Assessment of a novel BLOOMY score for predicting mortality in hospitalised adults with bloodstream infection.

PURPOSE: A German multicentre study BLOOMY was the first to use machine learning approach to develop mortality prediction scores for bloodstream infection (BSI) patients, but the scores have not been assessed in other cohorts. Our aim was to assess how the BLOOMY 14-day and 6-month scores estimate mortality in our cohort of 497 cases with BSI. METHODS: Clinical data, laboratory data, and patient outcome were gathered retrospectively from patient records. The scores were calculated as presented in the BLOOMY study with the exception in the day of the evaluation. RESULTS: In our cohort, BLOOMY 14-day score estimated death by day 14 with an area under curve (AUC) of 0.87 (95% Confidence Interval 0.80-0.94). Using ≥ 6 points as a cutoff, sensitivity was 68.8%, specificity 88.1%, positive predictive value (PPV) 39.3%, and negative predictive value (NPV) 96.2%. These results were similar in the original BLOOMY cohort and outweighed both quick Sepsis-Related Organ Failure Assessment (AUC 0.76) and Pitt Bacteraemia Score (AUC 0.79) in our cohort. BLOOMY 6-month score to estimate 6-month mortality had an AUC of 0.79 (0.73-0.85). Using ≥ 6 points as a cutoff, sensitivity was 98.3%, specificity 10.7%, PPV 25.7%, and NPV 95.2%. AUCs of 6-month score to estimate 1-year and 5-year mortality were 0.80 (0.74-0.85) and 0.77 (0.73-0.82), respectively. CONCLUSION: The BLOOMY 14-day and 6-month scores performed well in the estimations of mortality in our cohort and exceeded some established scores, but their adoption in clinical work remains to be seen.

Risk of venous thromboembolism in COVID-19 infection.

The incidence of venous thromboembolism (VTE) for non-hospitalised patients with coronavirus disease-2019 infection has not been very widely studied. 13 019 persons with a positive SARS-CoV-2 nucleic acid amplification test were identified. In total, 447 (0.2%) VTEs were identified in the study population, 293 (66%) of these were pulmonary embolisms. A positive SARS-CoV-2 test did not increase the risk for VTE in the univariate analysis (odds ratio (OR): 1.0, 95% confidence interval (CI): 0.69-1.4) or multivariable analysis (OR: 1.36, 95% CI: 0.93-1.97).

Effect of non-cephalosporin antibiotic prophylaxis on the risk of periprosthetic joint infection after total joint replacement surgery: a retrospective study with a 1-year follow-up.

Background: Cephalosporins are recommended as first-line antibiotic prophylaxis in total joint replacement surgery. Studies have shown an increased risk for periprosthetic joint infection (PJI) when non-cephalosporin antibiotics have been used. This study examines the effect of non-cephalosporin antibiotic prophylaxis on the risk for PJI. Methods: Patients with a primary hip or knee replacement performed from 2012 to 2020 were identified (27 220 joint replacements). The primary outcome was the occurrence of a PJI in a one-year follow-up. The association between perioperative antibiotic prophylaxis and the outcome was examined using logistic regression analysis. Discussion: Cefuroxime was used as prophylaxis in 26,467 operations (97.2%), clindamycin in 654 (2.4%) and vancomycin in 72 (0.3%). The incidence of PJI was 0.86% (228/26,467) with cefuroxime and 0.80% (6/753) with other prophylactic antibiotics. There was no difference in the risk for PJI with different prophylactic antibiotics in the univariate (OR 1.06, 95% CI 0.47-2.39) or multivariable analysis (OR 1.02, 95% CI 0.45-2.30). Conclusion: Non-cephalosporin antibiotic prophylaxis in primary total joint replacement surgery was not associated with an increased risk for PJI.

Presence of Streptococcus pyogenes in the throat in invasive Group A Streptococcal disease: a prospective two-year study in two health districts, Finland.

