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Enterobacter cloacae demonstrating reduced susceptibility to third generation cephalosporins and ertapenem on a Level 3 Neonatal Unit
e12
Abstracts
Treatment is with standard anti-tuberculous medications with surgery reserved for those cases of airway compromise.
key areas including the timing of joint apiration, blood sampling (cultures and ESR), antibiotic choice, and also in terms of delayed diagnoses.
Conclusions
Discussion
Tuberculosis should be entertained as a possible diagnosis in patients with nonspecific laryngeal disease and it must be differentiated from malignancy. Local immunosuppression may be one of the risk factors for developing laryngeal TB.
Septic arthritis is a clinical emergency. While there is a scarcity of high quality data in some areas of management for SA such as duration of antibiotics, the BSR guidelines do provide comprehensive evidence based guidance on which to base management. Where deviation from this occurs, there is the potential for delays in diagnosis and suboptimal care. Awareness levels of the BSR guidelines have previously been shown to be low amongst junior doctors and should be improved.
THE CURRENT MANAGEMENT OF SEPTIC ARTHRITIS. A TWO CENTRE AUDITCATEGORY: SCIENTIFIC FREE PAPER Usman Butt 1, Christopher Elsworth 1 2
2
Royal Oldham Hospital, North West, United Kingdom Royal Preston Hospital, North West, United Kingdom
Introduction Infective or septic arthritis (SA) can lead to rapid and irreversible articular cartilage destruction if not appropriately treated in a timely fashion. Furthermore, there remains a significant mortality risk with reported figures as high as 11% for monoarticular sepsis and as high as 50% in polyarticular cases. Given the large differential for a hot swollen joint, firm diagnosis can often be difficult even for experienced clinicians. Early referral for specialist assessment and management under the care of a rheumatologist or orthopaedic surgeon is imperative if SA is suspected. Guidelines for the management of hot swollen joints were introduced in 2006 by a multi-disciplinary Working Party set up by the British Society for Rheumatology(BSR). In the guidelines, the diagnosis and treatment recommendations for SA are laid out. We conducted an audit of the management of all cases of native joint SA at Rochdale Infirmary and Royal Oldham Hospital from April 2007 to October 2009. All patients with a positive culture from a joint aspirate were identified. 92 sets of notes were retrieved and after careful scrutiny 24 cases of septic arthritis were confirmed. Data regarding all aspects in the management of the condition was collected and compared against the guidance set out by the BSR. In addition, demographic data and outcomes were also collected.
Scientific findings The mean patient age was 53 (16-96) with a male to female ratio of 14:9. Mean symptom duration was 5 days (1-20). The modal length of stay was 7 days (2-79). There were 2 deaths (9%) and 1 above knee amputation was carried out. Most cases involved the knee joint (17). Twenty-two patients were managed under the care of the orthopaedic surgeons and two cases under the rheumatologists. Management fell short of compliance with guidance in several
Conclusions We believe that wider dissemination of the guidance may result in more uniform care for the patient with a septic arthritis. Similar audits at other trusts in the UK along with reaudits to complete the cycle would be a valuable way of optimising the care of patients with this important condition.
ENTEROBACTER CLOACAE DEMONSTRATING REDUCED SUSCEPTIBILITY TO THIRD GENERATION CEPHALOSPORINS AND ERTAPENEM ON A LEVEL 3 NEONATAL UNITCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Nimal Wickramasinghe, Michael Weinbren, Kathryn Blake University Hospital of Coventry & Warwickshire, Coventry, West Midlands, United Kingdom
Introduction Enterobacter cloacae is a recognised pathogen in neonates. We identified 3 neonates on our NICU with E. cloacae in clinical samples within one week. The organisms were resistant to both penicillin-based antibiotics and cephalosporins, and sensitive only to gentamicin and ciprofloxacin on first line testing. In addition, the organisms showed reduced susceptibility to the carbapenems. Screening of the unit was undertaken alongside environmental screens to assess the extent of the cluster, and measures were taken to minimise the impact and spread of the organism. We report on our findings over an eight month period, and discuss the issues arising.
Scientific findings Over a 6 month period, 41 new colonised babies were identified. Molecular analysis of the strains revealed that there were at least 12 distinct strains. Environmental
Abstracts screening was negative. Carbapenem minimum inhibitory concentrations (MICs) were variable. Reduced susceptibility to these agents were attributed to porin loss together with AmpC beta-lactamase production rather than carbapenemase production. No babies suffered a clinically significant infection, and only one positive was found on a clinical sample after the first three were identified. No clear source was found to account for the origin of the cluster.
