Spread of Enterobacter cloacae carrying blaNDM-1, blaCTX-M-15, blaSHV-12 and plasmid-mediated quinolone resistance genes in a surgical intensive care unit in Croatia.

The objective of this study was to describe a hospital cluster of NDM-1-producing Enterobacter cloacae infections observed in the surgical intensive care unit (ICU) of a tertiary-care hospital at Pula, Croatia. NDM-1-producing E. cloacae strains isolated from clinical samples were screened by PCR for the presence of carbapenemases. Genetic relatedness of NDM-1-producing E. cloacae strains was determined by multilocus sequence typing (MLST). During the period October 2013 to April 2014, four patients, with overlapping hospital stay in the surgical ICU, developed severe infections caused by E. cloacae demonstrated to produce carbapenemases. According to MLST, all strains belonged to ST133 and were positive by PCR for the blaNDM-1 carbapenemase gene, for blaCTX-M-15 and blaSHV-12 extended-spectrum ß-lactamase (ESBL) genes, and for blaTEM-1 and blaOXA-1 narrow-spectrum ß-lactamase genes. They were negative for other carbapenemases genes including blaOXA-48, blaVIM and blaKPC as well as for AmpC and the armA and rmtB aminoglycoside resistance genes. All strains were positive for the HI2 replicon, suggesting that an IncHI2 plasmid is likely the plasmid carrying the blaNDM-1 gene. Infection control measures were implemented after the first case although they were not effective in avoiding spread of this organism to other patients in the surgical ICU. In conclusion, the evolving epidemiology of NDM-producing micro-organisms and the interspecies diffusion of this resistance mechanism to emerging pathogens such as E. cloacae necessitate the setting up of strong and urgent joint measures to control the spread of NDM carbapenemase especially in the ICU setting.

Carbapenem resistance and acquired class D beta-lactamases in Acinetobacter baumannii from Croatia 2009-2010.

The molecular epidemiology and the genetic basis of carbapenem resistance was investigated in 185 Acinetobacter baumannii isolates obtained from 13 centers of northern Croatia and Istria during 2009-2010. All isolates were multidrug-resistant, and 35 % (n = 64) were resistant to both imipenem and meropenem. ISAba1-driven overexpression of the intrinsic bla OXA-51-like gene was observed in all carbapenem resistant isolates, and 69 % of these (n = 44) also produced acquired OXA-type carbapenemases. The presence of bla OXA-58-like, bla OXA-24/40-like, and bla OXA-23-like genes was demonstrated in 33 % (n = 21), 27 % (n = 17) and 9 % (n = 6) of carbapenem-resistant isolates, respectively. None of the isolates harbored the bla IMP, bla VIM, bla SIM, bla NDM or bla PER ß-lactamase genes, while bla TEM-1 was detected in five carbapenem- and ampicillin/sulbactam-resistant isolates. Sequence group determination showed a high prevalence (81 %) of isolates belonging to the International clonal lineage (ICL)-I, although the majority (80 %) of isolates carrying acquired carbapenemase genes belonged to the ICL-II. Random amplified polymorphic DNA analysis and multilocus-sequence typing of a subset of carbapenem-resistant isolates revealed a low degree of genetic variability within both ICL-I and ICL-II populations, irrespective of the genetic basis of carbapenem resistance. Overall, an increasing trend toward carbapenem resistance was observed for A. baumannii in Croatia, and the emergence of ICL-II strains producing a variety of acquired carbapenemases.

Local application of mupirocin ointment in the eradication of Staphylococcus aureus from nasal mucosa in patients on chronic hemodialysis.

Efficacy of locally applied mupirocin in the elimination of Staphylococcus aureus (SA) from the nasal mucosa in patients on maintenance hemodialysis was studied. SA was isolated in 27 patients (33.3% of the population of dialysis patients) and trials were carried out in 25 patients by applying a 2% mupirocin ointment for five days. The eradication amounted to 92% immediately upon therapy completion, and to 84%, 56%, 52% and 32% after 1, 2, 3 and 9 months. All SA strains isolated before and after the treatment were sensitive to mupirocin. The authors believe that mupirocin is efficient in the elimination of SA from nasal mucosa, however, control swabs should be periodically taken at two-month intervals.

Continuous hemofiltration in patients with acute renal failure.

Many intensive care unit (ICU) patients with acute renal failure (ARF) have multiple organ failure (MOF) and cardiovascular instability. Continuous hemofiltration (CH) is a widely accepted technique for the treatment of such critically ill patients. The authors treated ten patients with ARF and MOF. Continuous arteriovenous hemofiltration (CAVH) and venovenous hemofiltration (CVVH) were performed in five patients each. The mean duration of treatment was 88.6 +/- 82.8 h and the mean ultrafiltrate rate 392 +/- 272 ml/min. Serum urea i creatinine were stable, with good control of fluid balance. Only two of our patients survived: one of them recovered renal function and the other required chronic hemodialysis (HD). CVVH offered better control of blood flow and ultrafiltration rate, longer hemofilter use and has the advantage of requiring only venous access.