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.
gCases of invasive mycosis due to Blastobotrys serpentis and B. proliferans identified by sequencing in a preterm patient and a rhabdomyosarcoma patient, respectively, are reported. Both species revealed elevated fluconazole and echinocandin MICs by the CLSI broth microdilution method. Additionally, B. serpentis exhibited high amphotericin B MICs, thus posing serious therapeutic challenges. CASE REPORTSC ase 1. A 29-week gestation preterm male infant at birth was admitted on 24 April 2013 because of respiratory distress. The infant was born by normal vaginal delivery to a 24-year-old primigravida mother. On admission at day 1, the child was not active and had tachypnoea with a respiratory rate of 68/min and his chest X-ray showed mild haziness. Examination of the cardiovascular system revealed no abnormal heart sounds and equal bilateral peripheral pulses. The abdomen was soft, with no organomegaly noted. On day 5, a loud murmur was detected and an echocardiography revealed a large patent ductus arteriosus of 2.2 mm in size which was surgically closed. His total leukocyte count was elevated (24,000 cells/l), and his C-reactive protein level was 0.1 mg/liter. Two days later, the infant developed abdominal distension and the X-ray revealed a pneumoperitoneum. This was managed with a peritoneal drainage followed by laparotomy. During surgery, a gangrenous gastric fundus with a sloughed greater curvature, leading to an approximately 40% to 45% loss of stomach volume, was seen. The necrotic tissues were removed; gastric anastomosis was done with placement of a gastrojejunal feeding tube via gastrotomy. The child underwent operation twice again, on days 14 and 29 of admission, because of anastomotic leakage and perforation due to a gangrenous bowel. Histopathological examination of tissue biopsy specimens of the distal ileum, terminal ileum, and stoma showed active inflammatory changes, but no granuloma and ganglion cells were present, ruling out Hirschsprung disease. The child was empirically treated with ampicillin and gentamicin starting from day 1 of admission along with prophylactic fluconazole (3 mg/kg of body weight twice weekly) due to a high risk for invasive candidiasis. Further during the course of treatment, meropenem therapy was included on day 3, cefoperazone-sulbactam therapy a week later, and ofloxacin therapy on day 17. The clinical course and the therapy instituted are depicted in Fig. 1. Cultures of the discharge from the laprotomy incision site on day 15 of admission grew yeasts identified as Stephanoascus ciferrii (identification, 86%) by the use of a Vitek2 yeast ID system (bioMérieux, Marcy l'Etoile, France) which exhibited a high fluconazole MIC (Ͼ64 g/ml) by AST-YS06 (bioMérieux). Blood cultures in Bactec Peds Plus/F vials taken on days 16, 18, 21, 23, and 26 of admission grew fluconazole-resistant S. ciferrii after 2 to 3 days of incubation at 37°C. The endotracheal aspirate collected on day 23 also grew S. ciferrii. The patient had already received fluconazole (6 mg/kg) for 17 days; the trea...
Abstract. Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.
Central nervous system trichosporonosis is a rare clinical entity and so far only six cases including three each of brain abscess and meningitis has been on record. We report a rare case of chronic meningo-ventriculitis and intraventricular fungal ball due to Trichosporon asahii in an 18-year-old immunocompetent male from Burundi, east Africa. Neuroendoscopy showed multiple nodules and a fungal ball within the ventricle, which on culture grew T. asahii. He was initially empirically treated with liposomal amphotericin B. However, the antifungal susceptibility testing of T. asahii isolate revealed high minimum inhibitory concentration for amphotericin B (2 μg ml⁻¹), flucytosine (16 μg ml⁻¹) and caspofungin (2 μg ml⁻¹) but exhibited potent activity for voriconazole, posaconazole, itraconazole and fluconazole. The patient rapidly succumbed to cardiac arrest before antifungal therapy could be changed. Although disseminated trichosporonosis has been increasingly reported the diagnosis represents a challenge especially in rare clinical settings such as intraventricular fungal ball in the present case, which has not been described previously.
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