Molecular Epidemiology of Ceftriaxone Non-Susceptible Enterobacterales Isolates in an Academic Medical Center in the United States.

BACKGROUND: Knowledge of whether Enterobacterales are not susceptible to ceftriaxone without understanding the underlying resistance mechanisms may not be sufficient to direct appropriate treatment decisions. As an example, extended-spectrum ß-lactamase (ESBL)-producing organisms almost uniformly display non-susceptibility to ceftriaxone. Regardless of susceptibility to piperacillin-tazobactam or cefepime, carbapenem antibiotics are the treatment of choice for invasive infections. No such guidance exists for ceftriaxone non-susceptible organisms with mechanisms other than ESBL production. We sought to investigate the molecular epidemiology of ceftriaxone non-susceptible Enterobacterales. METHODS: All consecutive Escherichia coli, Klebsiellapneumoniae, Klebsiella oxytoca, or Proteus mirabilis clinical isolates with ceftriaxone MICs of ≥2 mcg/mL from unique patients at a United States hospital over an 8-month period were evaluated for ß-lactamase genes using a DNA microarray-based assay. RESULTS: Of 1929 isolates, 482 (25%) had ceftriaxone MICs of ≥2 mcg/mL and were not resistant to any carbapenem antibiotics. Of the 482 isolates, ESBL (blaCTX-M, blaSHV, blaTEM) and/or plasmid-mediated ampC (p-ampC) genes were identified in 376 (78%). ESBL genes were identified in 310 (82.4%), p-ampC genes in 2 (0.5%), and both ESBL and p-ampC genes in 64 (17.0%) of the 376 organisms. There were 211 (56%), 120 (32%), 41 (11%), and 4 (1%) isolates with 1, 2, 3, or 4 or more ESBL or p-ampC genes. The most common ESBL genes were of the blaCTX-M-1 group (includes blaCTX-M-15) and the most common p-ampC gene was the blaCMY-2. CONCLUSIONS: There is considerable diversity in the molecular epidemiology of ceftriaxone non-susceptible Enterobacterales. An understanding of this diversity can improve antibiotic decision-making.

Sextuplet heterotopic pregnancy presenting as ovarian hyperstimulation syndrome and hemoperitoneum.

OBJECTIVE: To describe a case of bilateral ruptured heterotopic pregnancies presenting as persistent ovarian hyperstimulation syndrome in a quadruplet pregnancy. DESIGN: Case report. SETTING: University hospital and clinic. PATIENT(S): An infertile patient who conceived using gonadotropin therapy. INTERVENTION(S): Culdocentesis with resultant aspiration of sanguinous fluid prompted laparoscopic exploration and bilateral salpingectomies. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): Gross hemoperitoneum and ruptured bilateral heterotopic sextuplet pregnancy. CONCLUSION(S): Patients who conceive after gonadotropin therapy should be closely monitored during treatment and in early pregnancy to recognize and minimize morbidity and complications. After superovulation, the presence of an intrauterine pregnancy, either single or multiple, does not rule out the possibility of ectopic pregnancy, and this should always be considered as a possibility in the setting of acute anemia.

The effect of air bubble position after blastocyst transfer on pregnancy rates in IVF cycles.

OBJECTIVE: To investigate the relationship between air bubble position after blastocyst transfer (BT) and pregnancy rates (PRs). DESIGN: Retrospective cohort study. SETTING: University-based infertility center. PATIENT(S): Three hundred fifteen consecutive nondonor BTs by a single provider. INTERVENTION(S): Catheters were loaded with 25 µL of culture media, 20 µL of air, 25 µL of media containing the blastocysts, 20 µL of air, and a small amount of additional media. The distance from the air bubble to the fundus, as seen on abdominal ultrasound examination, was measured at the time of transfer. Air bubble location was categorized as <10 mm, 10-20 mm, and >20 mm from the fundus. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate. RESULT(S): After controlling for age, parity, FSH and frozen transfers, and accounting for repeated cycles per patient, the PRs for both the >20-mm (38.3%) and the 10-20-mm (42.0%) from the fundus group were significantly reduced compared with the group in which the bubble was <10 mm from the fundus (62.5%). CONCLUSION(S): This study is the first to suggest that BT closer to the fundus is associated with higher PR. Although no ectopic pregnancies occurred in the <10-mm group, this outcome should be monitored closely in larger studies.