PURPOSE: Streptococcus pyogenes (Group A Streptococcus, GAS) is an important human pathogen that can cause severe invasive (iGAS) infections. Throat carriage has been assumed to possibly lead to hematogenous seeding. Retrospective studies may estimate the incidence of throat carriage in iGAS patients inaccurately. In this study we aimed to gather data on the presence of GAS in the throat among iGAS patients in a prospective setting. METHODS: We conducted a prospective clinical study covering iGAS infections in adult patients in two university hospitals in Finland from June 2018 to July 2020. Recruited patients' throats were swabbed for culture and isothermal amplification tests (IAT) to search for GAS. The study was registered at ClinicalTrials.gov as ID NCT03507101. RESULTS: We enrolled 45 patients. Throat swabs were obtained from 39/45 (87%) patients. Ten patients (22%) had a positive IAT for GAS. They were statistically significantly more likely to be male (9/10 [90%] vs 13/29 [45%], p = .024). Several different emm types caused the iGAS infections. CONCLUSIONS: GAS was frequently observed in throat swabs of patients with iGAS infection. This may suggest that hematogenous seeding from the nasopharynx is a possible portal of entry.

Long-term follow up of families with pathogenic NFKB1 variants reveals incomplete penetrance and frequent inflammatory sequelae.

Nuclear factor κ light-chain enhancer of activated B cells (NF-κB) family of evolutionarily conserved transcription factors are involved in key cellular signaling pathways. Previously, hypogammaglobulinemia and common variable immunodeficiency (CVID)-like phenotypes have been associated with NFKB1 variants and loss-of-function NFKB1 variants have been reported as the most common monogenic cause for CVID among Europeans. Here, we describe a Finnish cohort of NFKB1 carriers consisting of 31 living subjects in six different families carrying five distinct heterozygous variants. In contrast to previous reports, the clinical penetrance was not complete even with advancing age and the prevalence of CVID/hypogammaglobulinemia was significantly lower, whereas (auto)inflammatory manifestations were more common (42% of the total cohort). At current stage of knowledge, routine genetic screening of asymptomatic individuals is not recommended, but counseling of potential adult carriers seems necessary.

Population-Based Assessment of Contact Tracing Operations for Coronavirus Disease 2019 in Pirkanmaa Hospital District, Finland.

Background: The coronavirus disease 2019 (COVID-19) epidemic overwhelmed local contact tracing (CT) efforts in many countries. In Finland, severe acute respiratory syndrome coronavirus 2 incidence and mortality were among the lowest in Europe during 2020-2021. We evaluated CT efficiency, effectiveness, and transmission settings. Methods: Polymerase chain reaction (PCR) test-positive COVID-19 cases and high-risk contacts in the population-based CT database of Pirkanmaa Hospital District (population 540 000) during June 2020-May 2021 were interviewed. Results: Altogether 353 926 PCR tests yielded 4739 (1.3%) confirmed cases (average 14-day case notification rate, 34 per 100 000 population); about 99% of confirmed cases and high-risk contacts were reached by a CT team. Of 26 881 high-risk contacts who were placed in quarantine, 2275 subsequently tested positive (48% of new cases), 825 (17%) had been in quarantine ≥48 hours before symptoms, and 3469 (77%) of locally acquired cases were part of transmission chains with an identified setting. The highest secondary attack rates were seen in households (31%), healthcare patients (18%), and private functions (10%). Among the 311 hospitalized patients, COVID-19 diagnosis or exposure was known in 273 (88%) before emergency room admission (identified patients). Healthcare workers had the highest proportion of work-related infections (159 cases [35%]). The source of infection was classifiable in 65% and was most commonly a coworker (64 cases [62%]). Conclusions: Our data demonstrate the role of effective testing and CT implementation during the cluster phase of COVID-19 spread. Although half of newly diagnosed cases were already in quarantine, targeted public health measures were needed to control transmission. CT effectiveness during widespread community transmission should be assessed.

Nasal nitric oxide is decreased in acute mild COVID-19 and related to viral load.

Gaseous nitric oxide levels from the lungs (FeNO) and from the nose (nNO) have been demonstrated to react to acute infection or influenza vaccination. There are no published data on nNO levels during acute COVID-19, but normal levels of FeNO have been reported in one study. Our aim was to assess if acute mild COVID-19 alters nasal or bronchial NO output at the time of acute infection and at a two-month follow up, and if this is related to symptoms or viral load. This study included 82 subjects with mild acute airway infection who did not need hospitalization: 43 cases (reverse transcription polymerase chain reaction (RT-PCR)-positive for SARS-CoV-2 in routine testing from nasopharynx) and 39 age- (±5 years) and gender-matched controls (RT-PCR-negative for SARS-CoV-2). During acute infection, the cases had lower nNO compared to controls (158 [104-206] vs. 232 [203-279] nl min-1;p< 0.001), but after two months, there was no significant difference between the groups (230 [179-290] vs. 268 [222-320] nl min-1;p= 0.162). There was no difference in FeNO between the groups at either of the visits. Nasal NO correlated with the cycle threshold (Ct) value of the nasopharyngeal RT-PCR test for SARS-CoV-2 (Spearman'srs= 0.550;p< 0.001), that is, nNO was lower with a higher viral load. Nasal NO output was decreased in acute COVID-19 in relation to higher viral load, suggesting that the type and intensity of inflammatory response affects the release of NO from airway mucosa. In these subjects without significant lower airway involvement, there were no clinically relevant findings regarding FeNO.

