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A large-scale surveillance is an important measure to monitor the regional spread of antimicrobial resistance. We prospectively studied the prevalence and molecular characteristics of clinically important Gram-negative bacilli, including Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii complex (ABC), and Pseudomonas aeruginosa, from blood, respiratory tract, urine, and sterile sites at 47 hospitals across Thailand. Among 187,619 isolates, 93,810 isolates (50.0%) were critically drug resistant, of which 12,915 isolates (13.8%) were randomly selected for molecular characterization. E. coli was most commonly isolated from all specimens, except the respiratory tract, in which ABC was predominant. Prevalence of extended-spectrum cephalosporin resistance (ESCR) was higher in E. coli (42.5%) than K. pneumoniae (32.0%), but carbapenem-resistant (CR)-K. pneumoniae (17.2%) was 4.5-fold higher than CR-E. coli (3.8%). The majority of ESCR/CR-E. coli and K. pneumoniae isolates carried blaCTX-M (64.6% to 82.1%). blaNDM and blaOXA-48-like were the most prevalent carbapenemase genes in CR-E. coli/CR-K. pneumoniae (74.9%/52.9% and 22.4%/54.1%, respectively). In addition, 12.9%/23.0% of CR-E. coli/CR-K. pneumoniae cocarried blaNDM and blaOXA-48-like. Among ABC isolates, 41.9% were extensively drug resistant (XDR) and 35.7% were multidrug resistant (MDR), while P. aeruginosa showed XDR/MDR at 6.3%/16.5%. A. baumannii was the most common species among ABC isolates. The major carbapenemase gene in MDR-A. baumannii/XDR-A. baumannii was blaOXA-23-like (85.8%/93.0%), which had much higher rates than other ABC species. blaIMP, blaVIM, blaOXA-40-like, and blaOXA-58-like were also detected in ABC at lower rates. The most common carbapenemase gene in MDR/XDR-P. aeruginosa was blaIMP (29.0%/30.6%), followed by blaVIM (9.5%/25.3%). The findings reiterate an alarming situation of drug resistance that requires serious control measures.

The ST131 multilocus sequence type (MLST) of Escherichia coli is a globally successful pathogen whose dissemination is increasing rates of antibiotic resistance. Numerous global surveys have demonstrated the pervasiveness of this clone; in some regions ST131 accounts for up to 30% of all E. coli isolates. However, many regions are underrepresented in these published surveys, including Africa, South America, and Asia. We collected consecutive bloodstream E. coli isolates from three countries in Southeast Asia; ST131 was the most common MLST type. As in other studies, the C2/H30Rx clade accounted for the majority of ST131 strains. Clinical risk factors were similar to other reported studies. However, we found that nearly all of the C2 strains in this study were closely related, forming what we denote the SEA-C2 clone. The SEA-C2 clone is enriched for strains from Asia, particularly Southeast Asia and Singapore. The SEA-C2 clone accounts for all of the excess resistance and virulence of ST131 relative to non-ST131 E. coli. The SEA-C2 strains appear to be locally circulating and dominant in Southeast Asia, despite the intuition that high international connectivity and travel would enable frequent opportunities for other strains to establish themselves.

Objective: To assess the impact of chlorhexidine gluconate (CHG) bathing on skin bacterial burden in neonates Study Design: In this prospective observational study, arm and groin skin bacterial growth was measured in 40 CHG-exposed and non-exposed neonates admitted to the NICU. Exposed neonates received 2% CHG baths per protocol for central line-associated bloodstream infection (CLABSI) prevention or Staphylococcus aureus decolonization. Results: Forty neonates were enrolled, 18 of whom were CHG-exposed. Mean baseline Gram-positive (GP) bacterial burden was 2.19 log CFU/ml on the arm and 1.81 log CFU/ml on the groin. Bacterial burden decreased after the first bath, but returned to baseline by 72 hours. Residual skin CHG concentration declined over time, with a corresponding increase in GP bacterial burden. Conclusions: CHG bathing reduces skin bacterial burden, but burden returns to baseline after 72 hours. Twice weekly CHG bathing may be inadequate to suppress skin bacterial growth in hospitalized neonates.

A prospective study conducted in a Thai general practice clinic demonstrated a high prevalence (91.3%) of inappropriate empirical antibiotic use in women with uncomplicated cystitis and 42.6% Escherichia coli fluoroquinolone resistance. An annual update of antimicrobial resistance surveillance data of uropathogens may permit targeted treatment of patients in hospital care.

