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Clinical and microbiological characteristics of bloodstream infections due to AmpC β-lactamase producing Enterobacteriaceae: an active surveillance cohort in a large centralized Canadian region. BMC Infect Dis 2014; 14:647. [PMID: 25494640 PMCID: PMC4299784 DOI: 10.1186/s12879-014-0647-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 11/21/2014] [Indexed: 01/12/2023] Open
Abstract
Background The objective of this study was to describe the clinical and microbiological characteristics of bloodstream infections (BSIs) due to AmpC producing Enterobacteriaceae (AE) in a large centralized Canadian region over a 9-year period. Methods An active surveillance cohort design in Calgary, Canada. Results A cohort of 458 episodes of BSIs caused by AE was assembled for analysis. The majority of infections were of nosocomial origin with unknown sources. Enterobacter spp. was the most common species while BSIs due to Serratia spp. had a significant higher mortality when compared to other AE. Delays in empiric or definitive antibiotic therapy were not associated with a difference in outcome. However, patients that did not receive any empiric antimicrobial therapy had increased mortality (3/5; 60% vs. 57/453; 13%; p = 0.018) as did those that did not receive definitive therapy (6/17; 35% vs. 54/441; 12%; p = 0.015). Conclusions Delays in therapy were not associated with adverse outcomes although lack of active therapy was associated with increased mortality. A strategy for BSIs due to AE where β-lactam antibiotics (including oxyimino-cephalosporins) are used initially followed by a switch to non-β-lactam antibiotics once susceptibility results are available is effective.
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Nutman A, Glick R, Temkin E, Hoshen M, Edgar R, Braun T, Carmeli Y. A case-control study to identify predictors of 14-day mortality following carbapenem-resistant Acinetobacter baumannii bacteraemia. Clin Microbiol Infect 2014; 20:O1028-34. [DOI: 10.1111/1469-0691.12716] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 06/01/2014] [Accepted: 06/08/2014] [Indexed: 01/31/2023]
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153
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Yeh CF, Chen KF, Ye JJ, Huang CT. Derivation of a clinical prediction rule for bloodstream infection mortality of patients visiting the emergency department based on predisposition, infection, response, and organ dysfunction concept. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 47:469-77. [DOI: 10.1016/j.jmii.2013.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/01/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
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Peña C, Cabot G, Gómez-Zorrilla S, Zamorano L, Ocampo-Sosa A, Murillas J, Almirante B, Pomar V, Aguilar M, Granados A, Calbo E, Rodríguez-Baño J, Rodríguez-López F, Tubau F, Martínez-Martínez L, Oliver A. Influence of virulence genotype and resistance profile in the mortality of Pseudomonas aeruginosa bloodstream infections. Clin Infect Dis 2014; 60:539-48. [PMID: 25378459 DOI: 10.1093/cid/ciu866] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The type III secretion system (TTSS) is a major virulence determinant of Pseudomonas aeruginosa. The objective of this study was to determine whether the TTSS genotype is a useful prognostic marker of P. aeruginosa bacteremia mortality. We also studied the potential association between TTSS genotypes and multidrug-resistant (MDR) profiles, and how this interaction impacts the outcome of bloodstream infections. METHODS We performed a post hoc analysis of a published prospective multicenter cohort of P. aeruginosa bloodstream infections. The impact in mortality of TTSS genotypes (exoS, exoT, exoU, and exoY genes) and resistance profiles was investigated. Cox regression analysis was used to control for confounding variables. RESULTS Among 590 patients, the 30-day mortality rate was 30% (175 patients), and 53% of them died in the first 5 days (early mortality). The unadjusted probabilities of survival until 5 days was 31.4% (95% confidence interval [CI], 17.4%-49.4%) for the patients with exoU-positive isolates and 53.2% (95% CI, 44.6%-61.5%) for exoU-negative isolates (log rank P = .005). After adjustment for confounders, exoU genotype (adjusted hazard ratio [aHR], 1.90 [95% CI, 1.15-3.14]; P = .01) showed association with early mortality. In contrast, late (30-day) mortality was not influenced by TTSS genotype but was independently associated with MDR profiles (aHR,1.40 [95% CI, 1.01-1.94]; P = .04). Moreover, the exoU genotype (21% of all isolates) was significantly less frequent (13%) among MDR strains (particularly among extensively drug-resistant isolates, 5%), but was positively linked to moderately resistant (1-2 antipseudomonals) phenotypes (34%). CONCLUSIONS Our results indicate that the exoU genotype, which is associated with specific susceptibility profiles, is a relevant independent marker of early mortality in P. aeruginosa bacteremia.
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Affiliation(s)
- Carmen Peña
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Gabriel Cabot
- Unidad de Investigación, Servicio de Microbiología y Servicio de Medicina Interna, Hospital Universitario de Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca
| | - Silvia Gómez-Zorrilla
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Laura Zamorano
- Unidad de Investigación, Servicio de Microbiología y Servicio de Medicina Interna, Hospital Universitario de Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca
| | - Alain Ocampo-Sosa
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla-IFIMAV, Santander
| | - Javier Murillas
- Unidad de Investigación, Servicio de Microbiología y Servicio de Medicina Interna, Hospital Universitario de Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca
| | - Benito Almirante
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d'Hebrón
| | - Virginia Pomar
- Unidad de Enfermedades Infecciosas, Hospital Santa Creu i Sant Pau, Barcelona
| | - Manuela Aguilar
- Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen del Rocío, Sevilla
| | - Ana Granados
- Sección de Enfermedades Infecciosas, Consorci Hospitalari Parc Taulí, Sabadell
| | - Esther Calbo
- Sección de Enfermedades Infecciosas, Hospital Mutua de Terrasa
| | - Jesús Rodríguez-Baño
- Sección de Enfermedades Infecciosas, Hospital Universitario Virgen Macarena, Sevilla
| | | | - Fe Tubau
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge-IDIBELL, Barcelona
| | - Luis Martínez-Martínez
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla-IFIMAV, Santander Departamento de Biología Molecular, Universidad de Cantabria, Santander, Spain
| | - Antonio Oliver
- Unidad de Investigación, Servicio de Microbiología y Servicio de Medicina Interna, Hospital Universitario de Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca
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Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia. Dig Dis Sci 2014; 59:2790-6. [PMID: 24898101 DOI: 10.1007/s10620-014-3233-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 05/26/2014] [Indexed: 12/09/2022]
Abstract
BACKGROUND Biliary decompression with antibiotic therapy is the mainstay treatment for acute cholangitis with bacteremia. A few studies have been conducted to investigate the optimal duration and route of antibiotic therapy in biliary tract infection with bacteremia. METHODS Patients with acute cholangitis with bacteremia who achieved successful biliary drainage were randomly assigned to an early oral antibiotic switch group (group A, n = 29) and a conventional intravenous antibiotics group (group B, n = 30). Patients were discharged when they were afebrile over 2 days after oral antibiotic switch and showed consecutive improvement in the laboratory index. They were followed up and assessed at 30 days after diagnosis to evaluate the eradication of bacteria, recurrence of acute cholangitis, and 30-day mortality rate. RESULTS There were no statistically significant differences between the two groups in baseline characteristics, clinical and laboratory index, severity of acute cholangitis, bacteria isolated from blood cultures, and clinical outcomes. The rate of eradication of bacteria was 93.1 % in group A and 93.3 % in group B, respectively (p = 0.97). Using non-inferiority tests, the rate of eradication of bacteria in group A was not inferior to that in group B (95 % CI -0.13 to 0.14, p = 0.97). There was no statistically significant difference in the recurrence of acute cholangitis and a 30-day mortality rate between the two groups. CONCLUSIONS Early switch to oral antibiotic therapy following adequate biliary drainage for treatment of acute cholangitis with bacteremia was not inferior to conventional 10-day intravenous antibiotic therapy.
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Time to positivity in blood cultures of adults with nontyphoidal Salmonella bacteremia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 49:417-23. [PMID: 25311404 DOI: 10.1016/j.jmii.2014.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/23/2014] [Accepted: 08/07/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Nontyphoidal Salmonella (NTS) is an important bacterial etiology of diarrheal disease, and it causes invasive diseases in immunocompromised hosts. For bacteremia from some species, blood culture with a rapid time to positivity (TTP) is associated with greater mortality. This study investigated TTP of NTS bacteremia and its relationship to clinical parameters and prognosis. METHODS Adult patients with NTS bacteremia who were admitted to a tertiary care facility in northern Taiwan from January 2010 to December 2012 were enrolled. Demographics, clinical and microbiological characteristics, and treatment response were reviewed. The TTP for each patient was retrieved from the automated machine. RESULTS Sixty-six adult patients (mean age, 66.1 years; range, 27-96 years) with NTS bacteremia were identified by the following serogroup distributions: serogroup B (23.4%), serogroup C1 (1.6%), serogroup C2 (6.3%), and serogroup D (68.8%). The in-hospital mortality, 14-day mortality, and 30-day mortality were 15.2%, 7.6%, and 12.1%, respectively. The TTP ranged 6.5-41.7 hours (median: 11.5 hours). Patients with rapid TTP (less than 10 hours), compared to patients without rapid TTP, were more likely to have liver cirrhosis (31.6% vs. 6.4%, p = 0.013), endovascular lesions (21.1% vs. 4.3%, p = 0.05), higher bacteremia score, intensive care unit admission (57.9% vs. 25.5%, p = 0.021), and septic shock (63.2% vs. 12.8%, p < 0.001). There were no significant differences in the in-hospital mortality and 14-day mortality between patients with TTP <10 hours and patients with TTP ≥10 hours. CONCLUSION The TTP of blood cultures, interpreted with a cut-off point of <10 hours, in patients with NTS bacteremia may provide useful diagnostic and prognostic information.
