TRACHEOBRONCHIAL MORPHOMETRY CORRELATES WITH DEMOGRAPHIC CHARACTERISTICS AND INFECTIONS IN CRITICALLY ILL PATIENTS.

Tracheal measurements in the intensive care unit (ICU) are important for the choice of endotracheal tube and may correlate with patient demographic characteristics and infections. The study included 42 surgical patients, age 60 [48-71] years, who underwent diagnostic chest computed tomography (CT) scans during treatment in the ICU, Osijek University Hospital, in 2019 and 2020. CT scans were analyzed using AW Server 3.2. Measurement analysis showed that the diameters of the tracheobronchial tree, the length of the trachea and left main bronchus were significantly larger in men compared to women (p<0.05 all). The smallest tracheal upper diameter was 15.25 [IQR 11.8-18.8] mm vs. 17.95 [13.55-20.05] mm in septic and nonseptic patients, respectively (p=0.028). A total of 26 patients who underwent CT scans developed nosocomial pneumonia. It was right-sided in 15, left-sided in 6 and bilateral in 5 patients, and correlated significantly with the left main bronchus length (ρ=0.515, p=0.007). No correlation was observed between tracheobronchial measurements and length of ICU treatment, number of hours spent on mechanical ventilation, or survival. A larger study could provide better data on the importance of tracheobronchial tree measurements in ICU patients.

Colonisation with extended spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in children admitted to a paediatric referral hospital in South Africa.

INTRODUCTION: There are few studies describing colonisation with extended spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) and carbapenem-resistant Enterobacterales (CRE) among children in sub-Saharan Africa. Colonisation often precedes infection and multi-drug-resistant Enterobacterales are important causes of invasive infection. METHODS: In this prospective cross-sectional study, conducted between April and June 2017, 200 children in a tertiary academic hospital were screened by rectal swab for EBSL-PE and CRE. The resistance-conferring genes were identified using polymerase chain reaction technology. Risk factors for colonisation were also evaluated. RESULTS: Overall, 48% (96/200) of the children were colonised with at least one ESBL-PE, 8.3% (8/96) of these with 2 ESBL-PE, and one other child was colonised with a CRE (0.5% (1/200)). Common colonising ESBL-PE were Klebsiella pneumoniae (62.5%, 65/104) and Escherichia coli (34.6%, 36/104). The most frequent ESBL-conferring gene was blaCTX-M in 95% (76/80) of the isolates. No resistance- conferring gene was identified in the CRE isolate (Enterobacter cloacae). Most of the Klebsiella pneumoniae isolates were susceptible to piperacillin/tazobactam (86.2%) and amikacin (63.9%). Similarly, 94.4% and 97.2% of the Escherichia coli isolates were susceptible to piperacillin/tazobactam and amikacin, respectively. Hospitalisation for more than 7 days before study enrolment was associated with ESBL-PE colonisation. CONCLUSION: Approximately half of the hospitalised children in this study were colonised with ESBL-PE. This highlights the need for improved infection prevention and control practices to limit the dissemination of these microorganisms.

COVID-19 in lung transplant recipients.

Solid organ transplant recipients are considered at high risk for COVID-19 infection due to chronic immune suppression; little data currently exists on the manifestations and outcomes of COVID-19 infection in lung transplant recipients. Here we report 8 cases of COVID-19 identified in patients with a history of lung transplant. We describe the clinical course of disease as well as preexisting characteristics of these patients.

Comparison Between Healthcare-Associated and Community-Acquired Infective Endocarditis at Tertiary Care Hospitals in Japan.

