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Yuda Handaya A, Andrew J, Hanif AS, Tjendra KR, Kresna Aditya AF. Omental plug using double horizontal mattress suture for gastric perforation on elderly patients with boey score 3: A case series. Ann Med Surg (Lond) 2021; 68:102647. [PMID: 34401131 PMCID: PMC8347816 DOI: 10.1016/j.amsu.2021.102647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Gastric perforation is a life-threatening condition. Patients with gastric perforation with Boey score 3 has very high mortality rate. Immediate source control is required for primary repair and preventing further complications. Furthermore, elderly patients pose a greater risk of morbidity and mortality in cases of gastric perforation, especially during and after emergency surgery. CASE PRESENTATION We present two cases of elderly patients with gastric perforation with Boey score 3. We performed omental plugging technique with double horizontal mattress suture type. In these cases, we decided not to perform biopsy and margin freshening of the perforation. DISCUSSION We performed omental plugging technique because we are confident that it could cover the perforation completely without causing gastric outlet obstruction. An emergency source control surgery can be effectively done with this omental plugging procedure. During surgery, margin freshening and biopsy is not performed to perform source control more quickly. This surgical procedure aligned with "quick in-quick out" concept that we adopted for treating patients with gastric perforation. Omental plugging also allows patient to undergo ERAS program for better and faster recovery. The patients were discharged from the hospital without further complications and long-term follow-up showed good results. CONCLUSION Omental plugging has the least risk of complications than other perforation repair techniques and can be done for small and large perforation. Based on our case series, omental plug with double mattress suture is an effective and safe procedure to be performed in elderly patients with gastric perforation with Boey score 3.
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Affiliation(s)
- Adeodatus Yuda Handaya
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Joshua Andrew
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Ahmad Shafa Hanif
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Kevin Radinal Tjendra
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Azriel Farrel Kresna Aditya
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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202
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Zhang H, Zhang G, Yang Y, Zhang J, Li D, Duan S, Yang Q, Xu Y. Antimicrobial resistance comparison of Klebsiella pneumoniae pathogens isolated from intra-abdominal and urinary tract infections in different organs, hospital departments and regions of China between 2014 and 2017. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:639-648. [DOI: 10.1016/j.jmii.2020.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 12/27/2022]
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203
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Bass GA, Dzierba AL, Taylor B, Lane-Fall M, Kaplan LJ. Tertiary peritonitis: considerations for complex team-based care. Eur J Trauma Emerg Surg 2021; 48:811-825. [PMID: 34302503 PMCID: PMC8308068 DOI: 10.1007/s00068-021-01750-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/18/2021] [Indexed: 12/14/2022]
Abstract
Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104 USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- European Society of Trauma and Emergency Surgery, Visceral Trauma Section, Philadelphia, USA
| | - Amy L. Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY USA
| | - Beth Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Meghan Lane-Fall
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5 Dulles, Philadelphia, PA 19104 USA
| | - Lewis J. Kaplan
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104 USA
- Surgical Services, Section of Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104 USA
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204
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Top 10 Pearls for the Recognition, Evaluation, and Management of Maternal Sepsis. Obstet Gynecol 2021; 138:289-304. [PMID: 34237760 PMCID: PMC8288480 DOI: 10.1097/aog.0000000000004471] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/23/2021] [Indexed: 12/13/2022]
Abstract
Maternal sepsis is a leading cause of preventable maternal mortality that requires early recognition, expedient evaluation, and appropriate management. Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a challenge as the normal physiologic changes of pregnancy may mask the signs and symptoms of sepsis. Bedside assessment tools may aid in the detection of maternal sepsis. Timely and targeted antibiotic therapy and fluid resuscitation are critical for survival in patients with suspected sepsis. Once diagnosed, a search for etiologies and early application of source control measures will further reduce harms. If the patient is in septic shock or not responding to initial treatment, multidisciplinary consultation and escalation of care is necessary. Health care professionals should be aware of the unique complications of sepsis in critically ill pregnant and postpartum patients, and measures to prevent poor outcomes in this population. Adverse pregnancy outcomes may occur in association with sepsis, and should be anticipated and prevented when possible, or managed appropriately when they occur. Using a standardized approach to the patient with suspected sepsis may reduce maternal morbidity and mortality.
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205
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Kwok CPD, Tsui SYB, Chan KWE. Updates on bacterial resistance and empirical antibiotics treatment of complicated acute appendicitis in children. J Pediatr Surg 2021; 56:1145-1149. [PMID: 33845984 DOI: 10.1016/j.jpedsurg.2021.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery. METHODS A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted. RESULTS 257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615). CONCLUSION Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration. TYPE OF STUDY Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III.
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Affiliation(s)
- Chun Pong Daniel Kwok
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong.
| | - Siu Yan Bess Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Kin Wai Edwin Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
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206
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Dabaja-Younis H, Farah H, Miron R, Geffen Y, Slijper N, Steinberg R, Kassis I. The intraperitoneal bacteriology and antimicrobial resistance in acute appendicitis among children: a retrospective cohort study between the years 2007-2017. Eur J Pediatr 2021; 180:2091-2098. [PMID: 33594543 DOI: 10.1007/s00431-021-03994-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/24/2022]
Abstract
This study aims to describe the microbiology and susceptibility profile of the intraperitoneal flora in complicated appendicitis. It is a retrospective cohort study including children < 18-year-old with pathologically confirmed appendicitis, from 2007 to 2017. It included 1466 children. Intraperitoneal samples were obtained from 655 (44.7%) patients, and 201 (30.7%) had positive culture with 395 pathogens. Gram-negative rods comprised 67.6%, Gram-positive cocci 21.5%, and anaerobes 10.9% of the isolates. Gram-positive cocci were detected in 67 (37.8%) patients. Milleri group Streptococci was the most frequently isolated Gram-positive (44.7%). The proportional rate of Milleri group Streptococci from Gram-positive cocci increased from 9.5 to 56.3% (P < 0.001, OR 12.214). Patients with Gram-positive cocci had longer hospital stay (mean 9.36 + 6.385 vs 7.72 + 4.582, P = 0.036, (CI -3.165, -0.105)) and more complicated disease (89.5% vs 78.4%, P = 0.045, OR 2.342). Patients with Milleri group Streptococci isolates readmitted more frequently (26.5% vs 13.2%, P = 0.05, OR 2.37). Resistance to amoxicillin-clavulanate, gentamicin, ceftazidime, piperacillin-tazobactam, and amikacin were detected in 29.1%, 6.5%, 2.3%, 1.2%, and 0.7% of the Gram-negative rods, respectively.Conclusion: The rates of Gram-positive cocci and particularly Milleri group Streptococci in peritoneal fluid are increasing. More complicated disease and longer hospital stay in Gram-positive cocci and higher readmission rate in Milleri group Streptococci. These emphasize the role of anti-Gram-positive antimicrobials. What is known: • Gram-negative rods are the main isolates in complicated appendicitis. • The choice of antibiotic regimen is an unsettled issue due to resistance. What is new: • Increased rate of Gram-positive cocci and Milleri group Streptococci. • More complicated disease, longer hospital stay, and higher readmission rate.
