flexneri, 1 S. sonnei and 1 Shigella boydii) contained the qnrS gene. However, none of the isolates harboured qnrA or qnrB genes. PCR-RFLP analysis of gyrA showed a mutation profile in two nalidixic acid-resistant strains, including one S. sonnei and one S. flexneri. Sequencing of mutant gyrA genes revealed a point mutation at position 83, resulting in the replacement of serine by leucine. In conclusion, molecular mechanisms of resistance to quinolones were identified in 6 of 23 Shigella isolates. Other possible mechanisms of resistance should also be investigated for better characterisation of quinolone-resistant Shigella isolates.

Artemisia arborescens Essential Oil Composition, Enantiomeric Distribution, and Antimicrobial Activity from Different Wild Populations from the Mediterranean Area.

Aerial parts of Artemisia arborescens were collected from different sites of the Mediterranean area (southwestern Algeria and southern Italy) and the chemical composition of their essential oil (EO) extracted by hydrodistillation was studied by both gas chromatography (GC) equipped with an enantioselective capillary column and GC/mass spectrometry (GC/MS). The EOs obtained were tested against several Listeria monocytogenes strains. Using GC and GC/MS, 41 compounds were identified, accounting for 96.0 - 98.8% of the total EO. All EOs showed a similar terpene profile, which was rich in chamazulene, ß-thujone, and camphor. However, the concentration of such compounds varied among the EOs. A. arborescens EO inhibited up to 83.3% of the L. monocytogenes strains, but the inhibitory spectrum varied among the EOs, with those from Algeria showing a higher inhibition degree than the Italian EOs. Such effect likely depended on the ketone (ß-thujone + camphor) content of the EO. The differences in the EO composition support the hypothesis that A. arborescens has at least two different chemotypes: a ß-thujone and a chamazulene type. The EO inhibitory spectrum indicates the A. arborescens EO as a valuable option in the control of the food-borne pathogens.

A Snapshot on MRSA Epidemiology in a Neonatal Intensive Care Unit Network, Palermo, Italy.

OBJECTIVES: We performed a 1-year prospective surveillance study on MRSA colonization within the five NICUs of the metropolitan area of Palermo, Italy. The purpose of the study was to assess epidemiology of MRSA in NICU from a network perspective. METHODS: Transfer of patients between NICUs during 2014 was traced based on the annual hospital discharge records. In the period February 2014-January 2015, in the NICU B, at the University teaching hospital, nasal swabs from all infants were collected weekly, whereas in the other four NICUs (A, C, D, E) at 4 week-intervals of time. MRSA isolates were submitted to antibiotic susceptibility testing, SCCmec typing, PCR to detect lukS-PV and lukF-PV (lukS/F-PV) genes and the gene encoding the toxic shock syndrome toxin (TSST-1), multilocus variable number tandem repeat fingerprinting (MLVF), and multilocus sequence typing (MLST). RESULTS: In the period under study, 587 nasal swabs were obtained from NICU B, whereas 218, 180, 157, and 95 from NICUs A, C, D, and E, respectively. Two groups of NICUs at high prevalence and low prevalence of MRSA colonization were recognized. Overall, 113 isolates of MRSA were identified from 102 infants. Six MLVF types (A-F) were detected, with type C being subdivided into five subtypes. Five sequence types (STs) were found with ST22-IVa being the most frequent type in all NICUs. All the MRSA molecular subtypes, except for ST1-IVa, were identified in NICU B. CONCLUSIONS: Our findings support the need to approach surveillance and infection control in NICU in a network perspective, prioritizing referral healthcare facilities.

Complete Genome Sequence of KPC-3- and CTX-M-15-Producing Klebsiella pneumoniae Sequence Type 307.

Klebsiella pneumoniaesequence type (ST) 307, carryingblaKPC-3,blaCTX-M-15,blaOXA-1,aac(6')-Ib-cr, andqnrB1 genes, is replacing the predominant hyperepidemic ST258 clone in Italy. Whole-genome and complete plasmid sequencing of one ST307 strain was performed and new features were identified.

Extraintestinal pathogenic Escherichia coli sequence type 131 H30-R and H30-Rx subclones in retail chicken meat, Italy.

Extraintestinal pathogenic Escherichia coli sequence type 131 (ST131), typically fluoroquinolone-resistant (FQ-R) and/or extended-spectrum ß-lactamase (ESBL)-producing, has emerged globally. Among clinical isolates, ST131, primarily its H30-R and H30-Rx subclones, accounts for most antimicrobial-resistant E. coli and is the dominant E. coli strain worldwide. We assessed its prevalence and characteristics among raw chicken meat samples on sale in Palermo, Italy. A collection of 237 fluoroquinolone resistant and ESBL/AmpC producing E. coli isolates, which had been isolated from processed retail chicken meat in the period May 2013-April 2015, was analyzed. Established polymerase chain reaction methods were used to define ST131 and its H30 subclones, ESBL, AmpC, and plasmid-mediated quinolone resistance (PMQR) determinants. Amplified Fragment Length Polymorphism (AFLP) was performed to assess the relatedness among ST131 isolates. Out of the 237 E. coli isolates, 12 isolates belonged to the phylogenetic group B2. Based on the molecular definition of ExPEC, all isolates were attributed with the status of ExPEC. SNP-PCR results confirmed that nine isolates were ST131. SNP-PCR for H30-R and H30-Rx subclones showed that six and three ExPEC ST131 were positive for H30-R and H30-Rx, respectively. The results of AFLP showed that, except for four isolates grouped into two clusters which proved to be indistinguishable, the isolates under study were genetically heterogeneous. To the best of our knowledge, this is the first report of H30-R and H30-Rx subclones in animal food samples. Our findings appear to support the role of food chain in their transmission to humans.

Design, Implementation, and Evaluation of the Adolescents and Surveillance System for the Obesity Prevention Project.

The Adolescents Surveillance System for Obesity prevention (ASSO) Project aimed at developing standardized and web-based tools for collecting data on adolescents' obesity and its potential determinants. This has been implemented and piloted in the local area of Palermo city, Italy. The aim of the present study is to provide an overview of the Project's design, implementation, and evaluation, highlighting all the aspects for a potential scale-up of the surveillance system on the whole national territory and abroad, as a sustainable and effective source of data.The overall structure and management, the ASSO-toolkit, the ASSO-NutFit software, and all developed and used procedures for recruiting, training, and data collecting/analyzing are addressed. An interim evaluation has been performed through a feasibility study; a final Project evaluation has been performed reporting the Strengths, Weaknesses, Opportunities, and Threats (SWOT) and the attributes that a surveillance system should have.This article provides a detailed overview of the Project and highlights that ASSO can be considered a valid, logical, coherent, efficient, and sustainable surveillance system that is consistent with countries' needs and priorities.The system developed by the ASSO Project provides high-quality data and complies with several characteristics typical of a suitable surveillance system. It has a potential of being adopted within the National Health Service and other countries' Health Services for monitoring adolescents' obesity and its determinants, such as food intakes, behaviors, physical activity, and fitness profiles.

The Increasing Challenge of Multidrug-Resistant Gram-Negative Bacilli: Results of a 5-Year Active Surveillance Program in a Neonatal Intensive Care Unit.