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Blanchette LM, Kuti JL, Nicolau DP, Nailor MD. Clinical comparison of ertapenem and cefepime for treatment of infections caused by AmpC beta-lactamase-producing Enterobacteriaceae. ACTA ACUST UNITED AC 2014; 46:803-8. [DOI: 10.3109/00365548.2014.954262] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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158
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Hall RG, Blaszczyk AT, Thompson KA, Brouse SD, Giuliano CA, Frei CR, Forcade NA, Mortensen EM, Bell T, Bedimo RJ, Alvarez CA. Impact of empiric weight-based vancomycin dosing on nephrotoxicity and mortality in geriatric patients with methicillin-resistant Staphylococcus aureus bacteraemia. J Clin Pharm Ther 2014; 39:653-7. [PMID: 25200273 DOI: 10.1111/jcpt.12203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/12/2014] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Few studies have evaluated the effect of vancomycin dosing on the health outcomes in geriatric patients. Data are needed to determine whether higher vancomycin dosing strategies are more effective in geriatric patients and/or lead to excessive rates of adverse events. METHODS This study used a subset of patients aged ≥65 years from a multicentre, retrospective, cohort study of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Patients received ≥ 48 h of empiric vancomycin between 1 July 2002 and 30 June 2008. We compared the incidence of nephrotoxicity and in-hospital mortality in patients who received guideline-recommended dosing (at least 15 mg/kg/dose) to patients who received lower dosing. Multivariable generalized mixed-effect models were constructed to determine independent risk factors for nephrotoxicity and in-hospital mortality. RESULTS AND DISCUSSION Half of the cohort (46% of 92 patients) received guideline-recommended dosing. Empiric use of weight-based dosing did increase the percentage of patients achieving a vancomycin trough ≥ 15 mg/L (57% vs. 42%). Nephrotoxicity occurred in 32% of patients and 26% died during their hospitalization. Guideline-recommended dosing was not associated with significant changes in nephrotoxicity (OR 1·13; 95% CI 0·40-3·19) or in-hospital mortality (OR 1·14; 95% CI 0·41-3·18) in the multivariable analysis. WHAT IS NEW AND CONCLUSION In this study of geriatric patients, guideline-recommended dosing was not associated with significant changes in nephrotoxicity or mortality. As 40% of the patients who received guideline-recommended dosing failed to achieve a target vancomycin trough of ≥ 15 mg/L, future studies should focus on dosing strategies to increase target attainment rate.
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Affiliation(s)
- R G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, TX, USA; Department of Clinical Sciences, University of Texas Southwestern, Dallas, TX, USA
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Kim SJ, Park KH, Chung JW, Sung H, Choi SH, Choi SH. Prevalence and impact of extended-spectrum β-lactamase production on clinical outcomes in cancer patients with Enterobacter species bacteremia. Korean J Intern Med 2014; 29:637-46. [PMID: 25228840 PMCID: PMC4164728 DOI: 10.3904/kjim.2014.29.5.637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 04/17/2014] [Accepted: 05/22/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We examined the prevalence of extended-spectrum β-lactamase (ESBL) production and the impact of ESBL on clinical outcomes in cancer patients with Enterobacter spp. bacteremia. METHODS Using prospective cohort data on Enterobacter bacteremia obtained between January 2005 and November 2008 from a tertiary care center, the prevalence and clinical impact of ESBL production were evaluated. RESULTS Two-hundred and three episodes of Enterobacter spp. bacteremia were identified. Thirty-one blood isolates (15.3%, 31/203) scored positive by the double-disk synergy test. Among 17 isolates in which ESBL genes were detected by polymerase chain reaction and sequencing, CTX-M (n = 12), SHV-12 (n = 11), and TEM (n = 4) were the most prevalent ESBL types. Prior usage of antimicrobial agents (77.4% vs. 54.0%, p = 0.02) and inappropriate empirical antimicrobial therapy (22.6% vs. 3.0%, p < 0.001) were more commonly encountered in the ESBL-positive group than in the extended-spectrum cephalosporin-susceptible ESBL-negative group, respectively. Clinical outcomes did not differ significantly between the two groups (30-day mortality rate, 19.4% vs. 17.0%, p = 0.76; median length of hospital stay, 24.0 days vs. 30.5 days, p = 0.97). Initial presentation of severe sepsis/septic shock, pneumonia, and intra-abdominal infection were independently associated with 30-day mortality. CONCLUSIONS The prevalence of ESBL-producing isolates was 15.3% in cancer patients with Enterobacter bacteremia. Although inappropriate empirical therapy was more common in the ESBL-positive group, ESBL production was not associated with poorer outcomes.
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Affiliation(s)
- Sun Jong Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Ki-Ho Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Jin-Won Chung
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Ho Choi
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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160
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Mezzatesta ML, Gona F, Stefani S. Enterobacter cloacae complex: clinical impact and emerging antibiotic resistance. Future Microbiol 2014; 7:887-902. [PMID: 22827309 DOI: 10.2217/fmb.12.61] [Citation(s) in RCA: 308] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Species of the Enterobacter cloacae complex are widely encountered in nature, but they can act as pathogens. The biochemical and molecular studies on E. cloacae have shown genomic heterogeneity, comprising six species: Enterobacter cloacae, Enterobacter asburiae, Enterobacter hormaechei, Enterobacter kobei, Enterobacter ludwigii and Enterobacter nimipressuralis, E. cloacae and E. hormaechei are the most frequently isolated in human clinical specimens. Phenotypic identification of all species belonging to this taxon is usually difficult and not always reliable; therefore, molecular methods are often used. Although the E. cloacae complex strains are among the most common Enterobacter spp. causing nosocomial bloodstream infections in the last decade, little is known about their virulence-associated properties. By contrast, much has been published on the antibiotic-resistance features of these microorganisms. In fact, they are capable of overproducing AmpC β-lactamases by derepression of a chromosomal gene or by the acquisition of a transferable ampC gene on plasmids conferring the antibiotic resistance. Many other resistance determinants that are able to render ineffective almost all antibiotic families have been recently acquired. Most studies on antimicrobial susceptibility are focused on E. cloacae, E. hormaechei and E. asburiae; these studies reported small variations between the species, and the only significant differences had no discriminating features.
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Affiliation(s)
- Maria Lina Mezzatesta
- Department of Bio-Medical Sciences, Section of Microbiology, University of Catania, Via Androne 81, 95124 Catania, Italy.
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161
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Delgado-Valverde M, Sojo-Dorado J, Pascual A, Rodríguez-Baño J. Clinical management of infections caused by multidrug-resistant Enterobacteriaceae. Ther Adv Infect Dis 2014; 1:49-69. [PMID: 25165544 DOI: 10.1177/2049936113476284] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Enterobacteriaceae showing resistance to cephalosporins due to extended-spectrum β-lactamases (ESBLs) or plasmid-mediated AmpC enzymes, and those producing carbapenemases have spread worldwide during the last decades. Many of these isolates are also resistant to other first-line agents such as fluoroquinolones or aminoglycosides, leaving few available options for therapy. Thus, older drugs such as colistin and fosfomycin are being increasingly used. Infections caused by these bacteria are associated with increased morbidity and mortality compared with those caused by their susceptible counterparts. Most of the evidence supporting the present recommendations is from in vitro data, animal studies, and observational studies. While carbapenems are considered the drugs of choice for ESBL and AmpC producers, recent data suggest that certain alternatives may be suitable for some types of infections. Combined therapy seems superior to monotherapy in the treatment of invasive infections caused by carbapenemase-producing Enterobacteriaceae. Optimization of dosage according to pharmacokinetics/pharmacodynamics data is important for the treatment of infections caused by isolates with borderline minimum inhibitory concentration due to low-level resistance mechanisms. The increasing frequency and the rapid spread of multidrug resistance among the Enterobacteriaceae is a true and complex public health problem.
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Affiliation(s)
- Mercedes Delgado-Valverde
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jesús Sojo-Dorado
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alvaro Pascual
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, and Department of Microbiology, University of Seville, Seville, Spain
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Avda Dr Fedriani 3, 41009 Seville, Spain
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162
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Maseda E, Aguilar L, Gimenez MJ, Gilsanz F. Ceftolozane/tazobactam (CXA 201) for the treatment of intra-abdominal infections. Expert Rev Anti Infect Ther 2014; 12:1311-24. [DOI: 10.1586/14787210.2014.950230] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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163
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Albrich WC, Madhi SA, Adrian PV, van Niekerk N, Telles JN, Ebrahim N, Messaoudi M, Paranhos-Baccalà G, Giersdorf S, Vernet G, Mueller B, Klugman KP. Pneumococcal colonisation density: a new marker for disease severity in HIV-infected adults with pneumonia. BMJ Open 2014; 4:e005953. [PMID: 25113557 PMCID: PMC4127937 DOI: 10.1136/bmjopen-2014-005953] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE A high genomic load of Pneumococcus from blood or cerebrospinal fluid has been associated with increased mortality. We aimed to analyse whether nasopharyngeal colonisation density in HIV-infected patients with community-acquired pneumonia (CAP) is associated with markers of disease severity or poor outcome. METHODS Quantitative lytA real-time PCR was performed on nasopharyngeal swabs in HIV-infected South African adults hospitalised for acute CAP at Chris Hani Baragwanath Hospital, Soweto, South Africa. Pneumonia aetiology was considered pneumococcal if any sputum culture or Gram stain, urinary pneumococcal C-polysaccharide-based antigen, blood culture or whole blood lytA real-time PCR revealed pneumococci. RESULTS There was a moderate correlation between the mean nasopharyngeal colonisation densities and increasing CURB65 scores among all-cause patients with pneumonia (Spearman correlation coefficient r=0.15, p=0.06) or with the Pitt bacteraemia score among patients with pneumococcal bacteraemia (p=0.63). In patients with pneumococcal pneumonia, nasopharyngeal pneumococcal colonisation density was higher among non-survivors than survivors (7.7 vs 6.1 log10 copies/mL, respectively, p=0.02) and among those who had pneumococci identified from blood cultures and/or by whole blood lytA real-time PCR than those with non-bacteraemic pneumococcal pneumonia (6.6 vs 5.6 log10 copies/mL, p=0.03). Nasopharyngeal colonisation density correlated positively with the biomarkers procalcitonin (Spearman correlation coefficient r=0.37, p<0.0001), proadrenomedullin (r=0.39, p=0.008) and copeptin (r=0.30, p=0.01). CONCLUSIONS In addition to its previously reported role as a diagnostic tool for pneumococcal pneumonia, quantitative nasopharyngeal colonisation density also correlates with mortality and prognostic biomarkers. It may also be useful as a severity marker for pneumococcal pneumonia in HIV-infected adults.