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Affiliation(s)
- Halima Dabaja-Younis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel.
| | - Hanna Farah
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Ran Miron
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Healthcare Center, Haifa, Israel
| | - Nadav Slijper
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Ran Steinberg
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Imad Kassis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
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207
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Wang CH, Yang CC, Hsu WT, Qian F, Ding J, Wu HP, Tsai JJ, Yang CJ, Su MY, Chen SC, Lee CC. Optimal initial antibiotic regimen for the treatment of acute appendicitis: a systematic review and network meta-analysis with surgical intervention as the common comparator. J Antimicrob Chemother 2021; 76:1666-1675. [PMID: 33792691 DOI: 10.1093/jac/dkab074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The optimal antibiotic regimen for the medical management of acute appendicitis remains unknown due to a lack of head-to-head comparisons between different antibiotic regimens. METHODS We systematically searched the PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases from their inception through to August 2020. We selected randomized controlled trials (RCTs) or observational studies comparing antibiotic therapy and appendectomy as the initial treatment for adult or paediatric patients with acute appendicitis. We performed a Bayesian network meta-analysis (NMA) to obtain the indirect comparison results between different antibiotic regimens by employing the group managed by surgery as a common comparator. Antibiotic regimens were classified into three categories: those including a carbapenem; those including a cephalosporin; and those including a β-lactam/β-lactamase inhibitor combination. RESULTS A total of 9 RCTs (adults, n = 8; paediatrics, n = 1) and 12 observational studies (adults, n = 3; paediatrics, n = 9) were included in the NMA, with a total of 4551 patients. The most commonly administered regimen was a β-lactam/β-lactamase inhibitor combination (9/21; 43%), followed by a cephalosporin (7/21; 33%) or a carbapenem (5/21; 24%). The NMA indicated that surgery significantly increased 1 year treatment success, compared with cephalosporins [OR: 16.79; 95% credible interval: 3.8-127.64] or β-lactam/β-lactamase inhibitor combinations (OR: 19.99; 95% credible interval: 4.87-187.57), but not carbapenems (OR: 3.50, 95% credible interval: 0.55-38.63). In contrast, carbapenems were associated with fewer treatment-related complications compared with surgery (OR: 0.12; 95% credible interval: 0.01-0.85). CONCLUSIONS Carbapenems might be recommended as the initial antibiotic regimen for the non-operative management of adult patients with acute appendicitis. Nevertheless, due to the imprecise estimates in our NMA, additional RCTs are needed to corroborate these findings, especially for paediatric patients.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chun Yang
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Frank Qian
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Julia Ding
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Han-Ping Wu
- Department of Pediatric Emergency Medicine and Medical Research, Children's Hospital, China Medical University, Taichung, Taiwan.,Department of Medicine, School of Medicine, China Medical University, Taichung, Taiwan
| | - Jih-Jin Tsai
- Tropical Medicine Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Jui Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming Yang Su
- Department of Medicine, College of Medicine, National Cheng-Kung University, Tainan City, Taiwan
| | - Shyr-Chyr Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Center of Intelligent Healthcare, National Taiwan University Hospital, Taipei, Taiwan
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208
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Gatti M, Viaggi B, Rossolini GM, Pea F, Viale P. An Evidence-Based Multidisciplinary Approach Focused at Creating Algorithms for Targeted Therapy of BSIs, cUTIs, and cIAIs Caused by Enterobacterales in Critically Ill Adult Patients. Infect Drug Resist 2021; 14:2461-2498. [PMID: 34234476 PMCID: PMC8256626 DOI: 10.2147/idr.s314241] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/07/2021] [Indexed: 01/04/2023] Open
Abstract
Prompt implementation of appropriate targeted antibiotic therapy represents a valuable approach in improving clinical and ecological outcome in critically septic patients. This multidisciplinary opinion article focused at developing evidence-based algorithms for targeted antibiotic therapy of bloodstream (BSIs), complicated urinary tract (cUTIs), and complicated intrabdominal infections (cIAIs) caused by Enterobacterales. The aim was to provide a guidance for intensive care physicians either in appropriately placing novel antibiotics or in considering strategies for sparing the broadest-spectrum antibiotics. A multidisciplinary team of experts (one intensive care physician, one infectious disease consultant, one clinical microbiologist and one MD clinical pharmacologist), performed several rounds of assessment to reach agreement in developing six different algorithms according to the susceptibility pattern (one each for multi-susceptible, extended-spectrum beta-lactamase-producing, AmpC beta-lactamase-producing, Klebsiella pneumoniae carbapenemase (KPC)-producing, OXA-48-producing, and Metallo-beta-lactamase (MBL)-producing Enterobacterales). Whenever multiple therapeutic options were feasible, a hierarchical scale was established. Recommendations on antibiotic dosing optimization were also provided. In order to retrieve evidence-based support for the therapeutic choices proposed in the algorithms, a comprehensive literature search was performed by a researcher on PubMed-MEDLINE from inception until March 2021. Quality and strength of evidence was established according to a hierarchical scale of the study design. Only articles published in English were included. It is expected that these algorithms, by allowing prompt revision of antibiotic regimens whenever feasible, appropriate place in therapy of novel beta-lactams, implementation of strategies for sparing the broadest-spectrum antibiotics, and pharmacokinetic/pharmacodynamic optimization of antibiotic dosing regimens, may be helpful either in improving clinical outcome or in containing the spread of antimicrobial resistance.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi, University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
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209
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Kosaka H, Kaibori M, Kariya S, Ueno Y, Matsui K, Yamamoto H, Matsushima H, Hamamoto T, Sekimoto M. The percutaneous tandem drainage technique for radical treatment of intractable hepaticojejunostomy leakage. Drug Discov Ther 2021; 15:169-170. [PMID: 34234068 DOI: 10.5582/ddt.2021.01055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The principal concept of the percutaneous tandem drainage procedure for an intractable hepaticojejunostomy (HJ) leakage is to decrease the amount of fluid and divide the fluid-filled cavity into several small cavities, which can then be drained individually. Percutaneous abscess drainage (PAD) has a role in drainage of the fluid cavity, whereas percutaneous trans-anastomotic jejunum drainage (PTAJD) has a role in drainage to reduce the bile fluid and digestive juices. A decrease in fluid induces effective drainage of the fluid cavity by PAD. A negative pressure suction drain accelerates reduction of the fluid cavity. PAD is removed when the localized fluid cavity has collapsed. PTAJD is finally removed after a clamping test is performed. Since 2020, we performed the percutaneous tandem drainage for two patients, and an intractable HJ leakage was gently resolved within 3 months without any adverse event. The percutaneous tandem drainage technique is safe for steady drain management of an intractable HJ leakage.