Colonization and infection by multidrug-resistant gram-negative bacilli (MDR GNB) in neonatal intensive care units (NICUs) are increasingly reported.We conducted a 5-year prospective cohort surveillance study in a tertiary NICU of the hospital "Paolo Giaccone," Palermo, Italy. Our objectives were to describe incidence and trends of MDR GNB colonization and the characteristics of the most prevalent organisms and to identify the risk factors for colonization. Demographic, clinical, and microbiological data were prospectively collected. Active surveillance cultures (ASCs) were obtained weekly. Clusters of colonization by extended spectrum ß-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae were analyzed by conventional and molecular epidemiological tools.During the study period, 1152 infants were enrolled in the study. Prevalences of colonization by MDR GNB, ESBL-producing GNB and multiple species/genera averaged, respectively, 28.8%, 11.7%, and 3.7%. Prevalence and incidence density of colonization by MDR GNB and ESBL-producing GNB showed an upward trend through the surveillance period. Rates of ESBL-producing E coli and K pneumoniae colonization showed wide fluctuations peaking over the last 2 years. The only independent variables associated with colonization by MDR GNB and ESBL-producing organisms and multiple colonization were, respectively, the days of NICU stay (odds ratio [OR] 1.041), the days of exposure to ampicillin-sulbactam (OR 1.040), and the days of formula feeding (OR 1.031). Most clusters of E coli and K pneumoniae colonization were associated with different lineages. Ten out of 12 clusters had an outborn infant as their index case.Our study confirms that MDR GNB are an increasing challenge to NICUs. The universal once-a-week approach allowed us to understand the epidemiology of MDR GNB, to timely detect new clones and institute contact precautions, and to assess risk factors. Collection of these data can be an important tool to optimize antimicrobials use and control the emergence and dissemination of resistances in NICU.

Burden and viral aetiology of influenza-like illness and acute respiratory infection in intensive care units.

The purpose of this investigation was to study the viral aetiology of influenza-like illness (ILI) and acute respiratory tract infection (ARTI) among patients requiring intensive care unit admission. A cross-sectional retrospective study was carried out in Sicily over a 4-year period. A total of 233 respiratory samples of patients with ILI/ARTI admitted to intensive care units were molecularly analyzed for the detection of a comprehensive panel of aetiologic agents of viral respiratory infections. About 45% of patients was positive for at least one pathogen. Single aetiology occurred in 75.2% of infected patients, while polymicrobial infection was found in 24.8% of positive subjects. Influenza was the most common aetiologic agent (55.7%), especially among adults. Most of patients with multiple aetiology (76.9%) were adults and elderly. Mortality rates among patients with negative or positive aetiology did not significantly differ (52.4% and 47.6%, respectively). Highly transmissible respiratory pathogens are frequently detected among patients with ILI/ARTI admitted in intensive care units, showing the occurrence of concurrent infections by different viruses. The knowledge of the circulation of several types of microorganisms is of crucial importance in terms of appropriateness of therapies, but also for the implication in prevention strategies and hospital epidemiology.

Respiratory Tularemia: Francisella Tularensis and Microarray Probe Designing.

BACKGROUND: Francisella tularensis (F. tularensis) is the etiological microorganism for tularemia. There are different forms of tularemia such as respiratory tularemia. Respiratory tularemia is the most severe form of tularemia with a high rate of mortality; if not treated. Therefore, traditional microbiological tools and Polymerase Chain Reaction (PCR) are not useful for a rapid, reliable, accurate, sensitive and specific diagnosis. But, DNA microarray technology does. DNA microarray technology needs to appropriate microarray probe designing. OBJECTIVE: The main goal of this original article was to design suitable long oligo microarray probes for detection and identification of F. tularensis. METHOD: For performing this research, the complete genomes of F. tularensis subsp. tularensis FSC198, F. tularensis subsp. holarctica LVS, F. tularensis subsp. mediasiatica, F. tularensis subsp. novicida (F. novicida U112), and F. philomiragia subsp. philomiragia ATCC 25017 were studied via NCBI BLAST tool, GView and PanSeq Servers and finally the microarray probes were produced and processed via AlleleID 7.7 software and Oligoanalyzer tool, respectively. RESULTS: In this in silico investigation, a number of long oligo microarray probes were designed for detecting and identifying F. tularensis. Among these probes, 15 probes were recognized as the best candidates for microarray chip designing. CONCLUSION: Calibrated microarray probes reduce the biasis of DNA microarray technology as an advanced, rapid, accurate and cost-effective molecular diagnostic tool with high specificity and sensitivity. Professional microarray probe designing provides us with much more facility and flexibility regarding preparation of a microarray diagnostic chip.

Double Copies of bla(KPC-3)::Tn4401a on an IncX3 Plasmid in Klebsiella pneumoniae Successful Clone ST512 from Italy.