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Affiliation(s)
- Werner C Albrich
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St Gallen, St Gallen, Switzerland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases University of the Witwatersrand, Johannesburg, South Africa
| | - Peter V Adrian
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nadia van Niekerk
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - N Ebrahim
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Guy Vernet
- Emerging Pathogens Laboratory, Fondation Mérieux, Lyon, France
- Centre Pasteur du Cameroun, Yaoundé, Cameroun
| | - Beat Mueller
- Department of Internal Medicine, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Keith P Klugman
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Hubert Department of Global Health and Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Pneumonia Program, Bill and Melinda Gates Foundation, Seattle, Washington, USA
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Tsai HY, Chen YH, Tang HJ, Huang CC, Liao CH, Chu FY, Chuang YC, Sheng WH, Ko WC, Hsueh PR. Carbapenems and piperacillin/tazobactam for the treatment of bacteremia caused by extended-spectrum β-lactamase-producing Proteus mirabilis. Diagn Microbiol Infect Dis 2014; 80:222-6. [PMID: 25139843 DOI: 10.1016/j.diagmicrobio.2014.07.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/04/2014] [Accepted: 07/20/2014] [Indexed: 11/19/2022]
Abstract
This study was intended to delineate the role of carbapenems and piperacillin/tazobactam in treating bacteremia caused by extended-spectrum β-lactamase (ESBL)-producing Proteus mirabilis. We performed a multicenter and retrospective study of the patients with ESBL-producing P. mirabilis bacteremia. The outcomes of the patients treated by piperacillin/tazobactam or a carbapenem for at least 48 hours and the MICs of the prescribed drugs for these isolates were analyzed. Forty-seven patients with available clinical data were included. The overall 30-day mortality rate was 29.8%. All available isolates (n = 44) were susceptible to ertapenem, meropenem, and doripenem, and 95.6% were susceptible to piperacillin/tazobactam; however, only 11.4% of the isolates were susceptible to imipenem. Among the 3 patients infected with isolates exhibiting non-susceptibility to imipenem (MIC ≥2 mg/L) who were treated with imipenem, none died within 28 days. The 30-day (14.3% versus 23.1%, P = 0.65) or in-hospital (19.1% versus 30.8%, P = 0.68) mortality rate of 21 patients treated by a carbapenem was lower than that of 13 treated by piperacillin/tazobactam. However, among those treated by piperacillin/tazobactam, the mortality rate of those infected by the isolates with lower piperacillin/tazobactam MICs (≤0.5/4 mg/L) was lower than that of the isolates with MICs of ≥1/4 mg/L (0%, 0/7 versus 60%, 3/5; P = 0.045). ESBL-producing P. mirabilis bacteremia is associated with significant mortality, and carbapenem therapy could be regarded as the drugs of choice. The role of piperacillin/tazobactam, especially for the infections due to the isolates with an MIC ≤0.5/4 mg/L, warrants more clinical studies.
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Affiliation(s)
- Hsih-Yeh Tsai
- Section of Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yen-Hsu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Hung-Jen Tang
- Departments of Medicine and Medical Research, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chi-Chang Huang
- Department of Internal Medicine, National Cheng Kung University Hospital and Department of Medicine, National Cheng Kung University Medical College, No. 138, Sheng Li Road, Tainan, 704, Taiwan
| | - Chun-Hsing Liao
- Section of Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Fang-Yeh Chu
- Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yin-Ching Chuang
- Departments of Medicine and Medical Research, Chi Mei Medical Center, Tainan City, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital and Department of Medicine, National Cheng Kung University Medical College, No. 138, Sheng Li Road, Tainan, 704, Taiwan.
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7, Chung-Shan S. Rd, Taipei 100, Taiwan.
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Syue LS, Chen PL, Wu CJ, Lee NY, Lee CC, Li CW, Li MC, Tang HJ, Hsueh PR, Ko WC. Monomicrobial Aeromonas and Vibrio bacteremia in cirrhotic adults in southern Taiwan: Similarities and differences. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 49:509-15. [PMID: 25070280 DOI: 10.1016/j.jmii.2014.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/09/2014] [Accepted: 05/15/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Aeromonas and Vibrio are important water-borne pathogens causing substantial morbidity and mortality in cirrhotic patients in Taiwan, but the differences in clinical manifestations of Aeromonas and Vibrio bacteremia have not been reported in detail. METHODS From January 2003 to September 2013, cirrhotic patients with monomicrobial Aeromonas or Vibrio bacteremia at a medical center in Taiwan were included in this study. RESULTS The study population consisted of 77 cirrhotic patients with Aeromonas bacteremia and 48 patients with Vibrio bacteremia. Both pathogens clustered during the summer season; Vibrio bacteremia was more correlated with higher temperatures (Vibrio: r(2) = 0.95, p < 0.0001; Aeromonas: r(2) = 0.74, p = 0.006) and was associated with ingestion of undercooked seafood (p = 0.03) or cutaneous exposure (p < 0.001). Vibrio bacteremia mainly occurred in mildly or moderately decompensated cirrhosis (Child-Pugh class A and B: 45.8% vs. 20.8%, p = 0.003), and caused more soft-tissue infections (31.3% vs. 5.2%; p < 0.001) and renal dysfunction (1.6 ± 1.2 mg/dL vs. 1.3 ± 0.8 mg/dL, p = 0.006). Sepsis-related mortality was similar in the cases of Vibrio and Aeromonas bacteremia (14.6% vs. 14.3%, p = 0.96), but those with Vibrio bacteremia underwent a fulminant course, as evidenced by a shorter time from bacteremia onset to death (3.1 days vs. 8.2 days, p = 0.04). CONCLUSION In cirrhotic patients, bacteremia caused by Aeromonas and Vibrio species clustered in summer months and caused similar mortality, but Vibrio bacteremia led to a more severe and fulminant sepsis.
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Affiliation(s)
- Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Graduate Institute of Clinical Medicine, National Cheng Kung University, College of Medicine, Tainan, Taiwan
| | - Chi-Jung Wu
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan.
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López-Cortés LE, Cisneros JM, Fernández-Cuenca F, Bou G, Tomás M, Garnacho-Montero J, Pascual A, Martínez-Martínez L, Vila J, Pachón J, Rodríguez Baño J. Monotherapy versus combination therapy for sepsis due to multidrug-resistant Acinetobacter baumannii: analysis of a multicentre prospective cohort. J Antimicrob Chemother 2014; 69:3119-26. [PMID: 24970742 DOI: 10.1093/jac/dku233] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment of multidrug-resistant Acinetobacter baumannii (MDRAB) infection presents a challenge because of the scarcity of available options. Even though combination therapy (CT) is frequently used in clinical practice, data are needed to support its use instead of monotherapy (MT). METHODS A prospective observational study was conducted in 28 Spanish hospitals. Patients with sepsis caused by MDRAB, defined according to strict criteria, and who received active antibiotic treatment (according to in vitro susceptibility testing) for at least 48 h, were included. The main outcome variable was all-cause 30 day mortality after initiation of targeted therapy. Multivariate analysis, including a propensity score (for receiving CT), was performed by Cox regression. RESULTS One hundred and one patients were included in the analysis; 68 (67.3%) received MT and 33 (32.7%) received CT. Pneumonia was the most common infection (50.5%), 68.6% of cases being associated with mechanical ventilation. Colistin (67.6%) and carbapenems (14.7%) were the most common drugs used in MT; colistin plus tigecycline (27.3%) and carbapenem plus tigecycline (12.1%) were the most frequent combinations. Crude 30 day mortality was 23.5% and 24.2% for the MT and CT groups, respectively (RR = 1.03; 95% CI 0.49-2.16; P = 0.94). Multivariate analysis of 30 day survival showed no trend towards reduced 30 day mortality with CT (HR = 1.35; 95% CI 0.53-3.44; P = 0.53). Subgroup analysis showed similar results. CONCLUSIONS Our data do not support an association of CT with reduced mortality in MDRAB infections. More data for specific types of infection and combinations are needed.
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Affiliation(s)
- L E López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain
| | - J M Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - F Fernández-Cuenca
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain
| | - G Bou
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - M Tomás
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - J Garnacho-Montero
- Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain Unidad de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - A Pascual
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Departamento de Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - L Martínez-Martínez
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain Departamento de Biología Molecular, Universidad de Cantabria, Santander, Spain
| | - J Vila
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain
| | - J Pachón
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - J Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospitales Universitarios Virgen Macarena y Virgen del Rocío, Sevilla, Spain Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
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Short-Term Decline in All-Cause Acquired Infections With the Routine Use of a Decontamination Regimen Combining Topical Polymyxin, Tobramycin, and Amphotericin B With Mupirocin and Chlorhexidine in the ICU. Crit Care Med 2014; 42:1121-30. [DOI: 10.1097/ccm.0000000000000140] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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169
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Hsu MS, Huang YT, Hsu HS, Liao CH. Sequential time to positivity of blood cultures can be a predictor of prognosis of patients with persistent Staphylococcus aureus bacteraemia. Clin Microbiol Infect 2014; 20:892-8. [PMID: 24612429 DOI: 10.1111/1469-0691.12608] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 11/28/2022]
Abstract
A short time to positivity (TTP) correlates with poor clinical outcome in patients with Staphylococcus aureus bacteraemia, but the association between sequential TTPs and the outcome of these patients is unclear. Sequential TTPs from patients with S. aureus bacteraemia persisting for >48 h were analysed with respect to clinical parameters and patient outcome at a tertiary hospital. During the 5-year study period, 87 patients (9.2%; mean age of 64 years) had persistent S. aureus bacteraemia, with an average Pittsburgh bacteraemia score of 2.7. Forty-eight patients (55%) had methicillin-resistant S. aureus infection, and 28 (32%) had nosocomial infection. The most common underlying disease was end-stage renal disease (43%). The most common type of infection was catheter-related infection (31%), followed by infective endocarditis (18%). The in-hospital mortality rate was 40%. Higher Pittsburgh scores (p 0.005; OR 1.37; 95% CI 1.1-1.7) and a second TTP/first TTP ratio of <1.5 (p 0.004; OR 0.2; 95% CI 0.07-0.6) were independent risk factors for mortality. Among patients receiving adequate empirical therapy, a second positive blood culture growing within 12 h was more frequent in patients who finally died. Factors associated with a second TTP/first TTP ratio of <1.5 included older age (p 0.02; OR 0.96; 95% CI 0.92-0.99) and inadequate empirical antimicrobial therapy (p 0.01; OR 3.53; 95% CI 1.42-8.78). Among patients with persistent S. aureus bacteraemia, a second TTP/first TTP ratio of <1.5 is a predictor of poor outcome. Physicians should search for interventions guaranteeing that all patients with S. aureus bacteraemia receive adequate empirical therapy.