Alcohol Consumption and Its Influence on the Clinical Picture of Puumala Hantavirus Infection.

Puumala hantavirus (PUUV) causes hemorrhagic fever with renal syndrome. Characteristic clinical findings include acute kidney injury (AKI), thrombocytopenia, and capillary leakage. Smoking increases the risk of severe AKI, but it is not known whether alcohol consumption predisposes patients to a more severe infection. Liver and pancreatic enzymes, as well as biomarkers of alcohol consumption (gamma-glutamyl transferase, GGT; carbohydrate-deficient transferrin, CDT; GGT-CDT combination; and ethyl glucuronide, EtG), were measured from 66 patients with acute PUUV infection during hospitalization and at the convalescence phase. Alcohol consumption was present in 41% of the study population, 15% showing signs of heavy drinking. Alcohol use did not affect the severity of PUUV induced AKI nor the overall clinical picture of the infection. Liver enzyme levels (GGT or alanine aminotransferase, ALT) were elevated in 64% of the patients, but the levels did not associate with the markers reflecting the severity of the disease. Serum amylase activities at the convalescent stage were higher than those at the acute phase (p < 0.001). No cases with acute pancreatitis were found. In conclusion, our findings indicate that alcohol consumption does not seem to affect the clinical course of an acute PUUV infection.

Loss-of-function mutation in IKZF2 leads to immunodeficiency with dysregulated germinal center reactions and reduction of MAIT cells.

The Ikaros family transcription factors regulate lymphocyte development. Loss-of-function variants in IKZF1 cause primary immunodeficiency, but Ikaros family members IKZF2 and IKZF3 have not yet been associated with immunodeficiency. Here, we describe a pedigree with a heterozygous truncating variant in IKZF2, encoding the transcriptional activator and repressor Helios, which is highly expressed in regulatory T cells and effector T cells, particularly of the CD8+ T cell lineage. Protein-protein interaction analysis revealed that the variant abolished heterodimerization of Helios with Ikaros and Aiolos and also prevented Helios binding to members of the Mi-2/NuRD chromatin remodeling complex. Patients carrying the IKZF2 variant presented with a combined immunodeficiency phenotype characterized by recurrent upper respiratory infections, thrush and mucosal ulcers, and chronic lymphadenopathy. With extensive immunophenotyping, functional assays, and transcriptional analysis, we show that reduced Helios expression was associated with chronic T cell activation and increased production of proinflammatory cytokines both in effector and regulatory T cells. Lymph node histology from patients indicated dysregulated germinal center reactions. Moreover, affected individuals displayed a profound reduction in circulating MAIT cell numbers. In summary, we show that this previously undescribed loss-of-function variant in Helios leads to an immunodeficiency with signs of immune overactivation.

Infectious diseases specialist consultation in Staphylococcus lugdunensis bacteremia.

BACKGROUND: Commensal coagulase negative Staphylococcus lugdunensis may cause severe bacteremia (SLB) and complications. Treatment of SLB is not fully established and we wanted to evaluate if infectious diseases specialist consultation (IDSC) would improve management and prognosis. METHODS: Multicenter retrospective study of SLB patients followed for 1 year. Patients were stratified according to bedside (formal), telephone (informal) or lack of IDSC within 7 days of SLB diagnosis. RESULTS: Altogether, 104 SLB patients were identified: 24% received formal bedside and 52% informal telephone IDSC whereas 24% were managed without any IDSC. No differences in demographics, underlying conditions or severity of illness were observed between the groups. Patients with bedside IDSC, compared to telephone IDSC or lack of IDSC, had transthoracic echocardiography more often performed (odds ratio [OR] 4.00; 95% confidence interval [CI] 1.31-12.2; p = 0.012) and (OR 16.0; 95% CI, 4.00-63.9; P<0.001). Bedside IDSC was associated with more deep infections diagnosed compared to telephone IDSC (OR, 7.44; 95% CI, 2.58-21.4; p<0.001) or lack of IDSC (OR, 9.56; 95% CI, 2.43-37.7; p = 0.001). The overall mortality was 7%, 10% and 17% at 28 days, 90 days and 1 year, respectively. Considering all prognostic parameters, patients with IDSC, compared to lack of IDSC, had lower 90 days and 1 year mortality (OR, 0.11; 95% CI, 0.02-0.51; p = 0.005) and (OR, 0.22; 95% CI, 0.07-0.67; p = 0.007). CONCLUSION: IDSC may improve management and outcome of Staphylococcus lugdunensis bacteremia.

