Class of 2012 / Specific Aims: The primary aim of this study was to determine the time to appropriate therapy for all patients with candidemia and/or bacteriemia (due to either Enterococcus or Streptococcus species) during a one year period in relation to time of blood culture, time of Gram-stain result, time of PNA FISH species result, and time of final species determination result. The secondary and third aims were to compare the time to appropriate therapy based on clinician group that was notified of Gram-stain result and PNA FISH result and compare the time to appropriate therapy based on PNA FISH assay results reported during the day and night microbiology laboratory shifts. Methods: This Institutional Review Board approved project is a retrospective, chart review evaluation of the 24 hour/ 7 days a week use of PNA FISH assays with therapeutic interventions by infectious diseases pharmacists and physicians on patient outcome measures and time to appropriate therapy. All patients admitted to an academic medical center during a one year period (April 2010-March 2011) with either Enterococcus, Streptococcus, or Candida species isolated from blood were included. Main Results: A total of 168 subjects were identified with Candida species isolated from 31 subjects and Enterococcus/Streptococcus species isolated from blood in 137 subjects. Conclusions: While reporting conditions can affect interpretation and intervention rates, rapid species identification assays such as PNA FISH can be used by pharmacists to provide antimicrobial therapy recommendations based on the species identification and to decrease the time to appropriate antimicrobial therapy.

The treatment of Staphylococcus aureus bloodstream infections (SABSI) remains a major challenge. With an emphasis on complicated methicillin–sensitive S. aureus (MSSA), a comprehensive analysis of initial antibiotic treatment was conducted. The influence of treatment gaps on clinical outcomes were examined. Strategies were developed to improve the use of available antibiotics. Patient- and infection-related variables predictive for end-of-treatment failure included higher Charlson Comorbidity Index and healthcare-associated infection. Treatment variables of shorter duration of optimal targeted, shorter duration of optimal or adequate and lower TSE score were also predictive for end-of-treatment failure when tested separately in their own models. Strategies to optimize the treatment of complicated MSSA BSI at minimum should include: 1) Initiating at least an adequate therapy within 24 hours following the index blood culture draw and 2) Maintaining uninterrupted treatment, especially during the initial 7 days including at least 4 days of cloxacillin or cefazolin.

Yes / Background. Bacterial bloodstream infection (bBSI) is one of the leading causes of death in critically ill patients and accurate diagnosis is therefore crucial. We here report a 16S metagenomics approach for diagnosing and understanding bBSI. Methodology/Principal Findings. The proof-of-concept was delivered in 75 children (median age 15 months) with severe febrile illness in Burkina Faso. Standard blood culture and malaria testing were conducted at the time of hospital admission. 16S metagenomics testing was done retrospectively and in duplicate on the blood of all patients. Total DNA was extracted from the blood and the V3–V4 regions of the bacterial 16S rRNA genes were amplified by PCR and deep sequenced on an Illumina MiSeq sequencer. Paired reads were curated, taxonomically labeled, and filtered. Blood culture diagnosed bBSI in 12 patients, but this number increased to 22 patients when combining blood culture and 16S metagenomics results. In addition to superior sensitivity compared to standard blood culture, 16S metagenomics revealed important novel insights into the nature of bBSI. Patients with acute malaria or recovering from malaria had a 7-fold higher risk of presenting polymicrobial bloodstream infections compared to patients with no recent malaria diagnosis (p-value = 0.046). Malaria is known to affect epithelial gut function and may thus facilitate bacterial translocation from the intestinal lumen to the blood. Importantly, patients with such polymicrobial blood infections showed a 9-fold higher risk factor for not surviving their febrile illness (p-value = 0.030). Conclusions/Significance. Our data demonstrate that 16S metagenomics is a powerful approach for the diagnosis and understanding of bBSI. This proof-of-concept study also showed that appropriate control samples are crucial to detect background signals due to environmental contamination. / This work was supported by the Flemish Ministry of Sciences (EWI, SOFI project IDIS). / This paper has been subject to a correction. Please see Correction file above.