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Affiliation(s)
- M-S Hsu
- Department of Internal Medicine, Section of Infectious Disease, Far Eastern Memorial Hospital, Taipei, Taiwan
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170
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Siedner MJ, Galar A, Guzmán-Suarez BB, Kubiak DW, Baghdady N, Ferraro MJ, Hooper DC, O'Brien TF, Marty FM. Cefepime vs other antibacterial agents for the treatment of Enterobacter species bacteremia. Clin Infect Dis 2014; 58:1554-63. [PMID: 24647022 DOI: 10.1093/cid/ciu182] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Carbapenems are recommended for treatment of Enterobacter infections with AmpC phenotypes. Although isolates are typically susceptible to cefepime in vitro, there are few data supporting its clinical efficacy. METHODS We reviewed all cases of Enterobacter species bacteremia at 2 academic hospitals from 2005 to 2011. Outcomes of interest were (1) persistent bacteremia ≥1 calendar day and (2) in-hospital mortality. We fit logistic regression models, adjusting for clinical risk factors and Pitt bacteremia score and performed propensity score analyses to compare the efficacy of cefepime and carbapenems. RESULTS Three hundred sixty-eight patients experienced Enterobacter species bacteremia and received at least 1 antimicrobial agent, of whom 52 (14%) died during hospitalization. Median age was 59 years; 19% were neutropenic, and 22% were in an intensive care unit on the day of bacteremia. Twenty-nine (11%) patients had persistent bacteremia for ≥1 day after antibacterial initiation. None of the 36 patients who received single-agent cefepime (0%) had persistent bacteremia, as opposed to 4 of 16 (25%) of those who received single-agent carbapenem (P < .01). In multivariable models, there was no association between carbapenem use and persistent bacteremia (adjusted odds ratio [aOR], 1.52; 95% CI, .58-3.98; P = .39), and a nonsignificant lower odds ratio with cefepime use (aOR, 0.52; 95% CI, .19-1.40; P = .19). In-hospital mortality was similar for use of cefepime and carbapenems in adjusted regression models and propensity-score matched analyses. CONCLUSIONS Cefepime has a similar efficacy as carbapenems for the treatment of Enterobacter species bacteremia. Its use should be further explored as a carbapenem-sparing agent in this clinical scenario.
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Furlaneto-Maia L, Rocha KR, Siqueira VLD, Furlaneto MC. Comparison between automated system and PCR-based method for identification and antimicrobial susceptibility profile of clinical Enterococcus spp. Rev Inst Med Trop Sao Paulo 2014; 56:97-103. [PMID: 24626409 PMCID: PMC4085851 DOI: 10.1590/s0036-46652014000200002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 09/05/2013] [Indexed: 11/22/2022] Open
Abstract
Enterococci are increasingly responsible for nosocomial infections
worldwide. This study was undertaken to compare the identification and
susceptibility profile using an automated MicrosScan system, PCR-based assay and
disk diffusion assay of Enterococcus spp. We evaluated 30
clinical isolates of Enterococcus spp. Isolates were identified
by MicrosScan system and PCR-based assay. The detection of antibiotic resistance
genes (vancomycin, gentamicin, tetracycline and erythromycin) was also
determined by PCR. Antimicrobial susceptibilities to vancomycin (30 µg),
gentamicin (120 µg), tetracycline (30 µg) and erythromycin (15 µg) were tested
by the automated system and disk diffusion method, and were interpreted
according to the criteria recommended in CLSI guidelines. Concerning
Enterococcus identification the general agreement between
data obtained by the PCR method and by the automatic system was 90.0% (27/30).
For all isolates of E. faecium and E. faecalis
we observed 100% agreement. Resistance frequencies were higher in E.
faecium than E. faecalis. The resistance rates
obtained were higher for erythromycin (86.7%), vancomycin (80.0%), tetracycline
(43.35) and gentamicin (33.3%). The correlation between disk diffusion and
automation revealed an agreement for the majority of the antibiotics with
category agreement rates of > 80%. The PCR-based assay, the
van(A) gene was detected in 100% of vancomycin resistant
enterococci. This assay is simple to conduct and reliable in the identification
of clinically relevant enterococci. The data obtained reinforced the need for an
improvement of the automated system to identify some enterococci.
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Affiliation(s)
- Luciana Furlaneto-Maia
- Technological Federal University of Paraná, Brazil, Technological Federal University of Paraná, Brazil
| | - Kátia Real Rocha
- Department of Microbiology, State University at Londrina, Paraná, Brazil, Department of Microbiology, State University at Londrina, Paraná, Brazil
| | - Vera Lúcia Dias Siqueira
- Department of Clinical Analysis, State University at Maringa, Paraná, Brazil, Department of Clinical Analysis, State University at Maringa, Paraná, Brazil
| | - Márcia Cristina Furlaneto
- Department of Microbiology, State University at Londrina, Paraná, Brazil, Department of Microbiology, State University at Londrina, Paraná, Brazil
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Chong YP, Park KH, Kim ES, Kim MN, Kim SH, Lee SO, Choi SH, Jeong JY, Woo JH, Kim YS. Association of mannose-binding lectin 2 gene polymorphisms with persistent Staphylococcus aureus bacteremia. PLoS One 2014; 9:e89139. [PMID: 24595015 PMCID: PMC3942407 DOI: 10.1371/journal.pone.0089139] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
Objectives Mannose-binding lectin (MBL) is an important component of innate immunity. Structural and promoter polymorphisms in the MBL2 gene that are responsible for low MBL levels are associated with susceptibility to infectious diseases. The objective of this study was to investigate the association of serum MBL levels and MBL2 polymorphisms with persistent Staphylococcus aureus bacteremia (SAB) in adult Korean patients. Methods We conducted a case-control study nested in a prospective cohort of patients with SAB. The study compared 41 patients with persistent bacteremia (≥7 days) and 46 patients with resolving bacteremia (<3 days). In each subject, we genotyped six single-nucleotide polymorphisms in the promoter region (alleles H/L, X/Y, and P/Q) and exon 1 (alleles A/B, A/C, and A/D) of the MBL2 gene and measured serum MBL concentrations. We also compared MBL2 genotypes between SAB patients and healthy people. Results Patients with persistent bacteremia were significantly more likely to have low/deficient MBL-producing genotypes and resultant low serum MBL levels, than were patients with resolving bacteremia (P = 0.019 and P = 0.012, respectively). Independent risk factors for persistent bacteremia were metastatic infection (adjusted odds ratio [aOR], 34.7; 95% confidence interval [CI], 12.83–196.37; P = 0.003), methicillin resistance (aOR, 4.10; 95% CI, 3.19–29.57; P = 0.025), and low/deficient MBL-producing genotypes (aOR, 7.64; 95% CI, 4.12–63.39; P = 0.003). Such genotypes were significantly more common in patients with persistent bacteremia than in healthy people (OR, 2.09; 95% CI, 1.03–4.26; P = 0.040). Conclusions This is the first demonstration of an association of low MBL levels and MBL2 polymorphisms responsible for low or deficient MBL levels with persistent SAB. A combination of factors, including clinical and microbiological characteristics and host defense factors such as MBL levels, may together contribute to the development of persistent SAB.
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Affiliation(s)
- Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki-Ho Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Eun Sil Kim
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Yong Jeong
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Institute of Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Hsu AJ, Tamma PD. Treatment of multidrug-resistant Gram-negative infections in children. Clin Infect Dis 2014; 58:1439-48. [PMID: 24501388 DOI: 10.1093/cid/ciu069] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antibiotic resistance in conjunction with the erosion of the drug development pipeline may lead us into a bleak future, a "post-antibiotic era." Because of a shortage of studies addressing treatment options for multidrug-resistant Gram-negative (MDRGN) infections in children, data must be extrapolated from the adult literature. However, even adult studies are limited by significant methodological flaws. We are in urgent need of pediatric specific pharmacokinetic/pharmacodynamic data for agents with activity against MDRGN infections as well as improved clinical outcomes studies. For the time being, we must rely on in vitro studies, observational data, and clinical experience to guide our therapeutic decisions. In this review, we discuss treatment considerations for infections caused by extended-spectrum β-lactamase-producing organisms, AmpC β-lactamase-producing organisms, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii in the pediatric population.
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Affiliation(s)
- Alice J Hsu
- Department of Pharmacy, Division of Pediatric Pharmacy, The Johns Hopkins Hospital
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Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting. ACTA ACUST UNITED AC 2014; 61:e1-e19. [PMID: 24492197 DOI: 10.1016/j.redar.2013.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/04/2013] [Indexed: 02/07/2023]
Abstract
ICUs are areas where resistance problems are the largest, and these constitute a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are (i) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and (ii) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallo-betalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has led to multidrug resistance, a worrisome problem nowadays. This article reviews microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors.
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The effect of gentamicin in irrigating solutions on articular infection prophylaxis during arthroscopic ACL reconstruction. Arch Orthop Trauma Surg 2014; 134:257-61. [PMID: 24323062 DOI: 10.1007/s00402-013-1910-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate whether gentamicin irrigation solutions provide a potential new tool to prevent joint infection after arthroscopic ACL reconstruction. METHODS In this prospective randomized study, 360 consecutive ACL recondition patients were randomized in two groups alternately from Feb 2008 to March 2012. In the first group, 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride) solution. In the second group 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride solution) with added gentamicin (80 mg/L) (group 2). Three patients from group 1 and six patients from group 2 were excluded from the study due to loss of follow-up. The patients were followed for 6 months and assessed for signs of deep infection. RESULTS In group 1, a total of 4 (2.2%) postoperative septic arthritis cases were documented. In group 2, just one postoperative deep infection (septic arthritis) was documented (0.57%). Although the rate of septic arthritis in group 1 was higher than in group 2, statistical analysis showed that the difference between using the gentamicin irrigation solution (80 mg/L) and the saline solution alone was not significant. CONCLUSIONS Using gentamicin in irrigating solutions during arthroscopic ACL reconstruction surgery does not statistically decrease post operation septic arthritis. LEVEL OF EVIDENCE Therapeutic Level II.