SARS-CoV-2 late shedding may be infectious between immunocompromised hosts.

BACKGROUND: Immunocompromised patients shed SARS-CoV-2 for extended periods, but to our knowledge person-to-person transmission from late shedding has not been reported. THE CASE: We present a case in which a COVID-19 patient infected another over 28 days after the patient's initial symptoms, past current guideline recommendations of 20 days for length of isolation in immunocompromised patients. Whole genome sequencing of their viruses was performed to ascertain the transmission. DISCUSSION: Severely immunocompromised patients, whose clearance of the virus is impaired, may remain infectious for extended periods. Caution should be taken particularly in hospital settings where lapses in isolation procedures might pose increased risk, especially to other immunocompromised patients.

Healthcare-associated blood stream infections in hematological patients in Finland during the years 2006-2016.

OBJECTIVES: The aim was to identify the clinical characteristics, outcome, and antimicrobial susceptibility of healthcare-associated bloodstream infections (BSIs) in hematological patients. METHODS: This retrospectively collected laboratory-based surveillance data include 3404 healthcare-associated BSIs in 2296 patients with a hematological malignancy in hospitals participating in the Finnish Hospital Infection Program from January 1, 2006, to December 31, 2016. RESULTS: The most common underlying diseases were acute myelogenous leukemia (35%) and non-Hodgkin lymphoma (22%). Gram-positive organisms accounted for 60%-46% and gram-negative organisms for 24%-36% of BSIs in 2006-2016. The most common causative organism was coagulase-negative staphylococci (CoNS) (n = 731). The 7- and 28-day case fatality rates were 5.2% and 11.4%, respectively, and was highest in BSIs caused by Candida species (10.8% and 30.8%). The median age of patients increased from 59 years in 2006-2008 to 62 years in 2015-2016 (P < .01). Five percent of S aureus isolates were resistant to methicillin and five percent of Pseudomonas aeruginosa isolates were multidrug-resistant. Four percent of Klebsiella and seven percent of E coli isolates were resistant to ceftazidime. CONCLUSIONS: The proportion of gram-positive bacteria decreased and gram-negative bacteria increased over time. The case fatality rate was low and the median age of patients increased during the study.

Periprosthetic Joint Infections as a Consequence of Bacteremia.

BACKGROUND: The risk for developing a periprosthetic joint infection (PJI) during bacteremia is unclear, except for Staphylococcus aureus bacteremia. The aim of this study was to examine the risk for developing a PJI during bacteremia and to identify possible risk factors leading to it. METHODS: Patients with a primary knee or hip joint replacement performed in a tertiary care hospital between September 2002 and December 2013 were identified (n = 14 378) and followed up until December 2014. Positive blood culture results during the study period and PJIs were recorded. PJIs associated with an episode of bacteremia were identified and confirmed from patient records. Potential risk factors for PJI among those with bacteremia were examined using univariate logistic regression. RESULTS: A total of 542 (3.8%) patients had at least 1 episode of bacteremia. Seven percent (47/643) of the bacteremias resulted in a PJI. Development of a PJI was most common for Staphylococcus aureus (21% of bacteremias led to a PJI) and beta-hemolytic streptococci (21%), whereas it was rare for gram-negative bacteria (1.3%). Having ≥2 bacteremias during the study period increased the risk for developing a PJI (odds ratio, 2.29; 95% confidence interval, 1.17-4.50). The risk for developing a PJI was highest for bacteremias occurring within a year of previous surgery. Chronic comorbidities did not affect the risk for PJI during bacteremia. CONCLUSIONS: The development of a PJI during bacteremia depends on the pathogen causing the bacteremia and the timing of bacteremia with respect to previous joint replacement surgery. However, significant patient-related risk factors for PJI during bacteremia could not be found.