A carbapenem-resistant sequence type 512 (ST512) Klebsiella pneumoniae carbapenemase 3 (KPC-3)-producing K. pneumoniae strain showing a novel variant plasmid content was isolated in Palermo, Italy, in 2014. ST512 is a worldwide successful clone associated with the spread of bla(KPC) genes located on the IncFIIk pKpQIL plasmid. In our ST512 strain, the bla(KPC-3) gene was unusually located on an IncX3 plasmid, whose complete sequence was determined. Two copies of bla(KPC-3)::Tn4401a caused by intramolecular transposition events were detected in the plasmid.

A meta-analysis of the validity of FFQ targeted to adolescents.

OBJECTIVE: The present work is aimed at meta-analysing validity studies of FFQ for adolescents, to investigate their overall accuracy and variables that can affect it negatively. DESIGN: A meta-analysis of sixteen original articles was performed within the ASSO Project (Adolescents and Surveillance System in the Obesity prevention). SETTING: The articles assessed the validity of FFQ for adolescents, compared with food records or 24 h recalls, with regard to energy and nutrient intakes. SUBJECTS: Pearson's or Spearman's correlation coefficients, means/standard deviations, kappa agreement, percentiles and mean differences/limits of agreement (Bland-Altman method) were extracted. Pooled estimates were calculated and heterogeneity tested for correlation coefficients and means/standard deviations. A subgroup analysis assessed variables influencing FFQ accuracy. RESULTS: An overall fair/high correlation between FFQ and reference method was found; a good agreement, measured through the intake mean comparison for all nutrients except sugar, carotene and K, was observed. Kappa values showed fair/moderate agreement; an overall good ability to rank adolescents according to energy and nutrient intakes was evidenced by data of percentiles; absolute validity was not confirmed by mean differences/limits of agreement. Interviewer administration mode, consumption interval of the previous year/6 months and high number of food items are major contributors to heterogeneity and thus can reduce FFQ accuracy. CONCLUSIONS: The meta-analysis shows that FFQ are accurate tools for collecting data and could be used for ranking adolescents in terms of energy and nutrient intakes. It suggests how the design and the validation of a new FFQ should be addressed.

A Fitness Index model for Italian adolescents living in Southern Italy: the ASSO project.

BACKGROUND: Strong relations between physical fitness and health in adolescents have been established in the last decades. The main objectives of the present investigation were to assess major physical fitness components in a sample of Italian school adolescents, comparing them with international data, and providing a Fitness Index model derived from percentile cut-off values of five considered physical fitness components. METHODS: A total of 644 school pupils (15.9±1.1 years; M: N.=399; F: N.=245) were tested using the ASSO-Fitness Test Battery (FTB), a tool developed within the Adolescents and Surveillance System for the Obesity prevention project, which included the handgrip, standing broad-jump, sit-up to exhaustion, 4×10-m shuttle run and 20-m shuttle run tests. Stratified percentile values and related smoothed curves were obtained. The method of principal components analysis (PCA) was applied to the considered five fitness components to derive a continuous fitness level score (the Fit-Score). A Likert-type scale on the Fit-Score values was applied to obtain an intuitive classification of the individual level of fitness: very poor (X0.5) between the Fit-Score and all the fitness components. The median Fit-Score was equal to 33 for females and 53 for males (in a scale from 0 to 100). CONCLUSIONS: The ASSO-FTB allowed the assessment of health-related fitness components in a convenient sample of Italian adolescents and provided a Fitness Index model incorporating all these components for an intuitive classification of fitness levels. If this model is confirmed, the monitoring of these variables will allow early detection of health-related issues in a mass population, thus giving the opportunity to plan appropriate interventions.

Phenotypic and Molecular Epidemiology of Acinetobacter calcoaceticus baumannii Complex Strains Spread at Nemazee Hospital of Shiraz, Iran.