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Huh K, Kang CI, Kim J, Cho SY, Ha YE, Joo EJ, Chung DR, Lee NY, Peck KR, Song JH. Risk factors and treatment outcomes of bloodstream infection caused by extended-spectrum cephalosporin-resistant Enterobacter species in adults with cancer. Diagn Microbiol Infect Dis 2014; 78:172-7. [DOI: 10.1016/j.diagmicrobio.2013.11.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 10/22/2013] [Accepted: 11/05/2013] [Indexed: 10/26/2022]
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Suárez CJ, Lolans K, Villegas MV, Quinn JP. Mechanisms of resistance to β-lactams in some common Gram-negative bacteria causing nosocomial infections. Expert Rev Anti Infect Ther 2014; 3:915-22. [PMID: 16307504 DOI: 10.1586/14787210.3.6.915] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gram-negative bacilli remain major killers of hospitalized patients and continue to evolve new resistance mechanisms. This review describes the mechanisms of resistance to beta-lactam antibiotics from those Gram-negative pathogens most often isolated from nosocomial infections.
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Affiliation(s)
- Carlos José Suárez
- Bacterial Resistance Line, CIDEIM (International Center for Medical Research and Training), Cali, Colombia.
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Abstract
The threat of antibacterial resistance continues to increase globally, and therapeutic options for the treatment of some serious infectious diseases are diminishing. The carbapenems are a potent class of broad-spectrum drugs, and their stability against hydrolysis by many important beta-lactamases make them an important weapon in the treatment of beta-lactamase-producing bacterial pathogens. This review focuses on four carbapenems of clinical importance in the USA: imipenem, meropenem, ertapenem and doripenem. After a historical review of carbapenem development, these four carbapenems are evaluated based on their mechanism of action, spectrum of activity, potency, pharmacodynamics, clinical pharmacokinetics, clinical profiles and toxicity issues.
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Affiliation(s)
- Philip D Lister
- Creighton University School of Medicine, Department of Medical Microbiology and Immunology, 2500 California Plaza, Omaha, NE 68178, USA.
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Cartaxo Salgado FX, Gavilanes Sanchez TE, da Silva NB, Oliveira HB, Karnikowski M, de Oliveira Karnikowski MG. Evaluation of rational use of antimicrobial agents in a Brazilian intensive care unit. Health (London) 2014. [DOI: 10.4236/health.2014.62028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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180
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Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence 2013; 5:80-97. [PMID: 24184742 PMCID: PMC3916387 DOI: 10.4161/viru.26913] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.
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Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine; Section of Infectious Diseases; Health Sciences Centre; Winnipeg, MB Canada
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181
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Multicenter prospective observational study of the comparative efficacy and safety of vancomycin versus teicoplanin in patients with health care-associated methicillin-resistant Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2013; 58:317-24. [PMID: 24165181 DOI: 10.1128/aac.00520-13] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to compare the clinical efficacy and safety of vancomycin to those of teicoplanin for the treatment of adult patients with health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) bacteremia. A multicenter observational study was prospectively conducted in 15 teaching hospitals in Korea between February 2010 and July 2011. Adult patients (≥18 years old) with HA-MRSA bacteremia who were initially treated with vancomycin (VAN) (n = 134) or teicoplanin (TEC) (n = 56) were enrolled. Clinical and microbiological responses and drug-related adverse events were compared between the two treatment groups using univariate and multivariate logistic regression analyses. The vancomycin and teicoplanin MICs were determined by Etest. The MRSA-related mortality, duration of fever, and duration of MRSA bacteremia in the treatment groups were not significantly different. There was no significant difference in the occurrence of drug-related adverse events. Among the 190 MRSA isolates, the VAN MICs ranged from 0.5 to 2 μg/ml (MIC50 and MIC90, 1.5 μg/ml), and the TEC MIC ranged from 0.5 to 8 μg/ml (MIC50, 3 μg/ml; MIC90, 6 μg/ml). In multivariate analyses, the antibiotic type (vancomycin or teicoplanin) was not associated with treatment outcomes. This study indicates that teicoplanin is an effective and safe alternative to vancomycin for the treatment of HA-MRSA bacteremia.
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Tamma PD, Turnbull AE, Harris AD, Milstone AM, Hsu AJ, Cosgrove SE. Less is more: combination antibiotic therapy for the treatment of gram-negative bacteremia in pediatric patients. JAMA Pediatr 2013; 167:903-10. [PMID: 23921724 PMCID: PMC6857628 DOI: 10.1001/jamapediatrics.2013.196] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Definitive combination antibiotic therapy with a β-lactam and an aminoglycoside for the treatment of gram-negative bacteremia is commonly prescribed in pediatric patients; however, its efficacy and toxicity relative to β-lactam monotherapy are unknown. OBJECTIVE To determine whether definitive combination antibiotic therapy affects mortality and nephrotoxicity in pediatric patients with gram-negative bacteremia. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study including pediatric patients (aged ≤18 years) with gram-negative bacteremia hospitalized at the Johns Hopkins Children's Center between 2002 and 2011. MAIN OUTCOMES AND MEASURES Outcomes included 30-day mortality and nephrotoxicity classified according to the pediatric RIFLE (risk for renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal disease) criteria. To account for nonrandom assignment of combination therapy, propensity score weighting was combined with multivariable logistic regression to estimate the effect of combination therapy on mortality and nephrotoxicity. RESULTS Of the 879 eligible pediatric patients with bacteremia, 537 (61.1%) received combination therapy. After propensity score adjustment, baseline demographic and clinical characteristics between the groups were well balanced. There was no association between combination therapy and 30-day mortality (odds ratio, 0.98; 95% CI, 0.93-1.02; P = .27). There were 170 patients (19.3%) with evidence of acute kidney injury, including 135 (25.1%) and 35 (10.2%) in the combination therapy and monotherapy arms, respectively. Patients receiving combination therapy had approximately twice the odds of nephrotoxicity compared with those receiving monotherapy (odds ratio, 2.15; 95% CI, 2.09-2.21). CONCLUSIONS AND RELEVANCE The use of β-lactam monotherapy for gram-negative bacteremia in pediatric patients reduces subsequent nephrotoxicity without compromising survival.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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183
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Alexander EL, Satlin MJ, Gamaletsou MN, Sipsas NV, Walsh TJ. Worldwide challenges of multidrug-resistant bacteria in patients with hematologic malignancies. Int J Hematol Oncol 2013. [DOI: 10.2217/ijh.13.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The emergence of infections due to multidrug-resistant (MDR) bacteria poses a major public health threat to all patients, but patients with hematologic malignancies are especially at risk. A common thread across all classes of bacteria is that increased reliance on and usage of broad-spectrum antibacterial agents, combined with the intrinsic ability of bacteria to develop and transmit resistance-conferring mutations, has led to the widespread dissemination of MDR organisms. In this article, we summarize the most worrisome MDR bacteria, assess their clinical impact on patients with hematologic malignancies and outline measures that are required to mitigate this impact.
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Affiliation(s)
| | - Michael J Satlin
- Division of Infectious Diseases, Weill Cornell Medical Center, New York, NY, USA
- Transplantation–Oncology Infectious Diseases Program, Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Maria N Gamaletsou
- University of Athens School of Medicine & Laikon Hospital, Athens, Greece
| | - Nikolaos V Sipsas
- University of Athens School of Medicine & Laikon Hospital, Athens, Greece
| | - Thomas J Walsh
- Department of Pediatrics, Weill Cornell Medical Center, New York, NY, USA
- Department of Microbiology & Immunology, Weill Cornell Medical Center, New York, NY, USA
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185
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Su TY, Ye JJ, Hsu PC, Wu HF, Chia JH, Lee MH. Clinical characteristics and risk factors for mortality in cefepime-resistant Pseudomonas aeruginosa bacteremia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 48:175-82. [PMID: 24064286 DOI: 10.1016/j.jmii.2013.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/24/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To identify the clinical characteristics and risk factors for mortality of patients with cefepime-resistant Pseudomonas aeruginosa (FRPa) bacteremia. METHODS This retrospective study analyzed adult patients with FRPa bacteremia hospitalized between January 2006 and December 2011. RESULTS Seventy eight patients (46 male, 32 female; mean age: 72.2 ± 14.1 years) were included. Of them, 46 (59.0%) had ventilator use and 45 (57.7%) had intensive care unit stay. All the bacteremia episodes were health-care associated or hospital acquired, and 55.1% of FRPa blood isolates were multidrug resistant. The sources of bacteremia were identified in 42 patients (53.8%), with pneumonia being the most common one (28/42; 66.7%). The mean interval between admission and the sample date of the first FRPa-positive blood culture was 45.8 ± 52.6 days. The mean Pittsburgh bacteremia score was 5.0 ± 3.4. The 15-day and 30-day mortality rates were 50.0% and 65.4%, respectively. Patients (41; 52.6%) on appropriate antibiotic therapy within 72 hours of the first FRPa-positive blood culture had a higher 30-day survival rate than those without (48.8% vs. 18.9%, p = 0.011 by log-rank test). Multivariate analyses revealed that a higher Pittsburgh bacteremia score was an independent risk factor for either 15-day (p = 0.002) or 30-day mortality (p = 0.010), and appropriate antibiotic therapy within 72 hours was an independent protecting factor for either 15-day (p = 0.049) or 30-day mortality (p = 0.017). CONCLUSION FRPa bacteremia had a high mortality rate. The disease severity and appropriate antimicrobial therapy within 72 hours of positive blood culture were related to the patients' outcome.
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Affiliation(s)
- Ting-Yi Su
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Jung-Jr Ye
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Po-Chang Hsu
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Hsuan-Feng Wu
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Ju-Hsin Chia
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Hsun Lee
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan.
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186
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Pop-Vicas A, Opal SM. The clinical impact of multidrug-resistant gram-negative bacilli in the management of septic shock. Virulence 2013; 5:206-12. [PMID: 24200870 PMCID: PMC3916376 DOI: 10.4161/viru.26210] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Multi-antibiotic drug-resistant (MDR) gram-negative bacilli are becoming a major threat to the standard care of septic patients. Empiric antimicrobial drug regimens to cover likely bacterial pathogens have to be altered in keeping with the spread of MDR pathogens in the health care setting and in the community. Reliable antibiotics for broad spectrum coverage for sepsis such as extended spectrum β-lactam antibiotics, carbapenems, and fluoroquinolones can no longer be counted upon to provide activity against a range of common, virulent pathogens that cause sepsis. In some regions of Asia, South America, and Eastern Europe in particular, MDR pathogens have become a major concern, necessitating the use of potentially toxic and costly antibiotic combinations as initial antibiotic therapy for septic shock. In this brief review, we will focus on the emergence of MDR gram-negative pathogens, resistance mechanisms, and suggest some management and prevention strategies against MDR pathogens.