Background: Recent reports suggest that infections due to fluoroquinolone-resistant Escherichia coli ( E. coli ) are an increasingly common complication of transrectal biopsy of the prostate (TBP) in the United States. A better understanding of the magnitude and scope of these infections is needed to guide prevention efforts. Our objective is to determine whether the incidence of infections due to fluoroquinolone-resistant E. coli after TBP has increased nationwide in the Veterans Affairs Health Care System and to identify risk factors for infection. Methods: We performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with E. coli and with fluoroquinolone-resistant E. coli strains within 30 days after TBP. Secondary endpoints focused on the correlation between fluoroquinolone-resistance in all urinary E. coli isolates and post-TBP infection and risk factors for infection due to fluoroquinolone-resistant E. coli infection. Results: 245 618 patients undergoing 302 168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59 469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence of E. coli UTI (0.18%–0.93%) and a 4-fold increase in the incidence of E. coli bacteremia (0.04%–0.18%) after TBP that was attributable to an increase in the incidence of fluoroquinolone-resistant E. coli UTI (0.03%–0.75%) and bacteremia (0.01%–0.14%). The increasing incidence of fluoroquinolone-resistant E. coli infections after TBP occurred in parallel with increasing rates of fluoroquinolone-resistance in all urinary E. coli isolates. By multivariable logistic regression analysis, independent risk factors for fluoroquinolone-resistant E. coli UTI after TBP included diabetes mellitus, fluoroquinolone exposure, prior hospitalization, and prior cultures with fluoroquinolone-resistant gram-negative bacilli. Conclusion: In the Veterans Affairs Healthcare System, the incidence of E. coli infection after TBP has increased significantly since 2000 due to a dramatic rise in infections with fluoroquinolone-resistant E. coli . Keywords: bacteremia; case-control studies; cohort studies; early detection of cancer; Escherichia coli infections; microbial drug resistance; postoperative complications; prostate; retrospective studies; United States Department of Veterans Affairs; urinary tract infections.

Background Multidrug-resistant Gram-negative bacteria (MDRGN), including extended-spectrum β-lactamases (ESBLs) and multidrug-resistant glucose-nonfermenting Gram-negative bacilli (nonfermenters), have emerged and spread throughout Southeast Asia. Methods We reviewed and summarized current critical knowledge on the epidemiology and molecular characterization of MDRGN in Southeast Asia by PubMed searches for publications prior to 10 March 2016 with the term related to “MDRGN definition” combined with specific Southeast Asian country names (Thailand, Singapore, Malaysia, Vietnam, Indonesia, Philippines, Laos, Cambodia, Myanmar, Brunei). Results There were a total of 175 publications from the following countries: Thailand (77), Singapore (35), Malaysia (32), Vietnam (23), Indonesia (6), Philippines (1), Laos (1), and Brunei (1). We did not find any publications on MDRGN from Myanmar and Cambodia. We did not include publications related to Shigella spp., Salmonella spp., and Vibrio spp. and non-human related studies in our review. English language articles and abstracts were included for analysis. After the abstracts were reviewed, data on MDRGN in Southeast Asia from 54 publications were further reviewed and included in this study. Conclusions MDRGNs are a major contributor of antimicrobial-resistant bacteria in Southeast Asia. The high prevalence of ESBLs has been a major problem since 2005 and is possibly related to the development of carbapenem resistant organisms in this region due to the overuse of carbapenem therapy. Carbapenem–resistant Acinetobacter baumannii is the most common pathogen associated with nosocomial infections in this region followed by carbapenem-resistant Pseudomonas aeruginosa. Although Southeast Asia is not an endemic area for carbapenem-resistant Enterobacteriaceae (CRE), recently, the rate of CRE detection has been increasing. Limited infection control measures, lack of antimicrobial control, such as the presence of active antimicrobial stewardship teams in the hospital, and outpatient antibiotic restrictions, and travel throughout this region have likely contributed to the increase in MDRGN prevalence.

Background Streptococcus agalactiae (GBS) is a common pathogen known to cause neonatal and maternal infectious morbidity. Streptococcus pseudoporcinus (S pseudoporcinus) is a separate, recently identified β-hemolytic gram-positive coccus that can cause false-positive results on standard GBS agglutination testing assays. Objective To determine the prevalence and clinical implications of Streptococcus pseudoporcinus colonization in pregnancy. Materials and Methods This is a 2-year retrospective cohort study comparing pregnant women colonized with GBS to those colonized with S. pseudoporcinus. A proteomics method of identification, namely, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, was used to distinguish between S. pseudoporcinus and GBS colonization. Antibiotic susceptibility testing was carried out on all specimens. Maternal and neonatal chart reviews were conducted to identify predictors of S. pseudoporcinus colonization and to compare maternal and neonatal outcomes. Results S. pseudoporcinus colonization occurred in 1.6% of all pregnancies. A total of 2.5% of all GBS-positive results by agglutination assay were false positive, instead reflecting S. pseudoporcinus colonization. Clindamycin resistance among S. pseudoporcinus isolates is uncommon. S. pseudoporcinus colonization in pregnancy is independently associated with African American race, tobacco use, and body mass index ≥35. Preterm premature rupture of membranes or spontaneous preterm birth was more common in patients colonized with S. pseudoporcinus. Conclusion Although the prevalence of S. pseudoporcinus colonization is low, it primarily occurs in African American women and is associated with preterm premature rupture of membranes or spontaneous preterm birth when compared to individuals colonized with GBS.