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Affiliation(s)
- Hisashi Kosaka
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Masaki Kaibori
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Shuji Kariya
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Yutaka Ueno
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Kosuke Matsui
- Department of Surgery, Kansai Medical University, Osaka, Japan
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210
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Weller BM, Shaddix BP, Oschman A, Johnson PN, Neely SB, Chaaban H, Williams PK, Miller J. A Pilot Evaluation of the Possible Association of Metronidazole With Neurodevelopmental Outcomes in Premature Neonates. J Pediatr Pharmacol Ther 2021; 26:455-459. [PMID: 34239396 PMCID: PMC8244961 DOI: 10.5863/1551-6776-26.5.455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Metronidazole is recommended as a first-line treatment of necrotizing enterocolitis (NEC) in neonates. Metronidazole-associated neurotoxicity has been reported, but long-term neurodevelopmental effects in neonates have not been explored. The primary objective was to evaluate the relationship of cumulative metronidazole dose with each Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) composite score in neonates with NEC. Secondary objectives included comparison of seizure rates, mean Bayley-III scores, and neurodevelopmental impairment defined as 2 of 3 Bayley-III composite scores ≤ 79 or 1 score ≤ 70 between the metronidazole exposed and non-exposed groups. METHODS This multisite, retrospective cohort study compared infants with a birth weight < 1500 grams between January 1, 2011, and December 31, 2016, who developed stage 2 or greater NEC or spontaneous intestinal perforation and were followed up at a developmental clinic visit at approximately 1 year of age. Patients were excluded if admitted >72 hours of life, had congenital neurodevelopmental anomalies, hypoxic ischemic encephalopathy, grade III or IV intraventricular hemorrhage, or seizures prior to treatment of NEC. Included patients were stratified into 2 groups based on metronidazole exposure versus no metronidazole. Data were assessed using descriptive and inferential statistical techniques, using SAS 9.4. RESULTS Forty-one patients were included. Seven patients received metronidazole and 34 patients were in the non-metronidazole group. The only statistical difference noted between groups was for gestational age, with the non-exposed group being more premature. There was no statistical difference in Bayley-III scores, seizure rates, or neurodevelopmental impairment between groups. CONCLUSION No differences in neurodevelopmental outcomes were found between those with and without metronidazole exposure. Further studies are needed to validate our results.
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211
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Cardoso T, Rodrigues PP, Nunes C, Almeida M, Cancela J, Rosa F, Rocha-Pereira N, Ferreira I, Seabra-Pereira F, Vaz P, Carneiro L, Andrade C, Davis J, Marçal A, Friedman ND. Identification of hospitalized patients with community-acquired infection in whom treatment guidelines do not apply: a validated model. J Antimicrob Chemother 2021; 75:1047-1053. [PMID: 31873750 DOI: 10.1093/jac/dkz521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To develop and validate a clinical model to identify patients admitted to hospital with community-acquired infection (CAI) caused by pathogens resistant to antimicrobials recommended in current CAI treatment guidelines. METHODS International prospective cohort study of consecutive patients admitted with bacterial infection. Logistic regression was used to associate risk factors with infection by a resistant organism. The final model was validated in an independent cohort. RESULTS There were 527 patients in the derivation and 89 in the validation cohort. Independent risk factors identified were: atherosclerosis with functional impairment (Karnofsky index <70) [adjusted OR (aOR) (95% CI) = 2.19 (1.41-3.40)]; previous invasive procedures [adjusted OR (95% CI) = 1.98 (1.28-3.05)]; previous colonization with an MDR organism (MDRO) [aOR (95% CI) = 2.67 (1.48-4.81)]; and previous antimicrobial therapy [aOR (95% CI) = 2.81 (1.81-4.38)]. The area under the receiver operating characteristics (AU-ROC) curve (95% CI) for the final model was 0.75 (0.70-0.79). For a predicted probability ≥22% the sensitivity of the model was 82%, with a negative predictive value of 85%. In the validation cohort the sensitivity of the model was 96%. Using this model, unnecessary broad-spectrum therapy would be recommended in 30% of cases whereas undertreatment would occur in only 6% of cases. CONCLUSIONS For patients hospitalized with CAI and none of the following risk factors: atherosclerosis with functional impairment; previous invasive procedures; antimicrobial therapy; or MDRO colonization, CAI guidelines can safely be applied. Whereas, for those with some of these risk factors, particularly if more than one, alternative antimicrobial regimens should be considered.
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Affiliation(s)
- Teresa Cardoso
- Intensive Care Unit (UCIP) and Hospital Infection Control Committee; Hospital de Santo António, Oporto Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Pedro Pereira Rodrigues
- Department of Community Medicine, Information and Health Decision Sciences & CINTESIS, Faculty of Medicine, University of Porto, Rua Dr. Plácido Costa, s/n, 4200-450 Porto, Portugal
| | - Cristina Nunes
- Intensive Care Unit and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852 Bragança, Portugal
| | - Mónica Almeida
- Neurocritical Care Unit and Hospital Infection Control Committee, Hospital de Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal
| | - Joana Cancela
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - Fernando Rosa
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - Nuno Rocha-Pereira
- Infectious Diseases Department, São João Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Inês Ferreira
- Internal Medicine Department, Hospital de Santo António, Oporto Hospital Center, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Filipa Seabra-Pereira
- Intensive Care Unit (UCIP) and Hospital Infection Control Committee; Hospital de Santo António, Oporto Hospital Center, University of Porto, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Prudência Vaz
- Internal Medicine Department and Hospital Infection Control Committee, Hospital de Bragança, Northeastern Local Health Unit, Av. Abade Baçal, 5301-852 Bragança, Portugal
| | - Liliana Carneiro
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - Carina Andrade
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - Justin Davis
- Department of Renal Medicine, Barwon Health, Geelong, Victoria 3220, Australia
| | - Ana Marçal
- Internal Medicine Department, Hospital Pedro Hispano, Matosinhos Local Health Unit, R. Dr. Eduardo Torres, Sra. da Hora, Portugal
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria 3220, Australia
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Díaz-Hernández HA, Vázquez-Anaya G, Miranda-Zazueta G, Castro-Narro GE. The impact of different infectious complications on mortality of hospitalized patients with liver cirrhosis. Ann Hepatol 2021; 19:427-436. [PMID: 32299682 DOI: 10.1016/j.aohep.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/23/2020] [Accepted: 02/23/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Bacterial infections are common complications in patients with cirrhosis and are associated with poor prognosis. There are no studies that analyze the impact of different infectious complications in the mortality of these patients, so we aimed to perform this evaluation. MATERIALS AND METHODS We performed a case-control study in adult patients with cirrhosis with a follow-up period of one year. We recorded demographic data, prognostic scales, infectious complications and mortality at 30, 90 and 365 days. For the survival analysis, Kaplan-Meyer survival curve was performed and hazard ratios were calculated with 95% confidence intervals by Cox-regression in univariate and multivariate models. For the comparison between groups the Chi squared test, Fisher's exact test and Mann-Whitney U test were performed. RESULTS We included 500 patients. Median age was 58 years, predominant sex was woman (52%) and the most common infections were urinary tract infections (35%), pneumonia (28.2%) and spontaneous bacterial peritonitis (SBP) (18%). From the patients, 40.4% were CTP score C and median MELD score was 15. In the univariate analysis, infections in general, SBP, pneumonia and central nervous system (CNS) infections had an increased mortality at the three follow up periods, however in the multivariate analysis with the prognostic scales, only pneumonia (HR 2.03, CI 95%[1.06-3.86]) and CNS infections (HR 4.84, CI 95%[1.38-16.93]) remained with increased mortality. CONCLUSIONS Some infectious complications, as pneumonia and CNS infections, increase mortality in hospitalized patients with cirrhosis, regardless of the severity of liver disease.