Discussion The prevalence of neonates of extreme prematurity was unusually high, and therefore antibiotic (especially cephalosporin) usage was also high. At the outset of the cluster, there were two circulating strains. After a few months, these were replaced by predomninantly unique strains. This coincided with reduction in pressure on the unit, with fewer numbers of extremely premature infants. Carbapenem use on the unit was low, suggesting that the ertapenem resistance seen was in association with cephalosporin resistance and was a secondary effect. A review of E. cloacae isolates from NICU over 5 years revealed 8 similar isolates, possibly indicating a persisting low-level background presence.
Conclusions Screening appears to have highlighted what may be a natural phenomenon on the NICU, with E. cloacae present at a low level, and becoming more apparent under periods of stress on the unit. Further work may include the screening of other units using cephalosporins to see whether an unrecognised state of E. cloacae colonisation exists. Additionally, further work needs to be done on the association between hyperproduction of ampC beta-lactamase in E. cloacae, conferring resistance to cephalosporins, and concomitant porin loss conferring resistance to carbapenems. These results suggest that there may be a wider association than purely selection pressure from cephalosporin use.
EPIDEMIOLOGY OF EXTENDED SPECTRUM BETA LACTAMASES FROM BLOOD AND URINARY ISOLATES, COMPARING DETECTION BY DISC TESTING AND AN AUTOMATED METHODCATEGORY: SCIENTIFIC FREE PAPER Benjamin Cooke, Emma Hathorn, Kirstie Sharp, Amelia Tyers, John Coia, Brian Jones Glasgow Royal Infirmary, Glasgow, United Kingdom
e13 All urine samples submitted to Glasgow Royal Infirmary between 10th August and 11th September 2009 were tested for cefpodoxime resistance. Blood cultures were tested for ceftriaxone resistance. All resistant Gram-negative bacilli, (GNB), were tested for the presence of ESBL using the HPA standard disc synergy method. ESBL-positive isolates were then processed in the VITEK 2, to identify the organism and test antibiotic sensitivity. The rates of correct ESBL detection by the automated method were recorded, and the epidemiology of the isolates investigated. The reporting of cephalosporin sensitivity by the VITEK 2 was assessed. The rates of sensitivity to gentamicin and MeropenemÒ, which can be used therapeutically in the presence of an ESBL, were established.
Scientific findings 15,286 urine samples were submitted over the study period, and 3284 grew a GNB. The majority of urinary ESBLs were isolated from patients over 65 years (141 isolates, 77.9%). 95 Blood cultures grew GNB, 4 of which were ESBL positive, (4.3%). A sample of 69 ESBL-positive isolates was available for comparison with automated ESBL detection by VITEK 2. Of 65 urine ESBLs, 8 were Klebsiella spp, one was an Enterobacter and 55 were E. coli. The VITEK 2 correctly identified 66 of the ESBLs, (95.7%). 35 of the ESBLs were sensitive to gentamicin, (50.7%), and all were sensitive to MeropenemÒ.
Discussion The Advanced Expert System of the VITEK 2 correctly reported cefotaxime as resistant(R) or intermediate (I) in 67, (97%) of ESBL positive isolates. The 2 samples it reported sensitive were those it identified as penicillinase producers. It reported ceftazidime as R/I in 94.2%. Piperacillin/tazobactam use to treat ESBL-associated infections is controversial. Sensitivity testing results are not altered in the presence of an ESBL by the VITEK 2. 61 ESBL positive GNB were reported as sensitive to piperacillin/tazobactam, (88.4%).
Conclusions ESBLs account for 5.5% of urinary GNB in Glasgow. They are more common in the elderly and from catheter samples. The VITEK 2 identifies ESBL with 95.7% sensitivity, and appropriately reports cephalosporin sensitivity 94.2% of the time. Clinical microbiology input is thus still required when authorising results from this automated system.