BACKGROUNDStaphylococcus aureus is a common cause of healthcare-associated infections in neonates.OBJECTIVETo examine the impact of methicillin-susceptible S. aureus (MSSA) decolonization on the incidence of MSSA infection and to measure the prevalence of mupirocin resistance.METHODSWe retrospectively identified neonates admitted to a tertiary care neonatal intensive care unit (NICU) from April 1, 2011, through September 30, 2014. We compared rates of MSSA-positive cultures and infections before and after implementation of an active surveillance culture and decolonization intervention for MSSA-colonized neonates. We used 2 measurements to identify the primary outcome, NICU-attributable MSSA: (1) any culture sent during routine clinical care that grew MSSA and (2) any culture that grew MSSA and met criteria of the National Healthcare Safety Network’s healthcare-associated infection surveillance definitions. S. aureus isolates were tested for mupirocin susceptibility. We estimated incidence rate ratios using interrupted time-series models.RESULTSBefore and after the intervention, 1,523 neonates (29,220 patient-days) and 1,195 neonates (22,045 patient-days) were admitted to the NICU, respectively. There was an immediate reduction in the mean quarterly incidence rate of NICU-attributable MSSA-positive clinical cultures of 64% (incidence rate ratio, 0.36 [95% CI, 0.19–0.70]) after implementation of the intervention, and MSSA-positive culture rates continued to decrease by 21% per quarter (incidence rate ratio, 0.79 [95% CI, 0.74–0.84]). MSSA infections also decreased by 73% immediately following the intervention implementation (incidence rate ratio, 0.27 [95% CI, 0.10–0.79]). No mupirocin resistance was detected.CONCLUSIONActive surveillance cultures and decolonization may be effective in decreasing S. aureus infections in NICUs.Infect. Control Hosp. Epidemiol. 2016;37(4):381–387

Background: Corynebacterium species and gram-positive coryneform-like bacteria (coryneforms) are increasingly reported causes of opportunistic infections in immunocompromised patients. Biochemical identification methods for these bacteria are often inaccurate. We evaluated matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) for routine Corynebacterium and coryneform identification. Methods: A total of 286 Corynebacterium species and coryneforms recovered from patients were identified by MALDI-TOF MS analysis using the Bruker Microflex instrument, Biotyper software version 3.0, and database version 3.1.66 (Bruker Daltonics, Billerica, MA) following formic acid–based, direct on-plate extraction. The spectral cutoff scores used for interpretation were 2.0 or more for species-level identification and 1.7 or more for genus level. Scores lower than 1.7 were considered as no reliable identification. The results were compared with API Coryne (bioMerieux, Durham, NC) and sequencing of 16S ribosomal RNA genes. Results: Of the 231 Corynebacterium (19 species), 99.6% were correctly identified to the genus level and 88.7% to the species level. Of the 55 coryneforms (14 genera), 90.9% were correctly identified to the genus level and 67.3% to the species level. API Coryne was able to identify 89.2% of Corynebacterium species (species level) and 63.6% of coryneforms (genus level). Conclusions: Rapid on-plate testing yielded identification of more Corynebacterium species and related bacteria than biochemical methods.

During a 14-month period of using matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) for group B streptococcus (GBS) identification, we recovered 32 (1%) Streptococcus pseudoporcinus isolates from 3,276 GBS screening cultures from female genital sources (25 isolates from pregnant women and 7 from nonpregnant women). An additional two S. pseudoporcinus isolates were identified from a urine culture and a posthysterectomy wound culture. These isolates were found to cross-react with three different GBS antigen agglutination kits, PathoDx (Remel) (93%), Prolex (Pro-Lab Diagnostics) (38%), and Streptex (Remel) (53%). New approaches to bacterial identification in routine clinical microbiology laboratories may affect the prevalence of S. pseudoporcinus .