Spa type distribution in MRSA and MSSA bacteremias and association of spa clonal complexes with the clinical characteristics of bacteremia.

The genetic distribution of invasive methicillin-susceptible (MSSA) and resistant S. aureus (MRSA) strains has to be addressed in order to target infection control strategies. A large MRSA epidemic caused by a certain MRSA strain (spa type 067) broke out in 2001 in our health district. We wanted to investigate the current spa type distribution in MRSA and MSSA bacteremias and assess the potential association of spa clonal complexes (spaCC) with the clinical characteristics of S. aureus bacteremia. One hundred nine invasive MRSA isolates and 353 invasive MSSA isolates were spa typed and grouped into clonal complexes (spaCC). Spa type distribution was compared to that of colonizing MRSA strains. Spa type and spaCC data linked to clinical information on the course of bacteremic cases was used to search for differences in virulence between strains. Spa type distribution in MRSA is less heterogenic than in MSSA. t067 dominates both in MRSA colonisations and in invasive findings. Among MSSA, no such dominating strains were found. Of spaCCs, mortality was the highest in spaCC 067 (25.6%). SpaCC 008 was more often associated with endocarditis than other CCs (22.7 vs 5.8%, p = 0.013), spaCC 2133 with skin infections (68.4 vs 36.4%, p = 0.007), and spaCC 012 with foreign body infections (25.0 vs 9.3%, p = 0.029) than other clonal complexes. A single successful strain can explain the major proportion of MRSA among S. aureus bacteremias. Certain spaCCs showed association with certain clinical characteristics. These findings suggest that S. aureus strains differ in their virulence and invasiveness.

Trends in incidence and resistance patterns of Staphylococcus aureus bacteremia.

BACKGROUND: Staphylococcus aureus bacteremia (SAB) causes a significant burden on the population. Several infection control measures have been implemented in Pirkanmaa county to combat a local epidemic with methicillin-resistant Staphylococcus aureus (MRSA). We aimed to study the epidemiology of SAB and antibiotic resistance of S. aureus and the possible influence of improved infection control. METHODS: Register data from 2005 to 2015 were retrospectively analysed to study the antimicrobial susceptibility, the incidence and mortality in SAB in a population-based setting. RESULTS: The incidence of SAB increased during the study period from 21.6 to 35.8/100,000 population. The number of both health care-associated (HA) and community-associated (CA) cases has increased. The incidence of MSSA bacteremia increased from 19.9 to 35.2/100,000 population in Pirkanmaa in parallel to other parts of Finland. The incidence of MRSA bacteremia was 10-fold (4.5/100,000 population) higher in 2011 than in other parts of the country, but sank to the national level (0.59/100,000 population) in 2015. The fatality rate decreased from 22% to 17%. The proportion of penicillin-susceptible Staphylococcus aureus (PSSA) increased from 23.9% in 2008 to 43.1% in 2015. CONCLUSION: The incidence of both HA and CA SAB has increased since 2005. Conversely, the proportion of MRSA and PRSA bacteremia has decreased. Promotion of infection control measures may have reduced the incidence of MRSA bacteremia but not the overall incidence of SAB. The rising proportion of PSSA enables the use of targeted, narrow spectrum antimicrobials.

A Serratia marcescens outbreak in a neonatal intensive care unit was successfully managed by rapid hospital hygiene interventions and screening.

AIM: Serratia marcescens is a rare, but important, pathogen in hospital-acquired infections, especially in neonatal units. Outbreaks may cause significant mortality among neonates. This study describes how an outbreak of S. marcescens was handled in a neonatal intensive care unit in Finland in June 2015. METHODS: Tampere University Hospital is the only hospital that offers intensive care for preterm neonates in the Pirkanmaa health district area in Finland. Between June 9, 2015 and June 29, 2015, seven neonates were screened positive for S. marcescens in the hospital. We examined the management and outcomes, including environmental sampling. RESULTS: Two of the seven neonates developed a bloodstream infection, and one with S. marcescens sepsis died after six days of antibiotic treatment. The outbreak was rapidly managed with active hospital hygiene interventions, including strict hand hygiene, cleaning, patient screening, contact precautions and education. Environmental sampling was limited to one water tap and a ventilator, and the results were negative. The outbreak was contained within three weeks, and no further cases appeared. The screening of healthcare workers was not necessary. CONCLUSION: A S. marcescens outbreak caused significant morbidity in neonates and one death. Rapid hospital hygiene interventions and patient screening effectively contained the outbreak.