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Affiliation(s)
- Héctor Adrián Díaz-Hernández
- Department of Gastrointestinal Endoscopy, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Gerardo Vázquez-Anaya
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | - Godolfino Miranda-Zazueta
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
| | - Graciela Elia Castro-Narro
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico.
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Prospective Cohort Study of Micafungin Population Pharmacokinetic Analysis in Plasma and Peritoneal Fluid in Septic Patients with Intra-abdominal Infections. Antimicrob Agents Chemother 2021; 65:e0230720. [PMID: 33846133 DOI: 10.1128/aac.02307-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The objective of this study was to describe the pharmacokinetics (PK) of micafungin in plasma and peritoneal fluid in septic patients with intra-abdominal infections. Twelve patients with secondary peritonitis in septic shock receiving 100 mg micafungin once daily were included. Total micafungin plasma and peritoneal fluid were subjected to a population pharmacokinetic analysis using Pmetrics. Monte Carlo simulations were performed considering the total area under the curve from 0 to 24 h (AUC0-24)/MIC ratios in plasma. Micafungin concentrations in both plasma and the peritoneal exudate were best described by a three-compartmental PK model with the fat-free mass (FFM) as a covariate of clearance (CL) and the volume of the central compartment (Vc). The mean parameter estimates (standard deviations [SD]) were 1.18 (0.40) liters/h for CL and 12.85 (4.78) liters for Vc. The mean peritoneal exudate/plasma ratios (SD) of micafungin were 25% (5%) on day 1 and 40% (8%) between days 3 and 5. Dosing simulations supported the use of standard 100-mg daily dosing for Candida albicans (FFM, <60 kg), C. glabrata (FFM, <50 kg), and C. tropicalis (FFM, <30 kg) on the second day of therapy. There is a moderate penetration of micafungin into the peritoneal cavity (25 to 40%). For empirical treatment, a dose escalation of at least a loading dose of 150 mg depending on the FFM of patients and the Candida species is suggested to be effective from the first day of therapy.
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214
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Utility of Acute Physiology and Chronic Health Evaluation (APACHE II) in Predicting Mortality in Patients with Pyogenic Liver Abscess: A Retrospective Study. J Clin Med 2021; 10:jcm10122644. [PMID: 34208437 PMCID: PMC8235429 DOI: 10.3390/jcm10122644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/12/2021] [Accepted: 06/13/2021] [Indexed: 12/28/2022] Open
Abstract
Pyogenic liver abscess (PLA) is a major life-threatening disease with varied clinical features. This study aimed to determine predictors of mortality in patients with PLA using criteria determined upon admission. We retrospectively examined the data of 324 hospitalized adults in whom liver abscesses were confirmed using abdominal ultrasound and/or computed tomography. The relationship between various risk factors was assessed using multivariate analysis. A total of 109 (33.6%) patients were admitted to the intensive care unit (ICU). The overall mortality rate was 7.4% and was higher among ICU patients than non-ICU patients (21.1% vs. 0.5%, p < 0.001). PLA patients with an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥18 had a 19.31-fold increased risk, and those with concomitant infections had a 34.33-fold increased risk of 30-day mortality according to multivariate analysis. The estimated area under the receiver operating characteristic curve for predicting 30-day mortality revealed that APACHE II score ≥18 (sensitivity of 75% and specificity of 84%, p < 0.0001) had better discriminative power than Sequential Organ Failure Assessment (SOFA) ≥6 (sensitivity of 81% and specificity of 66%, p < 0.0001). APACHE II has shown better discrimination ability than SOFA in predicting mortality in PLA patients. To improve outcomes in patients with PLA, future management strategies should focus on high-risk patients.
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215
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Donà D, Gastaldi A, Barbieri E, Bonadies L, Aluvaala J, English M. Empirical Antimicrobial Therapy of Neonates with Necrotizing Enterocolitis: A Systematic Review. Am J Perinatol 2021; 40:646-656. [PMID: 34126646 PMCID: PMC7614399 DOI: 10.1055/s-0041-1730364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal tract characterized by ischemic necrosis of the intestinal mucosa, mostly affecting premature neonates. Management of NEC includes medical care and surgical approaches, with supportive care and empirical antibiotic therapy recommended to avoid any disease progression. However, there is still no clear evidence-based consensus on empiric antibiotic strategies or surgical timing. This study was aimed to review the available evidence on the effectiveness and safety of different antibiotic regimens for NEC. STUDY DESIGN MEDLINE, EMBASE, Cochrane CENTRAL, and CINAHL databases were systematically searched through May 31, 2020. Randomized controlled trials (RCTs) and nonrandomized interventions reporting data on predefined outcomes related to NEC treatments were included. Clinical trials were assessed using the criteria and standard methods of the Cochrane risk of bias tool for randomized trials, while the risk of bias in nonrandomized studies of interventions was evaluated using the ROBINS-I tool. The certainty in evidence of each outcome's effects was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Five studies were included in this review, two RCTs and three observational studies, for a total amount of 3,161 patients. One RCT compared the outcomes of parenteral (ampicillin plus gentamicin) and oral (gentamicin) treatment with parenteral only. Three studies (one RCT and two observational) evaluated adding anaerobic coverage to different parenteral regimens. The last observational study compared two different parenteral antibiotic combinations (ampicillin and gentamicin vs. cefotaxime and vancomycin). CONCLUSION No antimicrobial regimen has been shown to be superior to ampicillin and gentamicin in decreasing mortality and preventing clinical deterioration in NEC. The use of additional antibiotics providing anaerobic coverage, typically metronidazole, or use of other broad-spectrum regimens as first-line empiric therapy is not supported by the very limited current evidence. Well-conducted, appropriately sized comparative trials are needed to make evidence-based recommendations. KEY POINTS · Ampicillin and gentamicin are effective in decreasing mortality and preventing clinical deterioration in NEC.. · Metronidazole could be added in patients with surgical NEC.. · No study with high-quality evidence was found..
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Affiliation(s)
- Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Andrea Gastaldi
- Department of Pediatrics, Woman and Child Hospital, University of Verona, Verona, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department of Woman and Child Health, University Hospital of Padua, Padua, Italy
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, United Kingdom
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216
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Smith MJ, Boutzoukas A, Autmizguine J, Hudak ML, Zinkhan E, Bloom BT, Heresi G, Lavery AP, Courtney SE, Sokol GM, Cotten CM, Bliss JM, Mendley S, Bendel C, Dammann CE, Weitkamp JH, Saxonhouse MA, Mundakel GT, Debski J, Sharma G, Erinjeri J, Gao J, Benjamin DK, Hornik CP, Smith PB, Cohen-Wolkowiez M. Antibiotic Safety and Effectiveness in Premature Infants With Complicated Intraabdominal Infections. Pediatr Infect Dis J 2021; 40:550-555. [PMID: 33902072 PMCID: PMC9844130 DOI: 10.1097/inf.0000000000003034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In premature infants, complicated intraabdominal infections (cIAIs) are a leading cause of morbidity and mortality. Although universally prescribed, the safety and effectiveness of commonly used antibiotic regimens have not been established in this population. METHODS Infants ≤33 weeks gestational age and <121 days postnatal age with cIAI were randomized to ≤10 days of ampicillin, gentamicin, and metronidazole (group 1); ampicillin, gentamicin, and clindamycin (group 2); or piperacillin-tazobactam and gentamicin (group 3) at doses stratified by postmenstrual age. Due to slow enrollment, a protocol amendment allowed eligible infants already receiving study regimens to enroll without randomization. The primary outcome was mortality within 30 days of study drug completion. Secondary outcomes included adverse events, outcomes of special interest, and therapeutic success (absence of death, negative cultures, and clinical cure score >4) 30 days after study drug completion. RESULTS One hundred eighty infants [128 randomized (R), 52 nonrandomized (NR)] were enrolled: 63 in group 1 (45 R, 18 NR), 47 in group 2 (41 R, 6 NR), and 70 in group 3 (42 R, 28 NR). Thirty-day mortality was 8%, 7%, and 9% in groups 1, 2, and 3, respectively. There were no differences in safety outcomes between antibiotic regimens. After adjusting for treatment group and gestational age, mortality rates through end of follow-up were 4.22 [95% confidence interval (CI): 1.39-12.13], 4.53 (95% CI: 1.21-15.50), and 4.07 (95% CI: 1.22-12.70) for groups 1, 2, and 3, respectively. CONCLUSIONS Each of the antibiotic regimens are safe in premature infants with cIAI. CLINICAL TRIAL REGISTRATION NCT0199499.
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Affiliation(s)
- Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
| | | | - Julie Autmizguine
- Division of Pediatric Infectious Diseases, Universitaire Sainte-Justine, Montreal, Canada
| | - Mark L. Hudak
- Division of Neonatology, University of Florida College of Medicine, Jacksonville, FL
| | - Erin Zinkhan
- Division of Neonatology, University of Utah, Salt Lake City, UT
| | - Barry T. Bloom
- Division of Neonatology, Wesley Medical Center, Wichita, KS
| | - Gloria Heresi
- Division of Pediatric Infectious Diseases, University of Texas, Houston, TX
| | | | - Sherry E. Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - C. Michael Cotten
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
| | | | - Susan Mendley
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Catherine Bendel
- Division of Neonatology, University of Minnesota, Minneapolis, MN
| | | | | | | | | | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC
| | - Daniel K. Benjamin
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - P. Brian Smith
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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217
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Katz S, Banerjee R, Schwenk H. Antibiotic Stewardship for the Neonatologist and Perinatologist. Clin Perinatol 2021; 48:379-391. [PMID: 34030820 DOI: 10.1016/j.clp.2021.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.
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Affiliation(s)
- Sophie Katz
- Vanderbilt University Medical Center, 1161 21st Avenue, Nashville, TN 37232, USA
| | - Ritu Banerjee
- Vanderbilt University Medical Center, 1161 21st Avenue, Nashville, TN 37232, USA
| | - Hayden Schwenk
- Center for Academic Medicine, Pediatric Infectious Diseases, Mail code 5660, 453 Quarry Road, Stanford, CA 94304, USA.
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218
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Chen L, Wu X, Qin H, Zhu H. The PCT to Albumin Ratio Predicts Mortality in Patients With Acute Kidney Injury Caused by Abdominal Infection-Evoked Sepsis. Front Nutr 2021; 8:584461. [PMID: 34141715 PMCID: PMC8203818 DOI: 10.3389/fnut.2021.584461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/29/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose: Considerable evidence suggests that inflammation and malnutrition are common in patients with acute kidney injury (AKI) and correlated with mortality of various diseases. Despite this, few studies have reported the underlying predictive effects of inflammatory and nutritional markers in combination on the mortality of AKI patients. Herein, we aimed to explore the values of PCT and CRP as well as the ratios of PCT/Alb and CRP/Alb in the poor prognosis of patients with sepsis-induced AKI. Patients and Methods: A total of 171 patients with AKI, caused by abdominal infection-evoked sepsis, were retrospectively studied and divided into a survival group (107 cases) and a non-survival group (64 cases). Univariate analysis was used to compare the clinical data of the two groups. Multivariate logistic regression analysis was used to analyze the independent risk factors of poor prognosis in patients with sepsis-induced AKI. The ROC curve was used to evaluate the diagnostic value of PCT, CRP, PCT/Alb, and CRP/Alb in the poor prognosis of patients with sepsis-induced AKI. Results: Univariate analysis revealed that the values of PCT, CRP, CRP/Alb, and PCT/Alb were significantly different between AKI survival and non-survival groups, and further analysis found that PCT and PCT/Alb were independent risk factors for poor prognosis in patients with sepsis-induced AKI after adjusting with age and gender. Of note, the predictive accuracy (0.864 vs. 0.807), specificity (83.2 vs. 69.2), and sensitivity (79.7 vs. 76.6) of PCT/Alb were all higher than that of the simple PCT. Conclusions: The ratio of PCT to Alb is an independent risk factor possessing a robust and accurate risk assessment for the poor prognosis of patients with sepsis-induced AKI, and it offers the potential to improve the management of this type of disease and a lower resultant mortality.
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Affiliation(s)
- Lijuan Chen
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Xiaoli Wu
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Haiyan Qin
- Department of Pharmacy, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
| | - Hongchao Zhu
- Department of Nuclear Medicine, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huaian, China
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219
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Ridgway JP, Robicsek A, Shah N, Smith BA, Singh K, Semel J, Acree ME, Grant J, Ravichandran U, Peterson LR. A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship. Clin Infect Dis 2021; 72:e265-e271. [PMID: 32712674 DOI: 10.1093/cid/ciaa1048] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). METHODS We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. RESULTS In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). CONCLUSIONS Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.
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Affiliation(s)
- Jessica P Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ari Robicsek
- Providence St. Joseph Health, Seattle, Washington, USA
| | - Nirav Shah
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Becky A Smith
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kamaljit Singh
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jeffery Semel
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Jennifer Grant
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Lance R Peterson
- Pritzer School of Medicine, University of Chicago, Chicago, Illinois, USA
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220
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Sugiura R, Naruse H, Yamamoto Y, Hatanaka K, Kinoshita K, Abiko S, Miyamoto S, Suzuki K, Higashino M, Kohya R, Sakamoto N. Very urgent endoscopic retrograde cholangiopancreatography is associated with early discharge in patients with non-severe acute cholangitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 114:133-139. [PMID: 33947198 DOI: 10.17235/reed.2021.7995/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a first-line procedure for biliary drainage in patients with acute cholangitis, and no study focused very urgent ERCP within several hours of hospital arrival. We aimed to elucidate the utility of very urgent ERCP for non-severe acute cholangitis. METHODS This retrospective observational study included patients with non-severe acute cholangitis who underwent ERCP between April 2011 and June 2020 in the study institution. Patients were stratified into three groups based on the time to ERCP after hospital arrival: very urgent (≤3hours), urgent (3-24hours), and elective (>24hours). The primary outcome was length of hospital stay (LOS). RESULTS In the study cohort of 291 patients, including 168 males (57.7%), with a median age of 76 (interquartile range, 70-83) years, 47, 196, and 48 patients underwent very urgent, urgent, and elective ERCP, respectively. The median LOSs in the very urgent, urgent, and elective groups were 12, 14, and, 15 days, respectively (Kaplan-Meier method). A shorter LOS was associated with earlier ERCP (log-rank trend test, P=0.04). The rates of readmission within 30 days of discharge and adverse events were not significantly different among the three groups. By multivariate analysis, very urgent ERCP was associated with a significantly earlier discharge than urgent and elective ERCP (HR 0.71, P=0.04 and HR 0.47, P<0.01, respectively). In addition, age≥75years, pancreatitis, albumin≤2.8g/dL, and two or more ERCP procedures were associated with significantly longer LOS (HRs <1, P<0.05). CONCLUSIONS Very urgent ERCP for non-severe acute cholangitis was associated with early discharge.
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Affiliation(s)
- Ryo Sugiura
- Gastroenterology and Hepatology, Hakodate Municipal Hospital, Japan
| | - Hirohito Naruse
- Gastroenterology and Hepatology, Hakodate Municipal Hospital
| | | | | | - Kenji Kinoshita
- Gastroenterology and Hepatology, Hakodate Municipal Hospital
| | - Satoshi Abiko
- Gastroenterology and Hepatology, Hakodate Municipal Hospital
| | | | - Kazuharu Suzuki
- Gastroenterology and Hepatology, Hakodate Municipal Hospital
| | | | - Risako Kohya
- Gastroenterology and Hepatology, Hakodate Municipal Hospital
| | - Naoya Sakamoto
- Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine
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221
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Zhang Z, He Y, Wang Z, Bao L, Shi Y, Li L. Survey on antibiotic regimens for necrotizing enterocolitis prescribed by Chinese pediatricians in 2020. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000253. [DOI: 10.1136/wjps-2020-000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022] Open
Abstract
BackgroundNecrotizing enterocolitis (NEC) is a serious intestinal inflammatory disease in neonates, and intravenous antibiotics constitute the main therapeutic strategy. Studies have shown that substantial variation in the selection of antibiotic regimens for NEC remains in many countries. The variability in antibiotic therapy selection in China is unclear.MethodsA cross-sectional study using an online questionnaire regarding antibiotic regimens for NEC was conducted among pediatricians working in tertiary hospitals in China.ResultsA total of 284 pediatricians from 29 provinces completed the survey; 37.9% of them administered one antibiotic, 56.7% administered two antibiotics and 2.4% administered three antibiotics. The top three single-antibiotic regimens for NEC were beta-lactamase inhibitors (n=66, 41.5%), carbapenems (n=46, 28.9%) and cephalosporins (n=33, 20.8%). Twenty combinations of two antibiotics were identified, and the top three combinations were beta-lactamase inhibitors and antianaerobic agents (n=49, 19.6%), carbapenems and glycopeptides (n=42, 16.8%), and cephalosporins and antianaerobic agents (n=37, 14.8%). Regarding the therapeutic duration of antibiotic treatment, 77.5% (n=220) of the pediatricians chose 5–10 days for stage II NEC, and 79.6% (n=226) chose 7–14 days for stage III NEC. Forty-three percent (n=122) of the respondents preferred to use carbapenems when NEC was diagnosed, and 83.3% (n=135) adjusted the antibiotics to carbapenems if a patient’s medical condition deteriorated or if the therapeutic efficacy was poor.ConclusionThis survey revealed that carbapenems were the most common antibiotics selected when NEC was diagnosed or a patient’s condition deteriorated, but the duration of the course of treatment for NEC varied substantially among doctors.
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222
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Lo Re V, Carbonari DM, Jacob J, Short WR, Leonard CE, Lyons JG, Kennedy A, Damon J, Haug N, Zhou EH, Graham DJ, McMahill-Walraven CN, Parlett LE, Nair V, Selvan M, Zhou Y, Pocobelli G, Maro JC, Nguyen MD. Validity of ICD-10-CM diagnoses to identify hospitalizations for serious infections among patients treated with biologic therapies. Pharmacoepidemiol Drug Saf 2021; 30:899-909. [PMID: 33885214 DOI: 10.1002/pds.5253] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/11/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE Identifying hospitalizations for serious infections among patients dispensed biologic therapies within healthcare databases is important for post-marketing surveillance of these drugs. We determined the positive predictive value (PPV) of an ICD-10-CM-based diagnostic coding algorithm to identify hospitalization for serious infection among patients dispensed biologic therapy within the FDA's Sentinel Distributed Database. METHODS We identified health plan members who met the following algorithm criteria: (1) hospital ICD-10-CM discharge diagnosis of serious infection between July 1, 2016 and August 31, 2018; (2) either outpatient/emergency department infection diagnosis or outpatient antimicrobial treatment within 7 days prior to hospitalization; (3) inflammatory bowel disease, psoriasis, or rheumatological diagnosis within 1 year prior to hospitalization, and (4) were dispensed outpatient biologic therapy within 90 days prior to admission. Medical records were reviewed by infectious disease clinicians to adjudicate hospitalizations for serious infection. The PPV (95% confidence interval [CI]) for confirmed events was determined after further weighting by the prevalence of the type of serious infection in the database. RESULTS Among 223 selected health plan members who met the algorithm, 209 (93.7% [95% CI, 90.1%-96.9%]) were confirmed to have a hospitalization for serious infection. After weighting by the prevalence of the type of serious infection, the PPV of the ICD-10-CM algorithm identifying a hospitalization for serious infection was 80.2% (95% CI, 75.3%-84.7%). CONCLUSIONS The ICD-10-CM-based algorithm for hospitalization for serious infection among patients dispensed biologic therapies within the Sentinel Distributed Database had 80% PPV for confirmed events and could be considered for use within pharmacoepidemiologic studies.
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Affiliation(s)
- Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dena M Carbonari
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jerry Jacob
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William R Short
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles E Leonard
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer G Lyons
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Adee Kennedy
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Jolene Damon
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Nicole Haug
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Esther H Zhou
- United States Food and Drug Administration, Silver Spring, Maryland, USA
| | - David J Graham
- United States Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Vinit Nair
- Competitive Health Analytics, Humana Healthcare Research, Inc., Louisville, Kentucky, USA
| | - Mano Selvan
- Competitive Health Analytics, Humana Healthcare Research, Inc., Louisville, Kentucky, USA
| | - Yunping Zhou
- Competitive Health Analytics, Humana Healthcare Research, Inc., Louisville, Kentucky, USA
| | - Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Judith C Maro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Michael D Nguyen
- United States Food and Drug Administration, Silver Spring, Maryland, USA
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223
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Importance of Reviewing Antibiotic Courses by 48 Hours: Risk Factors for Third-Generation Cephalosporin Resistance Among AmpC Harboring Organisms in Urine and Respiratory Cultures. Pediatr Infect Dis J 2021; 40:440-445. [PMID: 33264210 DOI: 10.1097/inf.0000000000003006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Citrobacter, Enterobacter, Morganella, and Serratia (AmpC organisms) species can exhibit third-generation cephalosporin (TGC) resistance after TGC exposure. We aimed to assess if institutional TGC utilization correlated with institutional AmpC organism susceptibility and if prior TGC exposure ≤48 hours were associated with TGC resistance in the first culture of a future infection episode caused by an AmpC organism. METHODS A 5-year retrospective cohort study was performed, including AmpC organisms isolated from pediatric urinary and respiratory tract cultures at an institution with TGC courses reviewed by the antimicrobial stewardship program at 48 hours. Correlations were assessed by Pearson's correlation. Multivariable logistic regression identified factors independently associated with TGC resistance in a subcohort of infection episodes. RESULTS Among 654 cultures, AmpC organism TGC susceptibility increased from 74% in 2013 to 89.3% in 2017, and this correlated with a 26.1% decrease in TGC utilization (R = -0.906; P = 0.034). Among 275 AmpC organism infections, 21.1% were resistant. Resistance occurred in 13.6%, 17.4%, and 56.5% of infections with no exposure, ≤48 hours, and >48 hours of TGC exposure in the past 30 days, respectively. TGC exposure ≤48 hours was not associated with resistance (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.32-4.94; P = 0.74), whereas, TGC exposure >48 hours was (OR, 8.7; 95% CI, 3.67-20.6; P < 0.001). Infections in 2017 were less likely to be resistant (OR, 0.25; 95% CI, 0.08-0.8; P = 0.019). CONCLUSIONS Decreased TGC utilization, likely related to antimicrobial stewardship, correlated with increased AmpC organism susceptibility. Limiting TGC exposure to ≤48 hours when possible may reduce AmpC organism resistance in future infections.
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224
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Ahmed S, Bonnett L, Melhuish A, Adil MT, Aggarwal I, Ali W, Bennett J, Boldock E, Burns FA, Czarniak E, Dennis R, Flower B, Fok R, Goodman AL, Halai S, Hanna T, Hashem M, Hodgson SH, Hughes G, Hurndall KH, Hyland R, Iqbal MR, Jarchow-MacDonald A, Kailavasan M, Klimovskij M, Laliotis A, Lambourne J, Lawday S, Lee F, Lindsey B, Lund JN, Mabayoje DA, Malik KI, Muir A, Narula HS, Ofor U, Parsons H, Pavelle T, Prescott K, Rajgopal A, Roy I, Sagar J, Scarborough C, Shaikh S, Smart CJ, Snape S, Tabaqchali MA, Tennakoon A, Tilley R, Vink E, White L, Burke D, Kirby A. Development and internal validation of clinical prediction models for outcomes of complicated intra-abdominal infection. Br J Surg 2021; 108:441-447. [PMID: 33615351 DOI: 10.1093/bjs/znaa117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse. METHODS A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further. RESULTS Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively. CONCLUSION Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, these now require external validation.
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Affiliation(s)
- S Ahmed
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - L Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - A Melhuish
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M T Adil
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - I Aggarwal
- Infection Unit, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - W Ali
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - J Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - E Boldock
- Department of Microbiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - F A Burns
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Czarniak
- Department of Microbiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - R Dennis
- Colorectal Surgery Department, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - B Flower
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - R Fok
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - A L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - S Halai
- Department of Surgery, Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - T Hanna
- Department of Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - M Hashem
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - S H Hodgson
- Department of Infection, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - G Hughes
- Infectious Diseases and Microbiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - K-H Hurndall
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | - R Hyland
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - M R Iqbal
- Department of Surgery, Maidstone and Tunbridge Wells NHS Foundation Trust, Kent, UK
| | | | - M Kailavasan
- Department of Urology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Klimovskij
- Department of Surgery, Conquest Hospital, East Sussex NHS Healthcare Trust, East Sussex, UK
| | - A Laliotis
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge, UK
| | - J Lambourne
- Division of Infection, Barts Health NHS Trust, London, UK
| | - S Lawday
- Department of Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - F Lee
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - B Lindsey
- Department of Microbiology, The Whittington Hospital, Whittington Health NHS Trust, London, UK
| | - J N Lund
- Division of Medical Sciences and Graduate Entry Medicine, Royal Derby Hospital, University of Nottingham, Derby, UK
| | - D A Mabayoje
- Division of Infection, Barts Health NHS Trust, London, UK
| | - K I Malik
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Muir
- Department of Microbiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - H S Narula
- Department of Surgery, Chesterfield Royal Hospital NHS Trust Hospital, Chesterfield, UK
| | - U Ofor
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - H Parsons
- Department of Microbiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - T Pavelle
- Shrewsbury and Telford NHS Trust, Shrewsbury, UK
| | - K Prescott
- Microbiology and Infectious Diseases, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rajgopal
- Department of Microbiology, Calderdale and Huddersfield NHS Trust, Huddersfield, UK
| | - I Roy
- Colorectal Surgery Department, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - J Sagar
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | - C Scarborough
- Department of Infection, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - S Shaikh
- Department of Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - C J Smart
- Department of Surgery, Macclesfield District General Hospital, East Cheshire NHS Trust, Cheshire, UK
| | - S Snape
- Microbiology and Infectious Diseases, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M A Tabaqchali
- Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
| | - A Tennakoon
- Department of Surgery, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - R Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - E Vink
- Department of Microbiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - L White
- Department of Microbiology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - D Burke
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
| | - A Kirby
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Surgery, University Hospital North Tees, Stockton on Tees, UK
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Mergenhagen KA, Starr KE, Wattengel BA, Lesse AJ, Sumon Z, Sellick JA. Determining the Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Antimicrobial Stewardship. Clin Infect Dis 2021; 71:1142-1148. [PMID: 31573026 DOI: 10.1093/cid/ciz974] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, there is associated toxicity. The Department of Veterans Affairs (VA) hospitals screen each patient for MRSA nares colonization on admission and transfer. The objective was to determine the negative predictive value (NPV) of MRSA screening in the determination of subsequent positive clinical culture for MRSA. High NPVs with MRSA nares screening may be used as a stewardship tool. METHODS This was a retrospective cohort study across VA medical centers nationwide from 1 January 2007 to 1 January 2018. Data from patients with MRSA nares screening were obtained from the VA Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values, and NPVs were calculated for the entire cohort as well as subgroups for specific culture sites. RESULTS This cohort yielded 561 325 clinical cultures from a variety of anatomical sites. The sensitivity and specificity for positive MRSA clinical culture were 67.4% and 81.2%, respectively. The NPV of MRSA nares screening for ruling out MRSA infection was 96.5%. The NPV for bloodstream infections was 96.5%, for intraabdominal cultures it was 98.6%, for respiratory cultures it was 96.1%, for wound cultures it was 93.1%, and for cultures from the urinary system it was 99.2%. CONCLUSION Given the high NPVs, MRSA nares screening may be a powerful stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy.
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Affiliation(s)
- Kari A Mergenhagen
- Department of Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA
| | - Kaitlyn E Starr
- Department of Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA
| | - Bethany A Wattengel
- Department of Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA
| | - Alan J Lesse
- Department of Infectious Diseases, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA.,Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Zarchi Sumon
- Department of Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA
| | - John A Sellick
- Department of Infectious Diseases, Veteran Affairs Western New York Healthcare System, Buffalo, New York, USA.,Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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226
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Spangler R, Manning S. Disaster Diagnoses in Geriatric Patients with Abdominal Pain. Emerg Med Clin North Am 2021; 39:347-360. [PMID: 33863464 DOI: 10.1016/j.emc.2021.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Care of geriatric patients with abdominal pain can pose significant diagnostic and therapeutic challenges to emergency physicians. Older adults rarely present with classic signs, symptoms, and laboratory abnormalities. The incidence of life-threatening emergencies, including abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, and other surgical emergencies, is high. This article explores the evaluation and management of several important causes of abdominal pain in geriatric patients with an emphasis on high-risk presentations.