This work was primarily funded by the Ministry of Health, Singapore, awarded through the Singapore Infectious Disease Initiative grant (SIDI/2015/001). We were also supported by the Molecular Biology Laboratory and the Department of Laboratory Medicine, TTSH, Singapore. The culture analysis of fish was primarily funded by the National Environment Agency, Singapore. The statistical work was funded by the Project MODUS grant, while whole-genome sequencing and analysis were conducted at the Genome Institute of Singapore, partially funded by the POLARIS program, Agency for Science, Technology and Research (A*STAR) and the Singapore Ministry of Health’s National Medical Research Council (NMRC/CIRG/1357/2013). Background : Streptococcus agalactiae (group B Streptococcus [GBS]) has not been described as a foodborne pathogen. However, in 2015, a large outbreak of severe invasive sequence type (ST) 283 GBS infections in adults epidemiologically linked to the consumption of raw freshwater fish occurred in Singapore. We attempted to determine the scale of the outbreak, define the clinical spectrum of disease, and link the outbreak to contaminated fish. Methods : Time-series analysis was performed on microbiology laboratory data. Food handlers and fishmongers were screened for enteric carriage of GBS. A retrospective cohort study was conducted to assess differences in demographic and clinical characteristics of patients with invasive ST283 and non-ST283 infections. Whole-genome sequencing was performed on human and fish ST283 isolates from Singapore, Thailand, and Hong Kong. Results : The outbreak was estimated to have started in late January 2015. Within the study cohort of 408 patients, ST283 accounted for 35.8% of cases. Patients with ST283 infection were younger and had fewer comorbidities but were more likely to develop meningoencephalitis, septic arthritis, and spinal infection. Of 82 food handlers and fishmongers screened, none carried ST283. Culture of 43 fish samples yielded 13 ST283-positive samples. Phylogenomic analysis of 161 ST283 isolates from humans and fish revealed they formed a tight clade distinguished by 93 single-nucleotide polymorphisms. Conclusions : ST283 is a zoonotic GBS clone associated with farmed freshwater fish, capable of causing severe disease in humans. It caused a large foodborne outbreak in Singapore and poses both a regional and potentially more widespread threat. Postprint

Carbapenems are a mainstay of treatment for infections caused by Pseudomonas aeruginosa. Carbapenem resistance mediated by metallo-β-lactamases (MBLs) remains uncommon in the United States, despite the worldwide emergence of this group of enzymes. Between March 2012 and May 2013, we detected MBL-producing P. aeruginosa in a university-affiliated health care system in northeast Ohio. We examined the clinical characteristics and outcomes of patients, defined the resistance determinants and structure of the genetic element harboring the blaMBL gene through genome sequencing, and typed MBL-producing P. aeruginosa isolates using pulsed-field gel electrophoresis (PFGE), repetitive sequence-based PCR (rep-PCR), and multilocus sequence typing (MLST). Seven patients were affected that were hospitalized at three community hospitals, a long-term-care facility, and a tertiary care center; one of the patients died as a result of infection. Isolates belonged to sequence type 233 (ST233) and were extensively drug resistant (XDR), including resistance to all fluoroquinolones, aminoglycosides, and β-lactams; two isolates were nonsusceptible to colistin. The blaMBL gene was identified as blaVIM-2 contained within a class 1 integron (In559), similar to the cassette array previously detected in isolates from Norway, Russia, Taiwan, and Chicago, IL. Genomic sequencing and assembly revealed that In559 was part of a novel 35-kb region that also included a Tn501-like transposon and Salmonella genomic island 2 (SGI2)-homologous sequences. This analysis of XDR strains producing VIM-2 from northeast Ohio revealed a novel recombination event between Salmonella and P. aeruginosa, heralding a new antibiotic resistance threat in this region's health care system Fil: Perez, Federico. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Hujer, Andrea M.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Marshall, Steven H.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Ray, Amy, J.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Rather, Philip N.. Emory University School of Medicine. Atlanta; Estados Unidos. Department of Veterans Affairs Medical Center. Decatur; Estados Unidos Fil: Suwantaratf, Nuntra. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Dumford III, Donald. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: O'Shea, Patrick. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Domitrovic, T. Nicholas J.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Salata, Robert A.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Chavda, Kalyan D.. Rutgers University; Estados Unidos Fil: Chen, Liang. Rutgers University; Estados Unidos Fil: Kreiswirth, Barry N. Rutgers University; Estados Unidos Fil: Vila, Alejandro Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario. Instituto de Biología Molecular y Celular de Rosario. Universidad Nacional de Rosario. Facultad de Ciencias Bioquímicas y Farmacéuticas. Instituto de Biología Molecular y Celular de Rosario; Argentina Fil: Haussler, Susanne. Hannover Medical School and Helmholtz Center for Infection Research; Alemania Fil: Jacobs, Michael R.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Bonomo, Robert A.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos

Recent reports suggest that infections due to fluoroquinolone-resistantWe performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with245 618 patients undergoing 302 168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59 469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence ofIn the Veterans Affairs Healthcare System, the incidence of