Abstract This report aims, through interviews, observations and literature review to examine what some of the youngest children know about the heart, blood and bloodstream. The sample size was twenty children, half of them are at the age of three and the other half is at the age of six. The interviews showed that children at the age of six had better knowledge than children at the age of three, but one child knew that we have the blood corpuscle in the body. He was also the only one who mentioned the blood corpuscle of all children who participated in the research. Children at the age of three could not see the functional relationship between the blood and heart. One child who was six years told that the air we breathe goes directly in the heart from where the blood is circulating to the rest of the body, together with the food. Keywords: heart, blood, bloodstream, the body / Sammanfattning Uppsatsens syfte är att genom intervjuer, observationer och litteraturstudie undersöka vad några av de yngsta barnen vet om hjärtat, blodet och blodomloppet. Undersökningen gäller tjugo barn, hälften av dem är i treårsålder och den andra hälften är i sexårsåldern. Intervjuerna visade att sexåringar hade i stort sett bättre kunskaper än treåringar men en av treåringar visste att vi har blodkroppar i kroppen. Han var också den enda som nämnde blodkroppar av alla barn som deltog i undersökningen. Treåringar kunde inte se det funktionella sambandet mellan blodet och hjärtat. En av sexåringarna berättade att luften vi andas in hamnar direkt i hjärtat där den blir blod som cirkulerar vidare till resten av kroppen, tillsammans med maten. Nyckelord: hjärta, blod, blodomlopp, kroppen

Bakgrunn: Blodbaneinfeksjon er en av de alvorligste sykehusinfeksjonene pasienter kan utsettes for, og i intensivavdelingen rammes de mest sårbare pasientene. Målet med studien:Å finne insidensen av blodbaneinfeksjoner (BSI) i en intensivavdeling i et lokalsykehus i Norge, samt undersøke ulike risikofaktorer knyttet til Centrale Venekatetre (CVK) og generell infeksjon ved innleggelse i intensivavdelingen. Metode: Insidensregistrering av BSI i løpet av 12 mnd. der definisjoner av BSI bygger på 2001 International Sepsis Definition Conference. Data er samlet inn prospektivt etter hvert som pasientene ble lagt. Studiepopulasjonen er antallet pasienter som hadde vært innlagt i mer enn 48 timer i intensivavdelingen, og deles opp i tre åpne kohorter:Pasienter med diagnostisert BSI i løpet av oppholdet, pasienter som fikk lagt inn CVK og pasienter med infeksjon ved innleggelse. Resultater: 615 pasienter ble lagt inn i intensivavdelingen i løpet av 12 mnd, av disse ble 116 av de pasientene som hadde vært innlagt i intensivavdelingen i mer enn 48 timer inkludert i studien. Gjennomsnittlig liggetid i intensivavdelingen varierte fra 2 til 40 (median 4 dager). 73 av de 116 pasientene fikk lagt inn CVK, og av disse fikk 11 en bekreftet BSI. Tre pasienter uten CVK fikk bekreftet BSI, totalt 14. Av disse 14 var 6 nosokomiale, altså 5,2 % (6 av 116) eller 7,8 BSI/1000 pasientdøgn. Enpasient fikk diagnosen kateter-relatert BSI(CR-BSI), noe som tilsvarer 1,7 CR-BSI/1000 kateterdøgn. Det ble tatt totalt 69 blodkulturer, herav 54 fra pasienter med CVK. Pasienter med CVK har signifikant større risiko for å utvikle klinisk BSI, enn de utenCVK (OR=5,31; 95 % CI 2,32 –12,0; p&lt; 0,0001). Konklusjon: Denne studien viser en relativt lav forekomsten av BSI, NBSI og CR-BSI, men for å kunne sammenligne tall nasjonalt og internasjonalt er det behov for en consensus i fagmiljøet rundt definisjoner BSI og særlig CR-BSI. Det er signifikant sammenheng mellom CVK og utvikling av klinisk BSI, men studien viser ingen signifikant sammenheng mellom CVK og bekreftet BSI. Studien bør bidra til fokus på risikofaktorene knyttet til bruk av CVK, samt arbeid for consensus angående definisjoner og økt fokus på CR-BSI og klinisk BSI, siden dette har vist seg å ha like høy letalitet som bekreftet BSI / Background: BSIs is areof the most serious hospital infections patients are exposed to, and in the intensive care unit (ICU) it affects the most vulnerable patients. Aim: To find the incidence of BSI in an ICU in a local hospital in Norway, as well as examine the various risk factors related to Central venous catheters (CVK), as well as patients with general infection at point of admission. Method: Incidence registration of BSIs within 12 months, where the definitions of BSI is based upon the 2001 Sepsis Definition Conference. Data is collected prospectively as patients were admitted to the ICU. The study population is the number of patients who had been hospitalized for more than 48 hours in the ICU, and the study population is divided into three open cohorts.Patients with diagnosed BSI during their stay, patients with CVK during stay and patients with infection at admission. Results: 615 patients were in the ICU within 12 months, and 116 of those patients had been hospitalized for more than 48 hours in the ICU and were included in the study. Average length of stay ranged from 2 to 40 days (median 4 days). 73 of the 116 patients had CVK in place during their stay, andof these 11 had a laboratory confirmed BSI. Three patients without any central CVK in place during their stay in the ICU had a laboratory confirmed BSI, 14 in total. Of these 14, 6 weredefined nosocomial, i.e.5.2% (6 of 116) or 7.8 BSI/1,000 patient days. One patient was diagnosed with catheter-related BSI (CR-BSI), which corresponds to 1.7 CR-BSI/1, 000 catheter days. A total of 69 blood cultures were performed, of which 54 patients with CVK. Patients with CVK has a significantly higher risk of developing clinical BSI than those without CVK (OR = 5.3, 95% CI 2.32 to 12.0, p &lt; 0.0001). Conclusion: This study shows a relatively low incidence of BSI, NBSI and CR-BSI. CVK is significantly related to the development of clinical BSI, but the study shows no link between CVK and laboratory confirmed BSI. This study may encourage health care  workers to focus more on the risk factors associated with the use of CVK to critically ill patients. It should also encourage researchers to focus more on the importance of consensus regarding definitions of BSI and clinical BSI, since this have been proven to have as high lethality rates as laboratory confirmed BSI / <p>ISBN 978-91-86739-86-7</p>

