Multidrug-Resistant Acinetobacter baumannii

To the Editor: In the January 2007 issue of Emerging Infectious Diseases, Sunenshine et al. (1) described their finding of an independent association between patients with multidrug-resistant (MDR) Acinetobacter infection and increased hospital and intensive care unit (ICU) length of stay compared with that for patients with antimicrobial drug–susceptible Acinetobacter infection. The authors did not, however, find a statistically significant difference in mortality rates between the 2 groups of patients.

single-source exposure with C. botulinum type B in at least 3 IDUs; this implies that the heroin was obtained from a common source, where contamination with C. botulinum spores may have been introduced when mixed with adulterants or diluted with substances such as dextrose or dyed paper. Skin popping (subcutaneous and intramuscular injection), which may increase the odds of wound botulism by a factor >15 (9), was used by all patients for drug delivery. This study confi rms previous observations that the duration of clinical symptoms before antitoxin administration affects the need for and duration of mechanical ventilation (10). Here, the time from hospital admission to antitoxin treatment ranged from several hours to 4 days and correlated with the mechanical ventilation interval ranging from 0 days to 11 weeks. In addition, the extent of abscesses, which ranged from no abscesses to multiple abscesses, seems to affect clinical outcome. As soon as an index case of wound botulism in IDUs is diagnosed, a coordinated public health case-management effort, including hospitals, outpatient clinics, and information centers for drug addicts, is mandatory to alert the medical community and the drug users to consider wound botulism if typical symptoms occur and to enable the prompt administration of antitoxin. Obtaining tissue samples or abscess fl uid for culture and molecular epidemiologic studies of C. botulinum isolates is necessary to facilitate identifi cation of the source of the contaminated heroin.

Multidrug-Resistant
Acinetobacter baumannii To the Editor: In the January 2007 issue of Emerging Infectious Diseases, Sunenshine et al. (1) described their fi nding of an independent association between patients with multidrug-resistant (MDR) Acinetobacter infection and increased hospital and intensive care unit (ICU) length of stay compared with that for patients with antimicrobial drug-susceptible Acinetobacter infection. The authors did not, however, fi nd a statistically signifi cant difference in mortality rates between the 2 groups of patients.
Acinetobacter infections frequently occur in severely ill ICU patients with other chronic illnesses or prolonged hospitalizations. We analyzed data for 27 neutropenic cancer patients with A. baumannii-associated bacteremia (15 with MDR and 12 with drug-susceptible A. baumannii infections) but no other chronic illness. We considered A. baumannii strains to be MDR if they were resistant to amikacin, meropenem, and ciprofl oxacin. Univariate analysis (Epi Info 2000; Centers for Disease Control and Prevention, Atlanta, GA, USA) showed that most of the bacteremic episodes were associated with certain risk factors, such as catheter insertion, neutropenia, acute leukemia, and previous prophylactic treatment with quinolones or therapeutic treatment with cephalosporins or carbapenems (meropenem or imipenem) (Table).
Septic shock developed in 4 (14.8%) of the 27 neutropenic patients with A. baumannii-associated bacteremia, and 2 (7.4%) of the 27 died (Table). However, we did not fi nd a statistically signifi cant association between death among patients with bacteremia caused by MDR A. baumanni (1 death) compared with death among those with bacteremia caused by A. baumannii strains susceptible to the carbapenems, ciprofl oxacin, and amikacin (1 death) (Table). This fi nding is similar to that described by Sunenshine et al. (1) in the general ICU population and in neutropenic cancer patients with bacteremia; however, multivariate analysis was not conducted to control for severity of illness and coexisting illness. In conclusion, neutropenic cancer patients with bacteremia due to MDR A. baumannii infection do not appear to be at increased risk for death compared with patients with bacteremia due to antimicrobial drug-susceptible A. baumannii.  (1). N. meningitidis serogroup X was fi rst described in the 1960s and has been found to cause a few cases of invasive disease across North America, Europe, and Africa (2). In Africa, small serogroup X outbreaks have been described in Ghana (9 cases over a 2-year period) and in Niger (134 cases between 1995 and 2000) (3,4). In 2006, however, 51% of 1,139 confi rmed cases of meningococcal meningitis in Niger were found to be caused by serogroup X (5). Before the 2005-06 meningococcal epidemic season, no published reports had described serogroup X isolates in East Africa. We report the involvement of N. meningitidis serogroup X in an outbreak of meningococcal disease in Western Kenya.
In Over the course of the outbreak, cerebrospinal fl uid samples were obtained from 18 patients. Due to low population density, poor access to seminomadic populations, and the

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