SUMMARY Carbapenem-resistant Gram-negative bacteria, in particular the Acinetobacter baumannii-calcoaceticus complex and Enterobacteriaceae , are escalating global public health threats. We review the epidemiology and prevalence of these carbapenem-resistant Gram-negative bacteria among countries in South and Southeast Asia, where the rates of resistance are some of the highest in the world. These countries house more than a third of the world's population, and several are also major medical tourism destinations. There are significant data gaps, and the almost universal lack of comprehensive surveillance programs that include molecular epidemiologic testing has made it difficult to understand the origins and extent of the problem in depth. A complex combination of factors such as inappropriate prescription of antibiotics, overstretched health systems, and international travel (including the phenomenon of medical tourism) probably led to the rapid rise and spread of these bacteria in hospitals in South and Southeast Asia. In India, Pakistan, and Vietnam, carbapenem-resistant Enterobacteriaceae have also been found in the environment and community, likely as a consequence of poor environmental hygiene and sanitation. Considerable political will and effort, including from countries outside these regions, are vital in order to reduce the prevalence of such bacteria in South and Southeast Asia and prevent their global spread.

OBJECTIVETo determine the prevalence and acquisition of extended-spectrum β-lactamases (ESBLs), plasmid-mediated AmpCs (pAmpCs), and carbapenemases (“MDR Enterobacteriaceae”) colonizing children admitted to a pediatric intensive care unit (PICU).DESIGNProspective study.SETTING40-bed PICU.METHODSAdmission and weekly thereafter rectal surveillance swabs were collected on all pediatric patients during a 6-month study period. Routine phenotypic identification and antibiotic susceptibility testing were performed. Enterobacteriaceae displaying characteristic resistance profiles underwent further molecular characterization to identify genetic determinants of resistance likely to be transmitted on mobile genetic elements and to evaluate relatedness of strains including DNA microarray, multilocus sequence typing, repetitive sequence-based PCR, and hsp60 sequencing typing.RESULTSEvaluating 854 swabs from unique children, the overall prevalence of colonization with an MDR Enterobacteriaceae upon admission to the PICU based on β-lactamase gene identification was 4.3% (n=37), including 2.8% ESBLs (n=24), 1.3% pAmpCs (n=11), and 0.2% carbapenemases (n=2). Among 157 pediatric patients contributing 603 subsequent weekly swabs, 6 children (3.8%) acquired an incident MDR Enterobacteriaceae during their PICU stay. One child acquired a pAmpC (E. coli containing blaDHA) related to an isolate from another patient.CONCLUSIONSApproximately 4% of children admitted to a PICU were colonized with MDR Enterobacteriaceae (based on β-lactamase gene identification) and an additional 4% of children who remained in the PICU for at least 1 week acquired 1 of these organisms during their PICU stay. The acquired MDR Enterobacteriaceae were relatively heterogeneous, suggesting that a single source was not responsible for the introduction of these resistance mechanisms into the PICU setting.Infect Control Hosp Epidemiol 2016;37:535–543

We report a case of Nocardia farcinica ruptured intracranial mycotic aneurysm associated with bortezomib and corticosteroid treatment in a multiple myeloma patient. The patient was treated with trimethoprim-sulfamethoxazole and moxifloxacin together with surgical repairment of intracranial mycotic aneurysm. Keywords: Nocardia, Nocardia farcinica, Mycotic aneurysm, Multiple myeloma, Proteasome inhibitor

Background There are limited data on routine use of anaerobic blood cultures and the prevalence of patients with anaerobic bacteremia in Thailand. Methods Thammasat University Hospital is a 650-bed university hospital located in central Thailand. We implemented routine blood culture work up for adults using paired aerobic/anaerobic bottles using the BACTEC FX system (BD Diagnostics) as a standard practice. Gram stain and inoculation of positive blood cultures on aerobic and anaerobic culture media were performed and maintained in anaerobic conditions by the Anoxomat™ system (Mart Microbiology). Vitek2 system (BioMerieux) was used for bacterial identification. Data on positive blood cultures, bacterial identification, and time to positivity (TTP) between aerobic and anaerobic bottles were compared. Characteristics of patients with bacteremia were reviewed. Results During December 2016–October 2017, 323 blood culture sets were processed (one BACTEC anaerobic Plus bottle and two aerobic bottles). Majority of samples received were from patients hospitalized in an intensive care unit (surgical ICU 28% and medical ICU 25%) followed by general medical unit (19%) and surgical unit (16%). There were 21 positive cultures from anaerobic bottles (21/323, 6.5%) vs. 30 positive cultures from aerobic bottle (30/646, 4.6%) (P = 0.3). Bacteria isolated from anaerobic bottles included Staphylococcus aureus (n = 8), coagulase-negative staphylococci (n = 3), viridans group streptococci (n = 1), Klebsiella pneumoniae (n = 8), and Escherichia coli (n = 1). Positivity rate of Gram-positive bacteria (GP) from anaerobic bottle was slightly higher than the rate of GP from aerobic bottle (12/203, 3.1% vs. 12/646, 1.9%; P = 0.08) There was no isolation of anaerobic bacteria. TTP from anaerobic bottles (mean of 15.6 hours, range 11–26 hours) was significantly faster than TTP from aerobic bottles (mean of 49.5 hours, range 13–100 hours) (P

We report the first case of a child in the United States infected with an organism producing a Verona Integron-Encoded Metallo-β-Lactamase. This child succumbed to a ventilator-associated pneumonia caused by a Klebsiella pneumoniae producing this resistance mechanism.