Abstract In Oulu University Hospital Haematological Ward during the years 1990–1991, a manual blood culture system was able to detect bloodstream infection (BSI) in 23% of febrile episodes of patients with acute myeloid leukaemia (AML), whereas during the years 1992–1993 an automated continuous-monitoring blood culture system (CMBCS) BacT/Alert® detected BSI in 40% of febrile episodes (p = 0.043). During the years 1997–2003, regimens containing high-dose cytarabine predisposed patients to laboratory-confirmed BSI (LCBI) with an odds ratio (OR) of 2.3 (with 95% confidence interval (CI) from 1.2 to 4.2). The LCBI risk was lowest after thioguanine-containing regimens (OR 0.26, 95% CI; 0.12–0.58). In the register data (years 1992–2006) from the prospective multi-centre AML -92 trial, when compared to cycle I, the OR for LCBI was significantly higher (from 4.8 to 5.8) in subsequent cycles (p &lt; 0.001). In all, 67% of mortality due to BSI occurred in patients with active leukaemia. An inoculum of microorganisms to produce 10 colony-forming units (cfu)/ml of 10 gram-positive coccal strains, 10 gram-negative bacillar strains and 8 Candida yeast strains was cultured in BacT/Alert® blood culture bottles in the presence of several chemotherapeutic drugs. Of the chemotherapeutic drugs tested, the anthracyclines exhibited inhibitory effects on the growth of microorganisms in concentrations corresponding to the therapeutic levels. In the standard bottles, doxorubicin increased the incubation time of gram-positive cocci and idarubicin increased the incubation time of Candida glabrata. However, no increase in the incubation time of any microbes was detected in the antimicrobial-neutralizing FAN bottles. In conclusion, the use of CMBCSs has resulted in an increased LCBI rate in neutropenic AML patients. In general, chemotherapeutic agents have no significant inhibitory effects on the growth of common microbial pathogens in blood culture. The detection of some difficult-to-culture microbial strains – C. glabrata for example – in blood cultures may be impaired by the presence of chemotherapeutics in blood. The chemotherapeutics may also affect the LCBI rate in other ways. As a predictor of adverse outcome of infection, the presence of active leukaemia is more important than the type of chemotherapy being administered.