Introduction This study looked at the epidemiology of ESBLs isolated from urine and blood samples submitted to a large diagnostic laboratory. The standard HPA detection method, (QSOP 51), was compared with an automated method rieux). (VITEK 2, bioMe
ITCHING TO KNOW THE DIAGNOSISCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Chloe Keane, Alistair Leanord Southern General Hospital, Glasgow, United Kingdom
Abstracts
Treatment is with standard anti-tuberculous medications with surgery reserved for those cases of airway compromise.
key areas including the timing of joint apiration, blood sampling (cultures and ESR), antibiotic choice, and also in terms of delayed diagnoses.
Conclusions
Discussion
Tuberculosis should be entertained as a possible diagnosis in patients with nonspecific laryngeal disease and it must be differentiated from malignancy. Local immunosuppression may be one of the risk factors for developing laryngeal TB.
Septic arthritis is a clinical emergency. While there is a scarcity of high quality data in some areas of management for SA such as duration of antibiotics, the BSR guidelines do provide comprehensive evidence based guidance on which to base management. Where deviation from this occurs, there is the potential for delays in diagnosis and suboptimal care. Awareness levels of the BSR guidelines have previously been shown to be low amongst junior doctors and should be improved.
THE CURRENT MANAGEMENT OF SEPTIC ARTHRITIS. A TWO CENTRE AUDITCATEGORY: SCIENTIFIC FREE PAPER Usman Butt 1, Christopher Elsworth 1 2
2
Royal Oldham Hospital, North West, United Kingdom Royal Preston Hospital, North West, United Kingdom
Introduction Infective or septic arthritis (SA) can lead to rapid and irreversible articular cartilage destruction if not appropriately treated in a timely fashion. Furthermore, there remains a significant mortality risk with reported figures as high as 11% for monoarticular sepsis and as high as 50% in polyarticular cases. Given the large differential for a hot swollen joint, firm diagnosis can often be difficult even for experienced clinicians. Early referral for specialist assessment and management under the care of a rheumatologist or orthopaedic surgeon is imperative if SA is suspected. Guidelines for the management of hot swollen joints were introduced in 2006 by a multi-disciplinary Working Party set up by the British Society for Rheumatology(BSR). In the guidelines, the diagnosis and treatment recommendations for SA are laid out. We conducted an audit of the management of all cases of native joint SA at Rochdale Infirmary and Royal Oldham Hospital from April 2007 to October 2009. All patients with a positive culture from a joint aspirate were identified. 92 sets of notes were retrieved and after careful scrutiny 24 cases of septic arthritis were confirmed. Data regarding all aspects in the management of the condition was collected and compared against the guidance set out by the BSR. In addition, demographic data and outcomes were also collected.
Scientific findings The mean patient age was 53 (16-96) with a male to female ratio of 14:9. Mean symptom duration was 5 days (1-20). The modal length of stay was 7 days (2-79). There were 2 deaths (9%) and 1 above knee amputation was carried out. Most cases involved the knee joint (17). Twenty-two patients were managed under the care of the orthopaedic surgeons and two cases under the rheumatologists. Management fell short of compliance with guidance in several
Conclusions We believe that wider dissemination of the guidance may result in more uniform care for the patient with a septic arthritis. Similar audits at other trusts in the UK along with reaudits to complete the cycle would be a valuable way of optimising the care of patients with this important condition.
ENTEROBACTER CLOACAE DEMONSTRATING REDUCED SUSCEPTIBILITY TO THIRD GENERATION CEPHALOSPORINS AND ERTAPENEM ON A LEVEL 3 NEONATAL UNITCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Nimal Wickramasinghe, Michael Weinbren, Kathryn Blake University Hospital of Coventry & Warwickshire, Coventry, West Midlands, United Kingdom
Introduction Enterobacter cloacae is a recognised pathogen in neonates. We identified 3 neonates on our NICU with E. cloacae in clinical samples within one week. The organisms were resistant to both penicillin-based antibiotics and cephalosporins, and sensitive only to gentamicin and ciprofloxacin on first line testing. In addition, the organisms showed reduced susceptibility to the carbapenems. Screening of the unit was undertaken alongside environmental screens to assess the extent of the cluster, and measures were taken to minimise the impact and spread of the organism. We report on our findings over an eight month period, and discuss the issues arising.
Scientific findings Over a 6 month period, 41 new colonised babies were identified. Molecular analysis of the strains revealed that there were at least 12 distinct strains. Environmental
Abstracts screening was negative. Carbapenem minimum inhibitory concentrations (MICs) were variable. Reduced susceptibility to these agents were attributed to porin loss together with AmpC beta-lactamase production rather than carbapenemase production. No babies suffered a clinically significant infection, and only one positive was found on a clinical sample after the first three were identified. No clear source was found to account for the origin of the cluster.