Anti-interferon (IFN)-γ autoantibodies are increasingly recognized as a cause of adult-onset immunodeficiency and increased risk for infections with intracellular pathogens. We report on disseminated Talaromyces (Penicillium) marneffei and Mycobacterium abscessus infection in a 72-year-old, human immunodeficiency virus noninfected, Thai man with anti-IFN-γ autoantibody. The patient was successfully treated with antimicrobial therapy and rituximab to control B cell-derived autoantibodies.

Background There is limited data on incidence of MDROs colonization and outcome in patients undergoing elective orthopedic surgery. Methods We performed MDROs surveillance screening (swabs from nose, throat, groins, and rectum) in patients undergoing elective orthopedic surgery at the Thammasat University Hospital between March and August 2016. MDROs were defined as Gram-negative bacteria (GNB) possessing extended-spectrum β-lactamases (ESBLs), Carbapenem-resistant Enterobacteriaceae (CRE), and non-lactose fermenting GNB resistant to at least 3 antibiotic classes, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin resistant enterococci (VRE). MDROs were identified by the Vitek®2 automated system. Antimicrobial susceptibility testing (disk diffusion test) was performed using the CLSI Interpretive Guidelines. Incidence of MDROs colonization upon admission was determined. Patient’s clinical characteristics, risk factors for MDROs infection, procedure types and antibiotic prophylaxis were prospectively collected. Surgical sites infections (SSIs) and complications up to 6 months after surgery among the patients with and without MDROs colonization were compared. Results Of 384 swabs tested from 96 patients (median age, 58 years), ESBL-producing Escherichia coli (ESBL-E. coli) was identified in 31 rectal swabs (32.3%) and 7 groin swabs (7.3%). Seven patients (7.3%) were diagnosed with SSIs. A higher rate of SSIs was found among patients with ESBL-E. coli colonization (6/31, 19.4%) compared with patient without ESBL-E. coli colonization (1/65, 1.5%; P = 0.004, OR 15.4, 95% CI 1.7–356.3). From the multivariate logistic regression analysis, SSIs were significantly associated with ESBL-E.coli colonization (P = 0.009, adjusted OR 18.3, 95% CI 2.1–162.9). In addition, from the multivariate logistic regression analysis, ESBL-E.coli was a significantly risk factor associated with SSIs (6/7, 85.7%, P = 0.014, adjusted OR 16.5, 95% CI 1.8–153.4). Conclusion We found a high incidence of ESBL-E. coli colonization and rate of SSIs in patients who had elective orthopedic surgery. These patients did not have any other risk factors for MDROs infection. Active screening for colonization of ESBL-producing pathogens may be necessary to guide appropriate antibiotic prophylaxis to reduce rates of SSIs. Disclosures All authors: No reported disclosures.

Five chromogenic agars, evaluated using 400 stool specimens, were found to be superior in sensitivity (range, 89.9 to 93.9%) to bile esculin azide agar with vancomycin (BEAV) agar (84.8%) for detecting vancomycin-resistant enterococci (VRE), and the results were available 24 to 48 h sooner. The time to detection, need for supplemental testing, color distinction, and breakthrough of non-VRE organisms vary among the chromogenic media tested and may factor into the decision to use a particular medium.

In units that bathe patients daily with chlorhexidine gluconate (CHG), organisms causing central line–associated bloodstream infections (CLABSIs) were more likely to have reduced CHG susceptibility than organisms causing CLABSIs in units that do not bathe patients daily with CHG (86% vs 64%; P = .028). Surveillance is needed to detect reduced CHG susceptibility with widespread CHG use.Infect Control Hosp Epidemiol 2014;35(9):1183-1186

With interest, we read the paper by Korem et al. describing a case of Exserohilum rostratum sinusitis from which serum galactomannan (GM) levels were elevated upon diagnosis ([1][1]). They further demonstrated that the extract of the E. rostratum clinical isolate yielded positive GM results

The selective medium l-canavanine glycine bromothymol blue (CGB) agar is used with biochemical reactions to differentiate Cryptococcus gattii from C. neoformans ([1][1], [2][2]). The blue color of glycine assimilation on CGB agar indicates the positive reaction caused by C. gattii, whereas C.

An increase in the number of infections with fluoroquinolone (FQ)-resistant Escherichia coli following transrectal ultrasound-guided biopsy of the prostate (TRUBP) was observed in Louis Stokes Cleveland Department of Veterans Affairs Medical Center. This study investigated whether these infections were caused by a single strain of E. coli possessing distinct resistance and virulence determinants. Of 15 patients with urinary tract infection, 5 were complicated with bacteraemia and 1 with prostate abscess. Thirteen FQ-resistant isolates demonstrated mutations in the quinolone resistance-determining regions (QRDRs) of gyrA and parC but did not contain plasmid-mediated quinolone resistance determinants; blaCTX-M and blaCMY as well as genes coding for extended-spectrum β-lactamases were also absent. Genes encoding aminoglycoside-modifying enzymes were discovered in an isolate that was gentamicin-resistant. The most prevalent sequence type (ST) was ST43 (n = 7), corresponding to ST131 in Achtman's multilocus sequence typing (MLST) scheme. These isolates (i) were distinguished as >95% similar by repetitive sequence-based PCR (rep-PCR), (ii) belonged to the virulent phylogenetic group B2 and (iii) contained plasmid types FIB, FIA and Frep. Several other strain types were present (ST2, ST27, ST30, ST44, ST472, ST494, ST511 and ST627). Non-ST43 isolates infected patients with more co-morbidities but contained similar virulence factors (kpsMTII, iutA, papAH/papC and sfa/focDE). In our hospital, E. coli isolates causing TRUBP-related infection are quite heterogeneous (ST131 and other ST types) and are part of phylogenetic groups containing multiple virulence factors.

For patients undergoing transrectal ultrasound-guided biopsy of the prostate (TRUBP), use of rectal screening culture results to guide antimicrobial prophylaxis was effective for prevention of fluoro-quinolone-resistant Escherichia coli infections. In practice, elimination of infections after TRUBP required the rectal screening protocol and addition of gentamicin for patients missing prior screening.

Design.We conducted an investigation after identifying a cluster of 4 serious infections following transrectal ultrasound–guided biopsy of the prostate (TRUBP) during a 2-month period.Setting.veterans Affairs medical center.Patients.Patients with urinary tract infection (UTI) after TRUBP and time-matched controls with no evidence of infection.Methods.The incidence of UTI within 30 days after TRUBP was calculated from 2002 through 2010. We evaluated the correlation between infection with fluoroquinolone-resistant gram-negative bacilli (GNB) and fluoroquinolone resistance in outpatient Escherichia coli urinary isolates and performed a case-control study to determine risk factors for infection with fluoroquinolone-resistant GNB. Processes for TRUBP prophylaxis, procedures, and equipment sterilization were reviewed.Results.An outbreak of UTI due to fluoroquinolone-resistant E. coli after TRUBP began 2 years before the cluster was identified and was correlated with increasing fluoroquinolone resistance in outpatient E. coli. No deficiencies were identified in equipment processing or biopsy procedures. Fluoroquinolone-resistant E. coli UTI after TRUBP was independently associated with prior infection with fluoroquinolone-resistant GNB (adjusted odds ratio, 20.8; P = .005). A prediction rule including prior UTI, hospitalization in the past year, and previous infection with fluoroquinolone-resistant GNB identified only 17 (49%) of 35 cases.Conclusions.The outbreak of fluoroquinolone-resistant E. coli infections after TRUBP closely paralleled rising rates of fluoroquinolone resistance among outpatient E. coli isolates. The delayed detection of the outbreak and the absence of sensitive predictors of infection suggest that active surveillance for infection after TRUBP is necessary in the context of increasing fluoroquinolone resistance in the United States.

Patients with Hepatitis C Virus (HCV) infection have increased rates of glucose intolerance, and studies have shown the improvement of fasting plasma glucose (FPG) levels after clearance of HCV infection with standard ribavirin plus pegylated interferon treatment. The purpose of this study was to examine glycemic changes with standard HCV treatment in patients with impaired fasting glucose (IFG) and normal fasting glucose (NFG).A retrospective study of FPG changes in HCV patients with IFG and NFG treated with standard HCV therapy was conducted. Baseline characteristics and viral responses were assessed; FPG levels before treatment, at the end of treatment, and more than one-month post treatment were compared.The mean FPG levels increased by 8.68 mg/dl at the end of treatment in the NFG group but decreased by 9.0 mg/dl in the IFG group, a statistically significant difference (P=0.019). The change in FPG levels remained significantly different after adjusting for weight change (P=0.009) and weight changes and initial weight (P=0.039). FPG change from baseline at more than one month after treatment were similar in both groups (P=0.145). The change in FPG levels was not associated with sustained viral response.In HCV-infected patients, standard ribavirin plus pegylated interferon treatment reduced FPG levels in patients with IFG and increased FPG levels in NFG individuals; independent of initial weight, weight change, or viral response. Standard HCV treatment modulates fasting plasma glucose levels which supports the need for a prospective study to determine the clinical significance of this finding.