BACKGROUND: Acinetobacter calcoaceticus baumannii (ACB) complex are Gram-negative opportunistic bacteria with low virulence properties. Their resistance to antibiotics has become a matter of concern in hospital infections. OBJECTIVES: The present study aimed to determine the prevalence and antimicrobial susceptibility of ACB isolates collected from the Nemazee hospital of Shiraz. In addition, Pulsed Field Gel Electrophoresis (PFGE) was used to determine the genetic patterns of these strains. PATIENTS AND METHODS: In this cross-sectional study, 93 strains of ACB complex were isolated from patients of Nemazee hospital, Shiraz, Iran. The antibiotic susceptibility patterns of the isolates to the following 15 antibiotics were determined: gentamicin, ticarcillin, ceftazidime, co-trimoxazole, imipenem, piperacillin tazobactam, amikacin, aztreonam, sulbactam, meropenem, tobramycin, cefotaxime, ceftriaxone, colistin, polymyxin B. Pulsed Field Gel Electrophoresis was used to determine the clonal relationship of these strains. RESULTS: Most of the isolates were found to be resistant to cefotaxime, co-trimoxazole, ceftriaxone, aztreonam, ceftazidime and ticarcillin (90%), and the least resistance was observed to colistin and polymyxin B. Among the 93 tested samples, 35 antimicrobial susceptibility patterns and 47 PFGE patterns were obtained. CONCLUSIONS: High resistance to antibiotics was observed among the strains of ACB complex and the least resistance was towards colistin and polymyxin B, indicating that these antibiotics could be effective for treatment, in case there is no other choice. Using PFGE, the similarity between some strains of Acinetobacter was determined, which indicated epidemics in different parts of the hospital; such epidemics can in turn lead to increased incidence of Acinetobacter infections.

NDM-1-producing Acinetobacter baumannii ST85 now in Turkey, including one isolate from a Syrian refugee.

New Delhi metallo-ß-lactamase-1 (NDM-1), an acquired class B carbapenemase, is a significant clinical threat owing to the extended hydrolysis of ß-lactams including carbapenems. Here, to the best of our knowledge we describe for the first time in Turkey two NDM-1-producing Acinetobacter baumannii isolates recovered from intensive care unit patients. The presence of blaNDM-1 was detected by PCR and confirmed by sequencing. The clonal relationship was assessed by PFGE and multilocus sequence typing. Both isolates were positive for blaNDM-1 and were attributed with the sequence type 85. One isolate was from a Syrian refugee, whereas the second was from a patient who had never travelled outside Turkey. Our findings confirmed that the rapid spread of NDM-1-producing Gram-negative organisms could become a major challenge for the treatment and control of healthcare-associated infections in our geographical area. They suggest also that NDM-1-producing strains and/or their genetic determinants are probably being imported from Syria to neighbouring countries.

Bloodstream infections in intensive care unit patients: distribution and antibiotic resistance of bacteria.

Bloodstream infections (BSIs) are among the leading infections in critically ill patients. The case-fatality rate associated with BSIs in patients admitted to intensive care units (ICUs) reaches 35%-50%. The emergence and diffusion of bacteria with resistance to antibiotics is a global health problem. Multidrug-resistant bacteria were detected in 50.7% of patients with BSIs in a recently published international observational study, with methicillin resistance detected in 48% of Staphylococcus aureus strains, carbapenem resistance detected in 69% of Acinetobacter spp., in 38% of Klebsiella pneumoniae, and in 37% of Pseudomonas spp. Prior hospitalization and antibiotic exposure have been identified as risk factors for infections caused by resistant bacteria in different studies. Patients with BSIs caused by resistant strains showed an increased risk of mortality, which may be explained by a higher incidence of inappropriate empirical therapy in different studies. The molecular genetic characterization of resistant bacteria allows the understanding of the most common mechanisms underlying their resistance and the adoption of surveillance measures. Knowledge of epidemiology, risk factors, mechanisms of resistance, and outcomes of BSIs caused by resistant bacteria may have a major influence on global management of ICU patients. The aim of this review is to provide the clinician an update on BSIs caused by resistant bacteria in ICU patients.