Increased Antimicrobial Resistance against metronidazole and carbapenem in clinical anaerobic isolates from Pakistan.

Increased Antimicrobial Resistance against metronidazole and carbapenem in clinical anaerobic isolates from Pakistan was recently reported by reported by Shafquat and colleagues  from , Aga Khan University Hospital,in Karachi, Pakistan.

 Of the 223 clinically significant isolates collected between 2014 and 2017, 39 (17.5%) were metronidazole resistant. Imipenem resistance was determined in 29 metronidazole resistant isolates and of these 7 (24.1%) were found to be resistant. Proportion of metronidazole resistant strains was highest amongst Bacteroides species. A significant increase in metronidazole resistance from 12.3% in 2010-2011 to 17.5% in the current study was found. Carbapenem resistance also emerged in the period 2014-2017.

Isolates from malignancy and transplant patients showed lower odds of developing metronidazole resistance. Prolonged hospital stay was not associated with metronidazole resistance.

The worldwide rising trend of metronidazole resistance and emergence of carbapenem resistance in anaerobic bacteria is alarming. Continued surveillance with strengthening of laboratory capacity regarding anaerobic susceptibility testing is urgently needed.

Establishing the bacterial etiology of necrotizing soft tissue infections using 16S sequencing detection

Necrotizing soft tissue infections (NSTIs) are the most severe and rapidly progressing class of skin and soft tissue infections (SSTIs). They are a surgical emergency and are associated with high mortality and morbidity. While NSTIs remain relatively rare, their incidence is steadily rising.

Earlier diagnosis and more focused antibiotic treatments can potentially improve patient outcome, but both of these solutions require a more accurate understanding of the microbial component of these infections.

Streptococcus and Staphylococcus species, especially S. aureus, are most commonly aerobic isolates and Clostridium spp. (C.perfringens and C. septicum) and Bacteroides fragilis group are the commonest anaerobes detected. Clostridium spp. are often found in monomicrobial infections and are associated with mortality rates greater than 50%. Certain gram negative rods, including Escherichia coli and Pseudomonas species, are also found,

While molecular detection methods, namely 16S sequencing, have not been traditionally used to identify the causative microorganisms in NSTIs, they are becoming more commonplace as a diagnostic tool for other types of SSTIs, especially for chronic wound infections. In chronic wound infections, 16S sequencing has revealed a higher than previously detected prevalence of obligate anaerobes. The use of 16S sequencing may lead to the detection of a higher than expected proportion of obligate anaerobes in NSTIs and consequently improve the care of patients with NSTIs.

Necrotizing fasciitis 

Impact of Inappropriate Therapy on Mortality associated with Anaerobic Bacteremia.

Kim et al. analyzed the incidence and risk factors related to mortality and assess clinical outcomes of anaerobic bacteremia during 2012 in Yonsei University Hospital, Seoul, Korea.

A total of 70 anaerobic bacteria were isolated from blood of 70 bacteremia patients. The history of cardiovascular disease as host's risk factor was statistically significant. The incidence of anaerobic bacteremia in was 2.3% per 100 positive blood culture patients, and the mortality rate in patients with clinically significant anaerobic bacteremia was 21.4%. anaerobic bacteremia was frequently noted in patients with malignancy.

The survival rate of bacteremia was significantly worse in patients who had inappropriate therapy compared with those underwent appropriate therapy. The most frequently isolated organism was Bacteroides fragilis (32 isolates, 46%), Bacteroides thetaiotaomicron (10, 14%), and non-perfringens Clostridium (7, 10%).

Non-surgical circumcisions with low risk of infection approved by WHO used to reduces HIV in Africa

The World Health Organization (WHO) approved expanded use of an Israeli developed device that allows medical workers to perform “painless circumcisions.” The PrePex device, created by Israel-based Circ MedTech, will be granted WHO prequalification on May 31 for use with males age 13 and above in 14 African countries.