The state of Hawai'i has the highest prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection in the United States. Since vancomycin is the most frequently-prescribed antibiotic for healthcare-associated MRSA infection, there is concern for development of vancomycin resistance. We report on a 61 year-old woman with history of previous successful treatments of MRSA bacteremia with vancomycin. She was later hospitalized for catheter-related MRSA bacteremia that persisted despite vancomycin treatment. The vancomycin minimal inhibitory concentration (MIC) was initially 1-2 µg/ml, suggesting susceptibility, but changed to 4 µg/ml. At this level, the organism was classified as a vancomycin-intermediate Staphylococcus aureus (VISA). Therapy was changed from vancomycin to daptomycin, and the patient's blood cultures were sterilized. High suspicion of VISA should be raised in MRSA-infected patients who fail or have a history of vancomycin therapy so that additional susceptibility testing and appropriate antibiotic therapy can be promptly commenced to reduce the morbidity associated with VISA infection.

A 47-year-old male presented with signs and symptoms of left lower lobe pneumonia. At that time, sputum culture revealed only normal respiratory flora. The patient received intravenous ceftriaxone and azithromycin during his hospitalization, and after his discharge, he completed a 7-day course of

Answer: Actinomyces radicidentis bacteremia. The Gram stain of the isolate from the subculture of the positive blood culture on Trypticase soy agar plates supplemented with 5% sheep blood (5% SBA) at 48 h of incubation at 35°C in CO2 showed organisms consistent with Gram-positive cocci in clusters

Malignancies of the gallbladder, including neuroendocrine tumors, are uncommon, mostly found incidentally after cholecystectomy and are frequently asymptomatic in the early stages, but highly fatal. Limited data is available on adrenocorticotropic hormone (ACTH)-producing neuroendocrine tumors specifically originating from the gallbladder. We report the clinical and radiographic findings, which included positron emission tomography and computed tomography, of a patient with a gallbladder mass who presented with Cushing's syndrome. Subsequently, a diagnosis of ACTH-producing large cell neuroendocrine carcinoma of the gallbladder was made. Despite being rare and having a poor prognosis, hormone-producing neuroendocrine tumors should be part of the differential diagnosis in the approach of patients with Cushing's syndrome.

Tsai et al.1 recently reported a retrospective study of 143 patients with surgically confirmed necrotizing fasciitis (NF) in southwest Taiwan. Although the authors concluded that hypotensive shock, hypoalbuminemia, and increased banded leukocytes were predictors of mortality, these risk factors necessitate immediate surgical intervention. These indicators may reflect the high severity of disease in these NF patients. Once NF is suspected, prompt surgical intervention should be performed. We conducted a retrospective study at a major tertiary care hospital in Hawaii between 1998 and 2005 to specifically examine the risk factors and microbiology associated with mortality in histologi-cally confirmed NF. One hundred and twenty NF cases were identified by ICD-9 code (rate of 75 cases/100 000 hospital admissions). Among 58 cases confirmed by histopathology, the median age was 58 years; 69% were male and 36% Hawaiian/Pacific Islanders. Demographic information, bacteriology, co-morbidities, ethnicity, intensive care unit (ICU) admission, and APACHE II scores were determined, along with the time from admission to surgery and the length of hospital stay. These factors were compared between those who survived and those who died (Table 1). An APACHE II score >17 was a significant independent predictor of mortality. The majority of NF wound infections in our study were polymicrobial (58.6%), which is different to the study of Tsai et al. and others.1–3 Table 1 Comparison of characteristics and mortality of necrotizing fasciitis survivors versus non-survivors Group A Streptococcus (GAS) was also found to be associated with higher mortality.4 Erdem et al.5 reported molecular epidemi-ologic components of GAS in six NF patients (from two clusters of fatal GAS skin infection in 1997 and 2002) and 116 community-associated GAS infections in Hawaii in 2005. The results showed no predominant emm types from NF patients (emm types 1, 12, 74, 99, and 103), but emm type 64 was the most common type in GAS isolated in Hawaii and this may account for the increased mortality in Hawaii. Although Hawaii has a high prevalence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections,6 our study did not show a high prevalence of MRSA infection in NF compared to a study from California.7 The mortality rate of 22% in our cohort was significantly associated with GAS, age over 60 years, ICU admission, and APACHE II score >17. Overall, the mortality of patients with NF was related to patients with severe clinical diseases. Rapid detection and regional differences in pathogens can provide additional insight into severity and mortality risks. The prompt institution of broad-spectrum antibiotics, surgical intervention, and intensive support are essential for the effective management of NF patients.