Discussion The prevalence of neonates of extreme prematurity was unusually high, and therefore antibiotic (especially cephalosporin) usage was also high. At the outset of the cluster, there were two circulating strains. After a few months, these were replaced by predomninantly unique strains. This coincided with reduction in pressure on the unit, with fewer numbers of extremely premature infants. Carbapenem use on the unit was low, suggesting that the ertapenem resistance seen was in association with cephalosporin resistance and was a secondary effect. A review of E. cloacae isolates from NICU over 5 years revealed 8 similar isolates, possibly indicating a persisting low-level background presence.
Conclusions Screening appears to have highlighted what may be a natural phenomenon on the NICU, with E. cloacae present at a low level, and becoming more apparent under periods of stress on the unit. Further work may include the screening of other units using cephalosporins to see whether an unrecognised state of E. cloacae colonisation exists. Additionally, further work needs to be done on the association between hyperproduction of ampC beta-lactamase in E. cloacae, conferring resistance to cephalosporins, and concomitant porin loss conferring resistance to carbapenems. These results suggest that there may be a wider association than purely selection pressure from cephalosporin use.
EPIDEMIOLOGY OF EXTENDED SPECTRUM BETA LACTAMASES FROM BLOOD AND URINARY ISOLATES, COMPARING DETECTION BY DISC TESTING AND AN AUTOMATED METHODCATEGORY: SCIENTIFIC FREE PAPER Benjamin Cooke, Emma Hathorn, Kirstie Sharp, Amelia Tyers, John Coia, Brian Jones Glasgow Royal Infirmary, Glasgow, United Kingdom
e13 All urine samples submitted to Glasgow Royal Infirmary between 10th August and 11th September 2009 were tested for cefpodoxime resistance. Blood cultures were tested for ceftriaxone resistance. All resistant Gram-negative bacilli, (GNB), were tested for the presence of ESBL using the HPA standard disc synergy method. ESBL-positive isolates were then processed in the VITEK 2, to identify the organism and test antibiotic sensitivity. The rates of correct ESBL detection by the automated method were recorded, and the epidemiology of the isolates investigated. The reporting of cephalosporin sensitivity by the VITEK 2 was assessed. The rates of sensitivity to gentamicin and MeropenemÒ, which can be used therapeutically in the presence of an ESBL, were established.
Scientific findings 15,286 urine samples were submitted over the study period, and 3284 grew a GNB. The majority of urinary ESBLs were isolated from patients over 65 years (141 isolates, 77.9%). 95 Blood cultures grew GNB, 4 of which were ESBL positive, (4.3%). A sample of 69 ESBL-positive isolates was available for comparison with automated ESBL detection by VITEK 2. Of 65 urine ESBLs, 8 were Klebsiella spp, one was an Enterobacter and 55 were E. coli. The VITEK 2 correctly identified 66 of the ESBLs, (95.7%). 35 of the ESBLs were sensitive to gentamicin, (50.7%), and all were sensitive to MeropenemÒ.
Discussion The Advanced Expert System of the VITEK 2 correctly reported cefotaxime as resistant(R) or intermediate (I) in 67, (97%) of ESBL positive isolates. The 2 samples it reported sensitive were those it identified as penicillinase producers. It reported ceftazidime as R/I in 94.2%. Piperacillin/tazobactam use to treat ESBL-associated infections is controversial. Sensitivity testing results are not altered in the presence of an ESBL by the VITEK 2. 61 ESBL positive GNB were reported as sensitive to piperacillin/tazobactam, (88.4%).
Conclusions ESBLs account for 5.5% of urinary GNB in Glasgow. They are more common in the elderly and from catheter samples. The VITEK 2 identifies ESBL with 95.7% sensitivity, and appropriately reports cephalosporin sensitivity 94.2% of the time. Clinical microbiology input is thus still required when authorising results from this automated system.
Introduction This study looked at the epidemiology of ESBLs isolated from urine and blood samples submitted to a large diagnostic laboratory. The standard HPA detection method, (QSOP 51), was compared with an automated method rieux). (VITEK 2, bioMe
ITCHING TO KNOW THE DIAGNOSISCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Chloe Keane, Alistair Leanord Southern General Hospital, Glasgow, United Kingdom