BACKGROUND: Healthcare-associated infective endocarditis (HAIE) has become increasingly recognized worldwide because the underlying patient conditions are completely different from those of community-acquired infective endocarditis (CIE). However, data on HAIE in the Japanese population is lacking. We sought to clarify the patient characteristics and prognosis of HAIE in a Japanese population.Methods and Results:A retrospective study was conducted in 158 patients who were diagnosed with infective endocarditis, 53 of whom (33.5%) were classified as HAIE. Compared with patients with CIE, those with HAIE were older (median age 72 vs. 61 years; P=0.0002) and received surgical treatment less frequently (41.5% vs. 62.9%; P=0.01). Regarding causative microorganisms, staphylococci,including methicillin-resistant pathogens, were more common in patients with HAIE (32.1% vs. 14.3%; P=0.01). Patients with HAIE had higher in-hospital mortality (32.1% vs. 4.8%; P<0.0001) and Kaplan-Meier analysis showed worse prognosis for patients with HAIE than CIE (P<0.0001, log-rank test). On multivariate Cox analysis, HAIE (hazard ratio 3.26; 95% confidence interval 1.49-7.14), age ≥60 years, surgical treatment, stroke, and heart failure were independently associated with mortality. CONCLUSIONS: HAIE has different clinical characteristics and causative microorganisms, as well as worse prognosis, than CIE. Preventive strategies, and the prompt and appropriate identification of HAIE may improve the outcome of infective endocarditis.

Positron Emission Tomography Imaging with 2-[18F]F- p-Aminobenzoic Acid Detects Staphylococcus aureus Infections and Monitors Drug Response.

Staphylococcus aureus is the leading cause of life-threatening infections, frequently originating from unknown or deep-seated foci. Source control and institution of appropriate antibiotics remain challenges, especially with infections due to methicillin-resistant S. aureus (MRSA). In this study, we developed a radiofluorinated analog of para-aminobenzoic acid (2-[18F]F-PABA) and demonstrate that it is an efficient alternative substrate for the S. aureus dihydropteroate synthase (DHPS). 2-[18F]F-PABA rapidly accumulated in vitro within laboratory and clinical (including MRSA) strains of S. aureus but not in mammalian cells. Biodistribution in murine and rat models demonstrated localization at infection sites and rapid renal elimination. In a rat model, 2-[18F]F-PABA positron emission tomography (PET) rapidly differentiated S. aureus infection from sterile inflammation and could also detect therapeutic failures associated with MRSA. These data suggest that 2-[18F]F-PABA has the potential for translation to humans as a rapid, noninvasive diagnostic tool to identify, localize, and monitor S. aureus infections.

Quality improvement program of adult urinary tract infection management: Review and impact.

OBJECTIVE: A quality improvement program for adult urinary tract infection management was established to avoid unnecessary antibiotic treatment and to promote adequate prescription, associated with financial and time savings. METHODS: Management was integrated into a three-step approach: clinical diagnosis, bacteriological diagnosis, and therapeutic decision. For each step, areas for improvement were prioritized and implemented through corrective measures and key messages, measured by indicators. This program was applied to the whole hospital, which includes an emergency department and hospital units (672 beds). RESULTS: The diffusion of new recommendations on clinical diagnosis helped limit the use of Urine Dipstick Tests (UDT) and identify situations requiring the prescription of urine cytobacteriological test (UCBE) and antibiotic treatment: decreased annual consumption of UDTs (34%) and UCBEs (25%). The implementation of a new sampling system for UCBEs was associated with a 21% increase in conclusive analysis. Results of antimicrobial susceptibility testing were also optimized. Trainings on the proper use of antibiotics led to a 5.0% decline in global consumption. Only 23 antibiotic prescriptions for UTI resulted in pharmaceutical advice to prescribers in 2014. CONCLUSION: The program is part of a practice improvement strategy. Integrating the management of urinary tract infections into a global process helped improve each step of patient management.

Bacteriological incidence in pneumonia patients with pulmonary emphysema: a bacterial floral analysis using the 16S ribosomal RNA gene in bronchoalveolar lavage fluid.