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Affiliation(s)
- Aurora Pop-Vicas
- Infectious Disease Division; Memorial Hospital of RI; Providence, RI USA; The Alpert Medical School of Brown University; Providence, RI USA
| | - Steven M Opal
- Infectious Disease Division; Memorial Hospital of RI; Providence, RI USA; The Alpert Medical School of Brown University; Providence, RI USA
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Liao CH, Hsueh PR, Jacoby GA, Hooper DC. Risk factors and clinical characteristics of patients with qnr-positive Klebsiella pneumoniae bacteraemia. J Antimicrob Chemother 2013; 68:2907-14. [PMID: 23956373 DOI: 10.1093/jac/dkt295] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Plasmid-mediated quinolone resistance (PMQR) caused by qnr genes has been known for 15 years. Information about global distribution and prevalence of qnr genes is abundant, but clinical information concerning infections produced by these isolates and risk factors for their acquisition is limited. METHODS Klebsiella pneumoniae blood isolates (n = 227) from a 1 year prospective cohort of patients in Taiwan were studied. MICs of quinolones were determined for all isolates, and multiplex PCR for the presence of PMQR genes and DNA gyrase mutations was applied to all 24 isolates with ciprofloxacin MICs ≥ 0.12 mg/L and a control group of 72 isolates with MICs ≤ 0.06 mg/L. RESULTS All qnr isolates were in the group with ciprofloxacin MICs ≥ 0.12 mg/L, constituting 9.4% of tested isolates and 3.9% (qnrB 2.6% and qnrS 1.3%) of total isolates. aac(6')-Ib-cr and qepA were not found. Risk factors for qnr included nosocomial infection, bedridden status, surgery within 3 months, non-K1/K2 serotypes and prior antimicrobial use. Ciprofloxacin MIC ≥ 0.12 mg/L was associated with prior quinolone use; in contrast, prior cephalosporin use was more closely linked to the presence of qnr. Fourteen-day mortality was similar in patients infected with qnr-positive versus qnr-negative isolates, but there was a trend for increased in-hospital mortality in patients infected with qnr-positive isolates. CONCLUSIONS In K. pneumoniae blood isolates collected at a hospital in Taiwan, the overall prevalence of qnr genes was 3.9%. Prior quinolone use was linked to increased ciprofloxacin MIC, but not with the prevalence of qnr, which was most strongly linked to exposure to other antimicrobials, especially cephalosporins.
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Affiliation(s)
- Chun-Hsing Liao
- Division of Infectious Disease, Far Eastern Memorial Hospital, New Taipei City, Taiwan
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Kang CK, Kim ES, Song KH, Kim HB, Kim TS, Kim NH, Kim CJ, Choe PG, Bang JH, Park WB, Park KU, Park SW, Kim NJ, Kim EC, Oh MD. Can a routine follow-up blood culture be justified in Klebsiella pneumoniae bacteremia? A retrospective case-control study. BMC Infect Dis 2013; 13:365. [PMID: 23914899 PMCID: PMC3734211 DOI: 10.1186/1471-2334-13-365] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 07/25/2013] [Indexed: 11/29/2022] Open
Abstract
Background The need for mandatory confirmation of negative conversion in Klebsiella pneumoniae bacteremia (KpB) has not been adequately addressed. We conducted a retrospective case–control study of adult patients with KpB over a 5-year period in two tertiary-care hospitals to determine the risk factors for persistent bacteremia and to reevaluate the necessity of follow-up blood culture in KpB. Methods Persistent KpB is defined as the finding of K. pneumoniae in more than two separate blood-culture samples for longer than a two-day period in a single episode. The case- and control-groups were patients with persistent and non-persistent KpB, respectively, and they were matched 1-to-3 according to age and gender. Results Among 1068 KpB episodes analyzed after excluding polymicrobial infection and repeated KpB, follow-up blood cultures were performed in 862 cases (80.7%), 62 of which (7.2%) were persistent. Independent risk factors for persistence were intra-abdominal infection, higher Charlson’s comorbidity weighted index score, prior solid organ transplantation, and unfavorable treatment response, which was defined as positivity for at least two parameters among fever, leukocytosis, and no decrease of C-reactive protein on the second day after initial culture. A proposed scoring system using four variables, namely, intra-abdominal infection, nosocomial KpB, fever and lack of C-reactive protein decrease, the last two being assessed on the second day after the initial blood culture, showed that only 4.9% of the patients with no risk factors or with only intra-abdominal infection had persistent KpB. Conclusions Though persistent KpB is uncommon, follow-up blood culture was performed in as many as 80% of the cases in this study. A more careful clinical assessment is warranted to reduce the cost and patient inconvenience involved in follow-up blood culture.
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Affiliation(s)
- Chang Kyung Kang
- Seoul National University College of Medicine, 103 Daehak-ro, Jongro-gu, Seoul, Republic of Korea 110-460
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Paul M, Dickstein Y, Schlesinger A, Grozinsky-Glasberg S, Soares-Weiser K, Leibovici L. Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropenia. Cochrane Database Syst Rev 2013; 2013:CD003038. [PMID: 23813455 PMCID: PMC6457814 DOI: 10.1002/14651858.cd003038.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Continued controversy surrounds the optimal empirical treatment for febrile neutropenia. New broad-spectrum beta-lactams have been introduced as single treatment, and classically, a combination of a beta-lactam with an aminoglycoside has been used. OBJECTIVES To compare beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for cancer patients with fever and neutropenia. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 7, 2012), LILACS (August 2012), MEDLINE and EMBASE (August 2012) and the Database of Abstracts of Reviews of Effects (DARE) (Issue 3, 2012). We scanned references of all included studies and pertinent reviews and contacted the first author of each included trial, as well as the pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any beta-lactam antibiotic monotherapy with any combination of a beta-lactam and an aminoglycoside antibiotic, for the initial empirical treatment of febrile neutropenic cancer patients. All cause mortality was the primary outcome assessed. DATA COLLECTION AND ANALYSIS Data concerning all cause mortality, infection related mortality, treatment failure (including treatment modifications), super-infections, adverse effects and study quality measures were extracted independently by two review authors. Risk ratios (RRs) with their 95% confidence intervals (CIs) were estimated. Outcomes were extracted by intention-to-treat (ITT) analysis whenever possible. Individual domains of risk of bias were examined through sensitivity analyses. Published data were complemented by correspondence with authors. MAIN RESULTS Seventy-one trials published between 1983 and 2012 were included. All cause mortality was lower with monotherapy (RR 0.87, 95% CI 0.75 to 1.02, without statistical significance). Results were similar for trials comparing the same beta-lactam in both trial arms (11 trials, 1718 episodes; RR 0.74, 95% CI 0.53 to 1.06) and for trials comparing different beta-lactams-usually a broad-spectrum beta-lactam compared with a narrower-spectrum beta-lactam combined with an aminoglycoside (33 trials, 5468 episodes; RR 0.91, 95% CI 0.77 to 1.09). Infection related mortality was significantly lower with monotherapy (RR 0.80, 95% CI 0.64 to 0.99). Treatment failure was significantly more frequent with monotherapy in trials comparing the same beta-lactam (16 trials, 2833 episodes; RR 1.11, 95% CI 1.02 to 1.20), and was significantly more frequent with combination therapy in trials comparing different beta-lactams (55 trials, 7736 episodes; RR 0.92, 95% CI 0.88 to 0.97). Bacterial super-infections occurred with equal frequency, and fungal super-infections were more common with combination therapy. Adverse events were more frequent with combination therapy (numbers needed to harm 4; 95% CI 4 to 5). Specifically, the difference with regard to nephrotoxicity was highly significant. Adequate trial methods were associated with a larger effect estimate for mortality and smaller effect estimates for failure. Nearly all trials were open-label. No correlation was noted between mortality and failure rates and these trials. AUTHORS' CONCLUSIONS Beta-lactam monotherapy is advantageous compared with beta-lactam-aminoglycoside combination therapy with regard to survival, adverse events and fungal super-infections. Treatment failure should not be regarded as the primary outcome in open-label trials, as it reflects mainly treatment modifications.
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Affiliation(s)
- Mical Paul
- Unit of Infectious Diseases, Rambam Health Care Center. Haifa, Israel and Sackler Faculty of Medicine, Tel Aviv, Israel.
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Chen HL, Lu JH, Wang HH, Chen SJ, Chen CJ, Wu KG, Tang RB. Clinical analysis of Enterobacter bacteremia in pediatric patients: a 10-year study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2013; 47:381-6. [PMID: 23773708 DOI: 10.1016/j.jmii.2013.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 02/07/2013] [Accepted: 03/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Enterobacter species has emerged as an important pathogen of nosocomial bacteremia. The purpose of this study is to review the clinical characteristics of bacteremia in pediatric patients. MATERIALS AND METHODS We reviewed retrospectively the medical records of patients (under the age of 18 years) having Enterobacter bacteremia who were treated at Taipei the Veterans General Hospital from January 2001 to June 2011. RESULTS In total, 853 positive blood cultures were obtained from 620 patients during the study period. Among them, 96 episodes of Enterobacter bacteremia were found in 83 patients, accounting for 11.3% of all bacteremia. Eighty-two cases (98.8%) were nosocomial infections. Most of the cases were neonates (62 cases, 74.7%) and premature infants (51 cases, 61.5%). The common sources of bacteremia were the respiratory tract (53.0%), followed by intravascular catheter (10.8%), multiple sources (10.8%), and the gastrointestinal tract (8.4%). The overall case fatality rate was 18.1%, with the highest rate being reported among premature infants. The factors responsible for the deaths were leukocytosis and a higher median number of underlying diseases. CONCLUSION Based on the findings of the present study, it can be concluded that Enterobacter species are probably an important pathogen of nosocomial bacteremia in premature neonates. The number of underlying diseases should be considered a major factor influencing the prognosis.