Springer and European Journal of Clinical Microbiology and Infectious Diseases, 33, 2014, 1371-79, Seasonal trend and clinical presentation of Bacillus cereus bloodstream infection: association with summer and indwelling catheter, K. Kato & Y. Matsumura & M. Yamamoto & M. Nagao & Y. Ito & S. Takakura & S. Ichiyama, figure number 2, original copyright notice is given to the publication in which the material was originally published, by adding; with kind permission from Springer Science and Business Media / 京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19922号 / 医博第4142号 / 新制||医||1017(附属図書館) / 33008 / 京都大学大学院医学研究科医学専攻 / (主査)教授 中川 一路, 教授 佐藤 俊哉, 教授 玉木 敬二 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: Bloodstream infection (BSI) caused by Klebsiella pneumoniae (KP), is a leading cause of hospitalassociated childhood mortality. There are limited data on how poor outcomes of KPBSI can be predicted in poorly resourced areas. This study aimed to assess if the profile of differential counts from full blood counts (FBC) taken at two time points in children <13 years with KPBSI could be used to predict the risk of death. Methods We conducted a retrospective study of a cohort of children admitted to hospital between 2006-2011 with KPBSI. FBC collected within 48 hours (T1) of blood culture and 5-14 days later (T2), were reviewed. Differential counts were classified as abnormal if they were higher or lower than laboratory ranges for normal results. The risk of death was assessed for each category of differential counts. Risk ratios adjusted (aRR) for potential confounders were used to estimate the effect of cell counts on risk of death using multivariable analysis. Data were stratified by HIV status. Results: Of 296 children included, median age 5 (IQR:2-13) months, 82 were HIV -infected. Ninety-five (32%) of the children with KPBSI died. Mortality in HIV-infected and uninfected children was 39/82 (48%) and 56/214 (26%), respectively (p <0.001). Independent associations with mortality were observed with leucopenia, neutropenia and thrombocytopenia. Risk of mortality in children with thrombocytopenia at T1 and T2 was aRR 2.5 (95% CI: 1.34-4.64) and 3.18 (95% CI: 1.31-7.73) respectively in the HIV-uninfected group, whereas the risk for mortality in the HIV-infected group with thrombocytopaenia at T1 and T2 was aRR 1.99 (95% CI: 0.94-4.19) and 2.01 (95% CI: 0.65-5.99) respectively. Neutropenia in the HIV-uninfected group at T1 and T2, showed aRR 2.17 (95% CI: 1.22- 3.88) and 3.70 (95% CI 1.30-10.51) respectively, while in the HIV-infected group, they were aRR 1.18 (95% CI 0.69-2.03) and 2.05 (0.87-4.85) at similar time points. Risk of mortality related to leucopenia at T2 was associated with mortality in HIV-uninfected and HIV-infected patients was aRR 3.22 (95%CI 1.22-8.51) and 2.34 (1.09-5.04) respectively. Persistently high band cell percentage at T2 in HIVinfected children indicated a risk of mortality of aRR 2.91 (95% CI 1.20-7.06). Conclusion Abnormal neutrophil counts and thrombocytopenia are independently associated with significant mortality in children with KPBSI. In resource-limited countries haematological markers have the potential to predict KPBSI mortality.

Ethanol lock therapy is a novel technique that is being studied for its efficacy in eradicating catheter related bloodstream infections. A systematic review of interdisciplinary studies from CINAHL, Medline, Academic Search Premier, Biological Abstracts, and Web of Knowledge databases was performed. This meta-analysis examined the findings of thirty-five studies on ethanol lock therapy. Twenty-six of these studies compared ethanol to a placebo and nine studies performed a direct comparison of ethanol to other agents frequently used in antimicrobial lock technique. Ethanol lock therapy was shown to be effective as both a prophylactic therapy and as an active treatment in eradicating biofilms of organisms that frequently cause catheter-related blood stream infections, including Staphylococcus epidermis, Staphylococcus aureus, Klebsiella pneumonia, Pseudomonas aeruginosa, E. coli, and Candida albicans. Ethanol has been shown to have a synergistic effect with several other antimicrobial agents. The majority of studies examined in this thesis have found that ethanol has equal or greater efficacy to several antibiotic and antimicrobial agents used in practice and should therefore be considered for the treatment of catheter-related blood stream infections.

Monocytic human leukocyte antigen-D related (mHLA-DR) expression determined by flow cytometry has been suggested as a biomarker of sepsisinduced immunosuppression. In order to facilitate use of HLA-DR in clinical practice, a quantitative real-time PCR technique measuring HLA-DR at the transcription level was developed and evalutated. Levels of HLA-DR mRNA correlated to mHLADR expression and were robustly measured, with high reproducibility, during the course of infection. Dynamics of mHLA-DR expression was studied during the first weeks of bloodstream infection (BSI) and was found to be dependent on the bacterial etiology of BSI. Moreover, mHLA-DR was shown to be inversely related to markers of inflammation. In patients with unfavourable outcome, sustained high C-reactive protein level and high neutrophil count were demonstrated along with low mHLA-DR expression and low lymphocyte count. This supports the theory of sustained inflammation in sepsis-induced immunosuppression. The association between mHLA-DR and bacterial etiology may be linked to the clinical trajectory via differences in ability to cause intractable infection. Staphylococcus aureus was the dominating etiology among cases with unfavourable outcome. With focus on patients with S. aureus BSI, those with complicated S. aureus BSI were found to have lower HLA-DR mRNA expression during the first week than those with uncomplicated S. aureus BSI. If these results can be confirmed in a larger cohort, HLA-DR measurement could possibly become an additional tool for early identification of patients who require further investigation to clear infectious foci and achieve source control. In conclusion, PCR-based measurement of HLA-DR is a promising method for measurements of the immune state in BSI, but needs further evaluation in the intensive care unit setting to define the predictive and prognostic value for deleterious immunosuppression. The etiology of infection should be taken into consideration in future studies of translational immunology in sepsis.