Pulmonary emphysema is an important radiological finding in chronic obstructive pulmonary disease patients, but bacteriological differences in pneumonia patients according to the severity of emphysematous changes have not been reported. Therefore, we evaluated the bacteriological incidence in the bronchoalveolar lavage fluid (BALF) of pneumonia patients using cultivation and a culture-independent molecular method. Japanese patients with community-acquired pneumonia (83) and healthcare-associated pneumonia (94) between April 2010 and February 2014 were evaluated. The BALF obtained from pneumonia lesions was evaluated by both cultivation and a molecular method. In the molecular method, ~600 base pairs of bacterial 16S ribosomal RNA genes in the BALF were amplified by polymerase chain reaction, and clone libraries were constructed. The nucleotide sequences of 96 randomly selected colonies were determined, and a homology search was performed to identify the bacterial species. A qualitative radiological evaluation of pulmonary emphysema based on chest computed tomography (CT) images was performed using the Goddard classification. The severity of pulmonary emphysema based on the Goddard classification was none in 47.4% (84/177), mild in 36.2% (64/177), moderate in 10.2% (18/177), and severe in 6.2% (11/177). Using the culture-independent molecular method, Moraxella catarrhalis was significantly more frequently detected in moderate or severe emphysema patients than in patients with no or mild emphysematous changes. The detection rates of Haemophilus influenzae and Pseudomonas aeruginosa were unrelated to the severity of pulmonary emphysematous changes, and Streptococcus species - except for the S. anginosus group and S. pneumoniae - were detected more frequently using the molecular method we used for the BALF of patients with pneumonia than using culture methods. Our findings suggest that M. catarrhalis is more frequently detected in pneumonia patients with moderate or severe emphysema than in those with no or mild emphysematous changes on chest CT. M. catarrhalis may play a major role in patients with pneumonia complicating severe pulmonary emphysema.

Nosocomial legionellosis and invasive aspergillosis in a child with T-lymphoblastic leukemia.

Invasive aspergillosis of the lungs and the central nervous system and Legionella pneumophilia serotype 1 infection of the lungs were diagnosed in a 22-month old child during inpatient induction treatment for T-lymphoblastic leukemia. Environmental investigations i.e. samples from the hospital water system did not reveal any Legionella. The patient may have been exposed to waterborne pathogens despite terminal water filtration due to a technical device to release residual tap water from the hose after showering. A sodium chloride nose spray was found to be contaminated with the A. fumigatus isolate of the patient.

Hospital-acquired Urinary Tract Infections in Neonatal ICU Patients: Is Voiding Cystourethrogram Necessary?

OBJECTIVE: To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed with hospital-acquired urinary tract infection (UTI). MATERIALS AND METHODS: Children with no preexisting genitourinary anomalies undergoing a voiding cystourethrogram (VCUG) for culture-documented UTI during NICU admission were identified. Demographics, microbiology results, and imaging findings were evaluated. RESULTS: A total of 147 NICU patients underwent VCUG during the study period. Of these, the indication for VCUG was UTI in 58 children. Neonates diagnosed with UTI were born at a mean gestational age of 28 3/7 ± 4 3/7 weeks, and underwent VCUG at a mean of age of 70.3 ± 42 days. Urine culture grew Enterococcus in 32 (55.2%), Enterobacter in 6 (10.3%), coagulase negative staphylococcus in 6 (10.3%), Escherichia coli in 5 (8.7%), and other in 9 infants (15.5%). All patients underwent a retroperitoneal ultrasound, which was read as normal in 31 patients (53.4%). Fourteen children (24.1%) diagnosed with UTI were found to have vesicoureteral reflux on VCUG. On univariate analysis, no patient characteristics were associated with VCUG positivity. On multivariate analysis, the effect of age at VCUG differed by renal-bladder ultrasound results. Patients with an abnormal ultrasound were 3.6 (95% confidence interval, 1.39-9.24) times more likely to have a positive VCUG for every 1 month increase in age. CONCLUSION: Ultrasound anomalies are common in NICU patients diagnosed with UTI. The effect of age at VCUG differed by ultrasound result; the probability of vesicoureteral reflux in infants with sonographic abnormalities and UTI increases with age.

Radiographic evaluation of nursing- and healthcare-associated pneumonia.

AIM: Radiographic testing has an important role in the diagnosis and evaluation of pneumonia. The aim of the present study was to evaluate the usefulness of computed tomography (CT), in comparison with chest roentography (CR), in the diagnosis and evaluation of nursing- and healthcare-associated pneumonia (NHCAP) . METHODS: The utility of CT in the diagnosis of NHCAP was compared with that of CR in a prospective study of patients who visited the emergency room in Nissan Tamagawa Hospital, Tokyo, Japan, with clinical symptoms that were indicative of NHCAP. We also evaluated whether particular CT findings were risk factors for NHCAP-associated mortality. RESULTS: A total of 162 patients with suspected NHCAP were included in the study. The 162 patients included 147 (90.6%) patients who were diagnosed with NHCAP based on the detection of pneumonic infiltration on CT. In contrast, CR was not capable of recognizing pneumonic infiltration in 15 of the 147 (10.2%) patients. A multivariable analysis which was carried out to determine the risk factors for NHCAP-associated mortality, showed that oxygen desaturation had the greatest odds ratio, followed by a blood urea nitrogen level of ≥21 mg/dL and the detection of bilateral pneumonic infiltration by CT. CONCLUSIONS: We herein show that CT is superior to CR for the diagnosis and evaluation of NHCAP. The present study will provide a foundation for further studies to clarify whether the use of CT in the diagnosis and evaluation of NHCAP can improve the clinical outcome of patients with NHCAP. Geriatr Gerontol Int 2017; 17: 41-47.