Circumcision is one of the most effective ways to prevent the spread of AIDS – which affects nearly 30 million in Africa. Research and experience shows that male circumcision, when safely provided by well-trained health professionals, reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Circumcision can therefore play an important role in preventing the spread of HIV. Persuading adult to undergo circumcision is difficult mostly because it is painful. Furthermore surgical circumcision is done in a hospital or specialized clinic which are not available in the countryside.

PrePex which is produced by Circ Medtech is the first and so far only nonsurgical male circumcision device. Using the device does not require injected anesthesia, surgery, sutures, or sterile settings. The device, consisting of plastic and rubber rings that are placed on the penis and uses pressure to separate the foreskin from the head of the penis. The elastic pressure ring is applied to the foreskin, cutting off distal blood flow. The placement of PrePex band completely separate the foreskin from the glands penis. It causes death of all human cells within the foreskin preventing the spread of bacterial toxin or bacterial infection from the necrotic foreskin. After a week, the foreskin falls off, and the wound is treated with a salve.

PrePex Non Surgical Male Circumcision Procedure video

PrePex was found in studies conducted in association with the WHO to be safe and effective when performed by physicians and nurses, offering a virtually bloodless procedure that requires no injection of anesthesia, no knives, no sutures, and can be performed in a non-sterile environment. To date, more than 125,000 PrePex procedures have been conducted in 12 countries: Botswana, Kenya, Lesotho, Malawi, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe and Indonesia. More than 11 national Training Centers are located across Africa, training local healthcare professionals.

         PrePex Non Surgical Male Circumcision

Treating appendicitis with antibiotics

Surgical removal of the inflamed appendix has been the standard of care for over a 120 years.  More than 300,000 appendectomies are performed annually in the United States.  Even though appendectomy is generally well tolerated, it is a major surgical procedure and can be associated with postoperative morbidity.

A recent study by Salminen et al.  from Turku University Hospital in Finland found that three of four patients with appendicitis treated with antibiotics did not need to have their appendix surgically removed. Those who eventually needed the surgery were not harmed by postponing the procedure as there were no intra-abdominal abscesses or other major complications associated with delayed appendectomy.

The study illustrated that emergency appendectomy is only indicated in those with CT-proven complicated appendicitis that can cause the appendix to rupture, which make only about one in five of patients. In contrast, those with CT- proven uncomplicated appendicitis can be treated with antibiotics.

The investigator randomly assigned 273 patients with acute appendicitis to appendectomy and 256 to a 10-day course of antibiotics. Appendectomies were successful in all but one of 273 (0.4%) patients. Among 256 patients treated with antibiotics and followed for a year, 186 (73%) did not require surgery. However, 70 (27%) percent of the patients treated with antibiotics had to have their appendix removed within a year after treatment. No patient in the antibiotic group developed a serious infection resulting from delayed appendectomy, suggesting that the decision to delay appendectomy for uncomplicated acute appendicitis can be made with low likelihood of major complications resulting from delayed surgery.

These findings suggest that for CT-diagnosed uncomplicated appendicitis, an initial trial of antibiotics is reasonable followed by elective appendectomy for patients who do not improve with antibiotics or present with recurrent appendicitis. Because patients with complicated appendicitis, with appendicoliths, children, and pregnant women were excluded from this study, the results do not apply to these groups.

Future studies are warranted that should focus both on early identification of complicated acute appendicitis patients needing surgery and to prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.

The pitfalls of antibiotic treatment should also be addressed in future studies. Broad spectrum antibiotics can promote the emergence resistant organisms as well as Clostridium difficile infections. These potential adverse effects may tilt the balance towards performing appendectomy.

Furthermore, inclusion of greater number of patients is required in future studies to evaluate the ability of antibiotics to prevent pelvic abscesses as effectively as surgery.

These study has highlighted the need consider discarding routine appendectomy for patients with uncomplicated appendicitis. Because of the availability of precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis.