IntroductionAmong the several newer beta lactam+beta lactase inhibitors (BL/BLI), ceftazidime-avibactam is the only drug showing activity against OXA-48-like producers. Hence, it is being increasingly used in India to treat infections caused by carbapenem-resistant Enterobacteriaceae (CRE), especially as a colistin-sparing agent. We have used ceftazidime-avibactam in patients suspected and confirmed to have CRE infections in our center, and present a retrospective analysis of our experience. MethodsWe conducted a single-center, retrospective study involving all patients who were treated with ceftazidimeavibactam for suspected and proven CRE infections during a one-year period at our 500-bedded hospital. Our primary objective for this study was taken as all-cause mortality. The secondary objectives were to determine the clinical cure, defined as the end of the treatment regimen with a resolution of primary infection and resistance to ceftazidime-avibactam in patients who underwent the Epsilometer test (E-test). ResultsA total of 103 patients who received ceftazidime-avibactam were identified. The all-cause mortality was 27% while a clinical cure was achieved in 73%. Fifty-two patients received empirical therapy and 51 patients received ceftazidime-avibactam for confirmed CRE infection. Forty-eight patients had an E-test done, out of which 79% of patients had CREs sensitive to ceftazidime-avibactam, and 21% of patients had ceftazidimeavibactam resistant CREs. A higher Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index (CCI) score, intensive care unit (ICU) admission, inotrope requirement, and lower days of therapy (DOT) with ceftazidime-avibactam were found to be associated with increased mortality. ConclusionColistin has been considered to be the last-line agent in CRE infections, but there are concerns about its adverse effects and the emergence of resistance. Given our relatively low mortality of 27% in CRE infections treated with ceftazidime-avibactam, coupled with the high susceptibility of the tested isolates, there may be a role for the empirical use of this drug in infections caused by CRE, especially in a setting where colistin may not be ideal.

Without a vaccine or proven therapeutic options in COVID-19, the World Health Organization (WHO) recommends a combination of measures: rapid diagnosis and immediate isolation of cases; rigorous contact tracing; and precautionary self-isolation of close contacts to curb the spread of COVID-19. During a Nipah outbreak in Kerala, India in 2019, it was confined to a single case. The authors were involved in the in-hospital contact tracing. With a single patient producing a contact list of 98 in a healthcare setting, the implications in a community setting during a pandemic of the scale of COVID-19 are huge but it proves that early and rigorous tracing with quarantining is an effective strategy to limit clusters. We believe that if the public is encouraged to maintain their own contact list on a daily basis, it would help in significantly reducing the time and effort invested into contact tracing in the event of a person contracting COVID-19.

BackgroundWith rising trends of multi-drug organism infections and the limited availability of new antimicrobials, management of such cases has become a hassle for the clinician. Ceftazidime-Avibactam (CEF-AVI) is evolving as an effective alternative to polymyxins in the management of Carbapenem-Resistant Organisms (CRO) infections. The Food and Drug Administration (FDA) has approved CEF-AVI in a restricted group of clinical syndromes where the drug could have potential use. ObjectiveThe goal of this study was to evaluate the clinical outcome in terms of 14-day all-cause mortality and clinical cure at seven days in patients on CEF-AVI. MethodologyA retrospective study was conducted on patients who received CEF-AVI in a period of one year in our hospital. Patients were included in the study if they have received CEF-AVI for more than one day of therapy (DOT) and samples from relevant sites have been sent for culture and sensitivity. Variables and outcomes were collected from the hospital information system and medical records. ResultsA total of 78 patients were included, 52 (66.7%) were started empirically on CEF-AVI while 26 (33.3%) were on targeted therapy. Out of the 78 patients, 43 patients had positive cultures among which 32 patients had Carbapenem-Resistant Enterobacteriaceae (CRE)/Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) infection. The most common clinical syndrome in which the drug was used was occult sepsis (27/78; 34.6%) followed by primary bacteremia (20/78; 25.6%) and neutropenic sepsis (11/78; 14.1%). The clinical efficacy which was primarily assessed in terms of clinical cure was met for 55 (70.5%) patients. The 14-day mortality for the studies group was found to be 18 (23%). ConclusionThe analysis of results shows encouraging clinical cure rates and 14-day mortality rates in a subset of severe infections which has limited treatment options.

Infections remain one of the major complications in patients with multiple myeloma, having a significant impact on morbidity and mortality. The increased risk of infection in these patients are a result of various factors contributing to the impairment of immune system caused by the disease and the chemotherapy regimens given during the treatment phases. Here we report a rare case of pneumococcal bacteraemia and cryptococcal meningitis dual infection in a patient with underlying multiple myeloma who had a favourable clinical outcome. This case also serves to highlight the importance of adult vaccinations especially in patients with underlying comorbidities.

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