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Affiliation(s)
- Hui-Lan Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jen-Her Lu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Hui Wang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shu-Jen Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Jen Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Keh-Gong Wu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ren-Bin Tang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Tamma PD, Girdwood SCT, Gopaul R, Tekle T, Roberts AA, Harris AD, Cosgrove SE, Carroll KC. The use of cefepime for treating AmpC β-lactamase-producing Enterobacteriaceae. Clin Infect Dis 2013; 57:781-8. [PMID: 23759352 DOI: 10.1093/cid/cit395] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AmpC β-lactamase-producing organisms are associated with significant morbidity and mortality. Induction of resistance to third-generation cephalosporins after exposure to these agents complicates treatment options and carbapenems are considered optimal therapy. The role of cefepime, however, remains unclear. Our objective was to compare clinical outcomes for patients receiving cefepime compared with meropenem for invasive infections caused by organisms expressing AmpC β-lactamases. METHODS Hospitalized patients with blood, bronchoalveolar lavage, or intra-abdominal fluid cultures growing Enterobacter spp, Serratia spp, or Citrobacter spp were evaluated using the cefotetan-boronic acid disk test and the cefotetan-cloxacillin Etest to identify organisms with AmpC β-lactamase production from February 2010 to January 2011. In patients with organisms hyperproducing AmpC β-lactamases (positive by both methods), clinical outcomes for patients receiving cefepime or meropenem therapy were compared. To minimize the possibility of treatment selection bias, 1:1 nearest neighbor propensity score matching was performed prior to regression analysis. RESULTS Of 399 patients meeting eligibility criteria, 96 (24%) had confirmed infections with AmpC β-lactamase-producing organisms. Propensity score matching of patients infected with AmpC β-lactamase-positive organisms treated with cefepime or meropenem yielded 32 well-balanced patient pairs with no difference in 30-day mortality (odds ratio, 0.63; 95% confidence interval [CI], .23-2.11; P = .36) or length of hospital stay after infection (relative risk, 0.96; 95% CI, .79-1.26; P = .56) between the 2 groups. CONCLUSIONS Cefepime may be a reasonable option for the treatment of invasive infections due to AmpC β-lactamase-producing organisms, particularly when adequate source control is achieved.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, MHS Johns Hopkins Medical Institutions, 200 N Wolfe St, Baltimore, MD 21287, USA.
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Peña C, Suarez C, Ocampo-Sosa A, Murillas J, Almirante B, Pomar V, Aguilar M, Granados A, Calbo E, Rodríguez-Baño J, Rodríguez F, Tubau F, Oliver A, Martínez-Martínez L. Effect of adequate single-drug vs combination antimicrobial therapy on mortality in Pseudomonas aeruginosa bloodstream infections: a post Hoc analysis of a prospective cohort. Clin Infect Dis 2013; 57:208-16. [PMID: 23580739 DOI: 10.1093/cid/cit223] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Empirical combination therapy is recommended for patients with known or suspected Pseudomonas aeruginosa (PA) infection as a means to decrease the likelihood of administering inadequate antimicrobial treatment, to prevent the emergence of resistance, and to achieve a possible additive or even synergistic effect. METHODS We performed a post hoc analysis of patients with PA bloodstream infections from a published prospective cohort. Mortality was compared in patients treated with adequate empirical and definitive combination therapy (AECT, ADCT), and adequate empirical and definitive single-drug therapy (AESD, ADSD). Confounding was controlled by Cox regression analysis, and a propensity score for receiving AECT or ADCT was also used. RESULTS The final cohort comprised 593 patients with a single episode of PA bacteremia. The 30-day mortality was 30% (176 patients); 76 patients (13%) died during the first 48 hours. The unadjusted probabilities of survival until day 30 were 69.4% (95% confidence interval [CI], 59.1-81.6) for the patients receiving AECT, 73.5% (95% CI, 68.4%-79.0%) for the AESD group, and 66.7% (95% CI, 61.2%-72.7%) for patients who received inadequate empirical therapy (P = .17, log-rank test). After adjustment for confounders, the AESD group (adjusted hazard ratio [AHR], 1.17; 95% CI, .70-1.96; P = .54) and patients who received ADSD (AHR, 1.34; 95% CI, .73-2.47; P = .35) showed no association with 30-day mortality compared with the AECT and ADCT groups, respectively. CONCLUSIONS These results suggests that treatment with combination antimicrobial therapy did not reduce the mortality risk compared with single-drug therapy in PA bloodstream infections.
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Affiliation(s)
- Carmen Peña
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge-IDIBELL, Barcelona.
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193
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Chong YP, Park SJ, Kim HS, Kim ES, Kim MN, Park KH, Kim SH, Lee SO, Choi SH, Jeong JY, Woo JH, Kim YS. Persistent Staphylococcus aureus bacteremia: a prospective analysis of risk factors, outcomes, and microbiologic and genotypic characteristics of isolates. Medicine (Baltimore) 2013; 92:98-108. [PMID: 23429353 PMCID: PMC4553980 DOI: 10.1097/md.0b013e318289ff1e] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Persistent Staphylococcus aureus bacteremia (SAB) that fails to respond to appropriate antibiotic therapy is associated with poor outcomes. Comprehensive prospective studies on risk factors and outcomes of persistent bacteremia are limited. We investigated outcomes and risk factors encompassing clinical, pharmacokinetic, microbiologic, and genotypic characteristics associated with persistent bacteremia using a case-control study nested in a prospective cohort of patients with SAB at a tertiary-care hospital from August 2008 through September 2010. We compared the clinical characteristics, management, and outcomes of patients with persistent bacteremia (≥7 d) with controls with resolving bacteremia (<3 d). To detect associations between microbiologic and genotypic characteristics of methicillin-resistant S. aureus (MRSA) isolates and persistent bacteremia, we determined the heteroresistance phenotype, SCCmec type, agr genotype and functionality, multilocus sequence typing, and presence of 41 virulence genes. Our cohort consisted of 483 patients; 76 (15.7%) had persistent bacteremia, 212 (43.5%) had resolving bacteremia. In the multivariate analysis, independent risk factors associated with persistent bacteremia were community-onset bacteremia (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.24-6.87), bone and joint infection (OR, 5.26; 95% CI, 1.45-19.03), central venous catheter-related infection (OR, 3.36; 95% CI, 1.47-7.65), metastatic infection (OR, 36.22; 95% CI, 12.71-103.23), and methicillin resistance (OR, 16.99; 95% CI, 5.53-52.15). For patients with eradicable foci, delay (>3 d) in the removal of the infection focus was significantly associated with persistent bacteremia (OR, 2.18; 95% CI, 1.05-4.55). There were no significant associations of persistent bacteremia with high vancomycin minimal inhibitory concentration, vancomycin heteroresistance, and microbiologic/genotypic characteristics of MRSA isolates. However, initial vancomycin trough level <15 mg/L was an independent risk factor for persistent MRSA bacteremia (OR, 4.25; 95% CI, 1.51-11.96) in the multivariate analysis. Clinical outcomes were significantly worse for patients with persistent bacteremia. Relapse of bacteremia and attributable mortality within 12 weeks after SAB were significantly higher in patients with persistent bacteremia than in those with resolving bacteremia (9.2% [7/76] vs. 2.4% [5/212], p = 0.02 and 21.1% [16/76] vs. 9.4% [20/212], p = 0.009, respectively). In conclusion, patients with SAB should be given early aggressive treatment strategies, including early source control and maintenance of a vancomycin trough level ≥15 mg/L, to reduce the risk of persistent bacteremia.
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Affiliation(s)
- Yong Pil Chong
- From the Department of Infectious Diseases (YPC, KHP, SHK, SOL, SHC, JHW, YSK) and Department of Laboratory Medicine (MNK), Asan Medical Center, University of Ulsan College of Medicine, Center for Antimicrobial Resistance and Microbial Genetics (SJP, HSK, ESK, JYJ, YSK), Seoul, Republic of Korea
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194
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Hall RG, Hazlewood KA, Brouse SD, Giuliano CA, Haase KK, Frei CR, Forcade NA, Bell T, Bedimo RJ, Alvarez CA. Empiric guideline-recommended weight-based vancomycin dosing and nephrotoxicity rates in patients with methicillin-resistant Staphylococcus aureus bacteremia: a retrospective cohort study. BMC Pharmacol Toxicol 2013; 14:12. [PMID: 23402420 PMCID: PMC3575285 DOI: 10.1186/2050-6511-14-12] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 01/24/2013] [Indexed: 02/04/2023] Open
Abstract
Background Previous studies have established a correlation between vancomycin troughs and nephrotoxicity. However, data are currently lacking regarding the effect of guideline-recommended weight-based dosing on nephrotoxicity in methicillin-resistant Staphylococcus aureus bacteremia (MRSAB). Methods Adults who were at least 18 years of age with methicillin-resistant Staphylococcus aureus bacteremia and received of empiric vancomycin therapy for at least 48 hours (01/07/2002 and 30/06/2008) were included in this multicenter, retrospective cohort study. The association between guideline-recommended, weight-based vancomycin dosing (at least 15 mg/kg/dose) and nephrotoxicity (increase in serum creatinine (SCr) by more than 0.5 mg/dl or at least a 50% increase from baseline on at least two consecutive laboratory tests) was evaluated. Potential independent associations were evaluated using a multivariable general linear mixed-effect model. Results Overall, 23% of patients developed nephrotoxicity. Thirty-four percent of the 337 patients who met study criteria received weight-based dosing. The cohort was composed of 69% males with a median age of 55 years. The most common sources of MRSAB included skin/soft tissue (32%), catheter-related bloodstream bacteremia (20%), pulmonary (18%). Eighty-six percent of patients received twice daily dosing. Similar rates of nephrotoxicity were observed regardless of the receipt of guideline-recommended dosing (22% vs. 24%, OR 0.91 [95% CI 0.53-1.56]). This finding was confirmed in the multivariable analysis (OR 1.52 [95% CI 0.75-3.08]). Independent predictors of nephrotoxicity were (OR, 95% CI) vancomycin duration of greater than 15 days (3.36, 1.79-6.34), weight over 100 kg (2.74, 1.27-5.91), Pitt bacteremia score of 4 or greater (2.73, 1.29-5.79), vancomycin trough higher than 20 mcg/ml (2.36, 1.07-5.20), and age over 52 years (2.10, 1.08-4.08). Conclusions Over one out of five patients in this study developed nephrotoxicity while receiving vancomycin for MRSAB. The receipt of guideline-recommended, weight-based vancomycin was not an independent risk factor for the development of nephrotoxicity.
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Affiliation(s)
- Ronald G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, TX, USA.