[Nosocomial pneumonia from a radiological perspective]. / Nosokomiale Pneumonie aus radiologischer Sicht.

Due to the high morbidity and mortality, nosocomial pneumonia represents a serious risk in hospitalized patients. The increased risk of infections with multidrug-resistant (MDR) pathogens makes a timely diagnosis and prompt therapy indispensable. A newly occurring or progressive infiltrate in any patient who has been hospitalized for more than 48 h should be viewed with suspicion. In contrast to community acquired pneumonia (CAP), radiography plays a limited role in the diagnosis of hospital-acquired pneumonia (HAP). This is partly due to the technical challenges in imaging of patients who are in a lying position as well as the numerous other possible differential diagnoses. Careful analysis of the various radiological features, such as temporal progression, distribution and appearance can help to narrow down the differential diagnoses. In the absence of a single gold standard, clinical features and appropriate radiological features in addition to cultures obtained from respiratory secretions can help to maximize the diagnostic efficacy and expedite the treatment with appropriate antibiotic therapy.

[Clostridium difficile infections in geriatric patients]. / Clostridium-difficile-Infektion bei geriatrischen Patienten.

Clostridium difficile is the main cause of nosocomial antibiotic-associated diarrhea in adults in Europe and North America. Infections with C. difficile typically occur in elderly patients with comorbidities and prior antibiotic therapy. Other risk factors are proton pump inhibitors, which are taken by many elderly patients. The main virulence factors are toxins A and B. The clinical spectrum ranges from asymptomatic colonization to severe disease with abdominal complications and sepsis. The current diagnostic gold standard is anaerobic culture but is impractical in routine use due to the long duration. Proven techniques involve glutamate dehydrogenase, toxins A and B immunoassays and PCR. First infections and recurrences can be treated with 400-500 mg metronidazole 3 times a day for 10 days. Further recurrences, serious infections or patients with more than two positive predictors should be treated orally with 125 mg vancomycin 4 times a day for at least 10 days. Fidaxomicin, rifaximin, stool transplantation and monoclonal antibodies are promising alternative therapies.

Control of an Outbreak of Middle East Respiratory Syndrome in a Tertiary Hospital in Korea.

BACKGROUND: In 2015, a large outbreak of Middle East respiratory syndrome (MERS) occurred in the Republic of Korea. Half of the cases were associated with a tertiary care university hospital. OBJECTIVE: To document the outbreak and successful control measures. DESIGN: Descriptive study. SETTING: A 1950-bed tertiary care university hospital. PATIENTS: 92 patients with laboratory-confirmed MERS and 9793 exposed persons. MEASUREMENTS: Description of the outbreak, including a timeline, and evaluation of the effectiveness of the control measures. RESULTS: During the outbreak, 92 laboratory-confirmed MERS cases were associated with a large tertiary care hospital, 82 of which originated from unprotected exposure to 1 secondary patient. Contact tracing and monitoring exposed patients and assigned health care workers were at the core of the control measures in the outbreak. Nontargeted screening measures, including body temperature screening among employees and visitors at hospital gates, monitoring patients for MERS-related symptoms, chest radiographic screening, and employee symptom monitoring, did not detect additional patients with MERS without existing transmission links. All in-hospital transmissions originated from 3 patients with MERS who also had pneumonia and productive cough. LIMITATIONS: This was a retrospective single-center study. Statistical analysis could not be done. Because this MERS outbreak originated from a superspreader, effective control measures could differ in endemic areas or in other settings. CONCLUSION: Control strategies for MERS outbreaks should focus on tracing contacts of persons with epidemiologic links. Adjusting levels of quarantine and personal protective equipment according to the assumed infectivity of each patient with MERS may be appropriate. PRIMARY FUNDING SOURCE: Samsung Biomedical Research Institute.

Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery.

OBJECTIVE: Surgical site infection (SSI) is the most common nosocomial infection, in vascular surgery patients, who experience a high rate of readmission. Facilitating transition from hospital to outpatient care with digital image-based wound monitoring has the potential to detect and to enable treatment of SSI at an early stage. In this study, we evaluated whether smartphone digital images can supplant in-person evaluation of postoperative vascular surgery wounds. METHODS: We developed a wound assessment checklist using previously validated criteria. We recruited adults who underwent a vascular surgical procedure between 2014 and 2015, involving an incision of at least 3 cm, from a high-volume academic vascular surgery service. Vascular surgery care providers evaluated wounds in person using the assessment checklist; a different group of providers evaluated wounds by a smartphone digital image. Inter-rater agreement coefficients for wound characteristics and treatment plan were calculated within and between the in-person group and the digital image group; the sensitivity and specificity of digital images relative to in-person evaluation were determined. RESULTS: We assessed a total of 80 wounds. Regardless of modality, inter-rater agreement was poor when wounds were evaluated for the presence of ecchymosis and redness; moderate for cellulitis; and high for the presence of a drain, necrosis, or dehiscence. As expected, the presence of drainage was more readily observed in person. Inter-rater agreement was high for both in-person and image-based assessment with respect to course of treatment, with near-perfect agreement for treatments ranging from antibiotics to surgical débridement to hospital readmission. No difference in agreement emerged when raters evaluated poor-quality compared with high-quality images. For most parameters, specificity was higher than sensitivity for image-based compared with "gold standard" in-person assessment. CONCLUSIONS: Using smartphone digital images is a valid method for evaluating postoperative vascular surgery wounds and is comparable to in-person evaluation with regard to most wound characteristics. The inter-rater reliability for determining treatment recommendations was universally high. Remote wound monitoring and assessment may play an integral role in future transitional care models to decrease readmission for SSI in vascular or other surgical patients. These findings will inform smartphone implementation in the clinical care setting as wound images transition from informal clinical communication to becoming part of the care standard.

Intracranial complications of Serratia marcescens infection in neonates.

Even though Serratia marcescens is not one of the most common causes of infection in neonates, it is associated with grave morbidity and mortality. We describe the evolution of brain parenchymal affectation observed in association with S. marcescens infection in neonates. This retrospective case series details brain ultrasound findings of five neonates with hospital-acquired S. marcescens infection. Neonatal S. marcescens infection with or without associated meningitis can be complicated by brain parenchymal affectation, leading to cerebral abscess formation. It is recommended that all neonates with this infection should undergo neuro-imaging more than once before discharge from hospital; this can be achieved using bedside ultrasonography.

Internal and External Validation of a multivariable Model to Define Hospital-Acquired Pneumonia After Esophagectomy.

BACKGROUND: Pneumonia is an important complication following esophagectomy; however, a wide range of pneumonia incidence is reported. The lack of one generally accepted definition prevents valid inter-study comparisons. We aimed to simplify and validate an existing scoring model to define pneumonia following esophagectomy. PATIENTS AND METHODS: The Utrecht Pneumonia Score, comprising of pulmonary radiography findings, leucocyte count, and temperature, was simplified and internally validated using bootstrapping in the dataset (n = 185) in which it was developed. Subsequently, the intercept and (shrunk) coefficients of the developed multivariable logistic regression model were applied to an external dataset (n = 201) RESULTS: In the revised Uniform Pneumonia Score, points are assigned based on the temperature, the leucocyte, and the findings of pulmonary radiography. The model discrimination was excellent in the internal validation set and in the external validation set (C-statistics 0.93 and 0.91, respectively); furthermore, the model calibrated well in both cohorts. CONCLUSION: The revised Uniform Pneumonia Score (rUPS) can serve as a means to define post-esophagectomy pneumonia. Utilization of a uniform definition for pneumonia will improve inter-study comparability and improve the evaluations of new therapeutic strategies to reduce the pneumonia incidence.