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Treatment duration for uncomplicated Staphylococcus aureus bacteremia to prevent relapse: analysis of a prospective observational cohort study. Antimicrob Agents Chemother 2012; 57:1150-6. [PMID: 23254436 DOI: 10.1128/aac.01021-12] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Practice guidelines recommend at least 14 days of antibiotic therapy for uncomplicated Staphylococcus aureus bacteremia (SAB). However, these recommendations have not been formally evaluated in clinical studies. To evaluate the duration of therapy for uncomplicated SAB, we analyzed data from our prospective cohort of patients with SAB. A prospective observational cohort study was performed in patients with SAB at a tertiary-care hospital in Korea between August 2008 and September 2010. All adult patients with SAB were prospectively enrolled and observed over a 12-week period. Uncomplicated SAB was defined as follows: negative results of follow-up blood cultures at 2 to 4 days, defervescence within 72 h of therapy, no evidence of metastatic infection, and catheter-related bloodstream infection or primary bacteremia without evidence of endocarditis on echocardiography. Of 483 patients with SAB, 111 met the study criteria for uncomplicated SAB. Fifty-three (47.7%) had methicillin-resistant SAB. When short-course therapy (<14 days) and intermediate-course therapy (≥14 days) were compared, the treatment failure rates (10/38 [26.3%] versus 16/73 [21.9%]) and crude mortality (7/38 [18.4%] versus 16/73 [21.9%]) did not differ significantly between the two groups. However, short-course therapy was significantly associated with relapse (3/38 [7.9%] versus 0/73; P = 0.036). In multivariate analysis, primary bacteremia was associated with a trend toward increased treatment failure (P = 0.06). Therefore, in the treatment of uncomplicated SAB, it seems reasonable to consider at least 14 days of antibiotic therapy to prevent relapse, as practice guidelines recommend. Because of its poor prognosis, primary bacteremia, even with a low risk of complication, should not be treated with short-course therapy.
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196
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Combination therapy for treatment of infections with gram-negative bacteria. Clin Microbiol Rev 2012; 25:450-70. [PMID: 22763634 DOI: 10.1128/cmr.05041-11] [Citation(s) in RCA: 526] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa, those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.
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197
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Jung Y, Lee MJ, Sin HY, Kim NH, Hwang JH, Park J, Choe PG, Park WB, Kim ES, Park SW, Park KU, Kim HB, Kim NJ, Kim EC, Song KH, Oh MD. Differences in characteristics between healthcare-associated and community-acquired infection in community-onset Klebsiella pneumoniae bloodstream infection in Korea. BMC Infect Dis 2012; 12:239. [PMID: 23034099 PMCID: PMC3519694 DOI: 10.1186/1471-2334-12-239] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 09/27/2012] [Indexed: 11/10/2022] Open
Abstract
Background Healthcare-associated (HCA) infection has emerged as a new epidemiological category. The aim of this study was to evaluate the impact of HCA infection on mortality in community-onset Klebsiella pneumoniae bloodstream infection (KpBSI). Methods We conducted a retrospective study in two tertiary-care hospitals over a 6-year period. All adult patients with KpBSI within 48 hours of admission were enrolled. We compared the clinical characteristics of HCA and community-acquired (CA) infection, and analyzed risk factors for mortality in patients with community-onset KpBSI. Results Of 553 patients with community-onset KpBSI, 313 (57%) were classified as HCA- KpBSI and 240 (43%) as CA-KpBSI. In patients with HCA-KpBSI, the severity of the underlying diseases was higher than in patients with CA-KpBSI. Overall the most common site of infection was the pancreatobiliary tract. Liver abscess was more common in CA-KpBSI, whereas peritonitis and primary bacteremia were more common in HCA-KpBSI. Isolates not susceptible to extended-spectrum cephalosporin were more common in HCA- KpBSI than in CA-KpBSI (9% [29/313] vs. 3% [8/240]; p = 0.006). Overall 30-day mortality rate was significantly higher in HCA-KpBSI than in CA-KpBSI (22% [70/313] vs. 11% [27/240]; p = 0.001). In multivariate analysis, high Charlson’s weighted index of co-morbidity, high Pitt bacteremia score, neutropenia, polymicrobial infection and inappropriate empirical antimicrobial therapy were significant risk factors for 30-day mortality. Conclusions HCA-KpBSI in community-onset KpBSI has distinctive characteristics and has a poorer prognosis than CA-KpBSI, but HCA infection was not an independent risk factor for 30-day mortality.
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Affiliation(s)
- Younghee Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Seongnam 463-707, Republic of Korea
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Abstract
INTRODUCTION Ceftazidime is a third-generation cephalosporin that has activity against Gram-negative bacilli, including Pseudomonas aeruginosa. The increasing prevalence of antimicrobial resistance and the limited number of antimicrobial agents in development have necessitated a review of the current status of treatments involving ceftazidime. AREAS COVERED This review focuses on studies examining the in vitro antibacterial activity of ceftazidime against recent clinical isolates and recent randomized controlled trials studying the clinical efficacy of ceftazidime, and discusses strategies for the optimal use of ceftazidime for treating respiratory tract infections, mainly hospital-acquired pneumonia (HAP). EXPERT OPINION Although ceftazidime remains an important option for HAP treatment, its role as an effective antimicrobial agent has been compromised by the sharp increase in resistance rates over the last decade, especially in P. aeruginosa and Acinetobacter baumannii. To maintain or improve the clinical use of ceftazidime in patients with severe HAP, it will be essential to gain a thorough understanding of local resistance patterns, reserve ceftazidime use when pathogens are susceptible to other third-generation cephalosporins, optimize ceftazidime therapy using prolonged or continuous infusion, determine the effectiveness of the combination of ceftazidime with inhibitors of broad-spectrum β-lactamases and role of combination therapy for P. aeruginosa infections, and judiciously use antimicrobial agents through individualization of antimicrobial therapy for HAP.
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Affiliation(s)
- Sang-Ho Choi
- University of Ulsan College of Medicine, Asan Medical Center, Department of Infectious Diseases, Seoul, Republic of Korea
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Nyenje ME, Tanih NF, Green E, Ndip RN. Current status of antibiograms of Listeria ivanovii and Enterobacter cloacae isolated from ready-to-eat foods in Alice, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2012. [PMID: 23202673 PMCID: PMC3499856 DOI: 10.3390/ijerph9093101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This study assessed the antimicrobial susceptibility of 51 Listeria ivanovii and 33 Enterobacter cloacae strains isolated from various ready-to-eat foods sold in Alice, South Africa. Isolates were identified using standard microbiological tests and further confirmed using API 20E and API Listeria kits. The disc diffusion technique was used to screen for antimicrobial susceptibility against 15 antimicrobials; minimum inhibitory concentration of five antibiotics was determined by the broth dilution method. All the strains of E. cloacae (100%) and 96% of L. ivanovii isolates were resistant to at least four or more of the antibiotics; nineteen antibiotypes were obtained based on the antibiotics used in the study. Antibiotype A5: AR PGR VAR ER APR was predominant in both L. ivanovii (23.5%) and E. cloacae (57.5%) isolates. Marked susceptibility of Listeriaivanovii was observed against chloramphenicol, ciprofloxacin, streptomycin and trimethoprim/sulfamethoxazole (100%) each while E. cloacae registered 100% susceptibility to ciprofloxacin only. Various percentages of susceptibility was reported to chloramphenicol and gentamicin (91%) each, nalidixic acid (97%) and streptomycin (94%). The MIC90 ranged from 0.004–7.5 µg/mL with E. cloacae being the most susceptible organism. The study demonstrated the presence of multi-resistant strains of bacteria in ready-to-eat-foods and speculates that these foods could serve as important vehicles transmitting multi-resistant bacteria to humans.
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Affiliation(s)
- Mirriam E. Nyenje
- Department of Biochemistry and Microbiology, Faculty of Science and Agriculture, University of Fort Hare, PMB X1314, Alice 5700, South Africa; (M.E.N.); (N.F.T.); (E.G.)
| | - Nicoline F. Tanih
- Department of Biochemistry and Microbiology, Faculty of Science and Agriculture, University of Fort Hare, PMB X1314, Alice 5700, South Africa; (M.E.N.); (N.F.T.); (E.G.)
| | - Ezekiel Green
- Department of Biochemistry and Microbiology, Faculty of Science and Agriculture, University of Fort Hare, PMB X1314, Alice 5700, South Africa; (M.E.N.); (N.F.T.); (E.G.)
| | - Roland N. Ndip
- Department of Biochemistry and Microbiology, Faculty of Science and Agriculture, University of Fort Hare, PMB X1314, Alice 5700, South Africa; (M.E.N.); (N.F.T.); (E.G.)
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, P.O. Box 63, Buea, Cameroon
- Author to whom correspondence should be addressed; ; Tel: +27-782-696-191; Fax: +27-866-24-759
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Kilonzo-Nthenge A, Rotich E, Godwin S, Nahashon S, Chen F. Prevalence and antimicrobial resistance of Cronobacter sakazakii isolated from domestic kitchens in middle Tennessee, United States. J Food Prot 2012; 75:1512-7. [PMID: 22856579 DOI: 10.4315/0362-028x.jfp-11-442] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cronobacter sakazakii is an emerging opportunistic pathogen that has been implicated in cases of severe meningitis, sepsis, and necrotizing enterocolitis in premature and full-term infants. In this study, the prevalence of C. sakazakii was estimated in selected domestic kitchens in middle Tennessee. Antimicrobial resistance patterns of these C. sakazakii isolates were examined for points of public health significance. A total of 234 contact sites in 78 domestic kitchens were tested for C. sakazakii. Consumers' used dishcloths and cleaning sponges were also tested. Antimicrobial susceptibility of the identified C. sakazakii isolates was determined for 10 antimicrobial drugs by means of the disk diffusion method. C. sakazakii was recovered from 26.9% of domestic kitchens visited. Multidrug resistance was observed; the highest resistance was to penicillin (76.1% of isolates) followed by tetracycline (66.6%), ciprofloxacin (57.1%), and nalidixic acid (47.6%). None of the C. sakazakii isolates were resistant to gentamicin. These results suggest that antibiotic-resistant C. sakazakii could be present at various sites in domestic kitchens.
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Affiliation(s)
- A Kilonzo-Nthenge
- Department of Family and Consumer Sciences, Tennessee State University, 3500 John A. Merritt Boulevard, Nashville, TN 37209-1561, USA.
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