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Affiliation(s)
- Ryan Spangler
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Sara Manning
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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227
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Hamilton J, Crosthwaite G, Montalto M. Hospital in the home-based management of acute diverticulitis: a safe and effective alternative to inpatient care. ANZ J Surg 2021; 91:2106-2109. [PMID: 33908153 DOI: 10.1111/ans.16901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The traditional approach to management of acute uncomplicated diverticulitis involves admission to hospital, antibiotic therapy, gut rest and monitoring for the development of complications. Despite evidence to suggest this can safely be performed in an outpatient setting, inpatient care remains standard practice in Australia potentially due to a variety of factors (van Dijk et al. 2018; Cirocchi et al. 2019). Hospital in the home (HIH) allows patients requiring complex care including intravenous antibiotics, intravenous fluids and complex pain relief to be managed at home. This study examined the safety and efficacy of HIH-based care for acute diverticulitis over a 16-year period. METHODOLOGY A retrospective review of cases of acute diverticulitis managed under our HIH service from the period of 1st of January 2004 to 20th of October 2020 was completed. Baseline descriptive data relating to age, co-morbidities and severity of diverticulitis was collected. Details of medical treatment provided and subsequent complications were also collected. RESULTS During the study period, 23 patients with acute diverticulitis were treated under the HIH unit. Among the study population, the median age was 60 (interquartile range 15) with a slight female predominance (n = 13, 56.5%). This represented the first presentation in 60.9% of patients. Average length of stay was 3.6 days (SD = 1.0) with no acute complications recorded in the study period. Two patients (8.7%) had further episodes of acute diverticulitis within 60 days. CONCLUSION In this study, the lack of complications demonstrated indicates that HIH-based management of acute diverticulitis may be a viable and safe alternative to inpatient care.
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Affiliation(s)
- Jordan Hamilton
- Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Crosthwaite
- Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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228
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Consecutive antibiotic shortages highlight discrepancies between microbiology and prescribing practices for intra-abdominal infections. Antimicrob Agents Chemother 2021; 95:AAC.01980-20. [PMID: 33593836 PMCID: PMC8092895 DOI: 10.1128/aac.01980-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Piperacillin-tazobactam (TZP) is frequently used for intra-abdominal infection (IAI). Our institution experienced consecutive shortages of TZP and cefepime, providing an opportunity to review prescribing patterns and microbiology for IAI. Hospitalized adult patients treated for IAI, based on provider selection of IAI as the indication within the antibiotic order, between March 2014 and February 2018 were identified from the University of Virginia Clinical Data Repository and Infection Prevention and Control Database. Antimicrobial utilization, microbiologic data, and clinical outcomes were compared across four year-long periods: pre-shortage, TZP shortage, cefepime shortage, and post-shortage. There were 7,668 episodes of antimicrobial prescribing for an indication of IAI during the study period. Cefepime use for IAI increased 190% during the TZP shortage; meanwhile ceftriaxone use increased by only 57%. There was no increase in in-house mortality, colonization with resistant organisms, or Clostridiodes difficile infection among patients treated with IAI during the shortage periods. Among a subset of cases randomly selected for review, Pseudomonas sp. was a rare cause of IAI, but anti-pseudomonal antibiotics were commonly prescribed empirically. We observed a large increase in cefepime utilization for IAI during a TZP shortage that was not warranted based on the observed frequency of identification of Pseudomonas sp. as the causative organism in IAI, suggesting a need to revisit national guideline recommendations.
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229
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Rodríguez-Villodres Á, Gil-Marqués ML, Álvarez-Marín R, Bonnin RA, Pachón-Ibáñez ME, Aguilar-Guisado M, Naas T, Aznar J, Pachón J, Lepe JA, Smani Y. Extended-spectrum resistance to β-lactams/β-lactamase inhibitors (ESRI) evolved from low-level resistant Escherichia coli. J Antimicrob Chemother 2021; 75:77-85. [PMID: 31613964 DOI: 10.1093/jac/dkz393] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/29/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Escherichia coli is characterized by three resistance patterns to β-lactams/β-lactamase inhibitors (BLs/BLIs): (i) resistance to ampicillin/sulbactam and susceptibility to amoxicillin/clavulanic acid and piperacillin/tazobactam (RSS); (ii) resistance to ampicillin/sulbactam and amoxicillin/clavulanic acid, and susceptibility to piperacillin/tazobactam (RRS); and (iii) resistance to ampicillin/sulbactam, amoxicillin/clavulanic acid and piperacillin/tazobactam (RRR). These resistance patterns are acquired consecutively, indicating a potential risk of developing resistance to piperacillin/tazobactam, but the precise mechanism of this process is not completely understood. METHODS Clinical isolates incrementally pressured by piperacillin/tazobactam selection in vitro and in vivo were used. We determined the MIC of piperacillin/tazobactam in the presence and absence of piperacillin/tazobactam pressure. We deciphered the role of the blaTEM genes in the new concept of extended-spectrum resistance to BLs/BLIs (ESRI) using genomic analysis. The activity of β-lactamase was quantified in these isolates. RESULTS We show that piperacillin/tazobactam resistance is induced in E. coli carrying blaTEM genes. This resistance is due to the increase in copy numbers and transcription levels of the blaTEM gene, thus increasing β-lactamase activity and consequently increasing piperacillin/tazobactam MICs. Genome sequencing of two blaTEM-carrying representative isolates showed that piperacillin/tazobactam treatment produced two types of duplications of blaTEM (8 and 60 copies, respectively). In the clinical setting, piperacillin/tazobactam treatment of patients infected by E. coli carrying blaTEM is associated with a risk of therapeutic failure. CONCLUSIONS This study describes for the first time the ESRI in E. coli. This new concept is very important in the understanding of the mechanism involved in the acquisition of resistance to BLs/BLIs.
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Affiliation(s)
- Ángel Rodríguez-Villodres
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - María Luisa Gil-Marqués
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Rocío Álvarez-Marín
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Rémy A Bonnin
- EA7361, Université Paris-Saclay, LabEx Lermit, Bacteriology-Hygiene unit, APHP, Hôpital Bicêtre, EERA 'Evolution and Ecology of Resistance to Antibiotics' Unit, Institut Pasteur-APHP-Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - María Eugenia Pachón-Ibáñez
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Manuela Aguilar-Guisado
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Thierry Naas
- EA7361, Université Paris-Saclay, LabEx Lermit, Bacteriology-Hygiene unit, APHP, Hôpital Bicêtre, EERA 'Evolution and Ecology of Resistance to Antibiotics' Unit, Institut Pasteur-APHP-Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Javier Aznar
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain.,Department of Microbiology, University of Seville, Seville, Spain
| | - Jerónimo Pachón
- Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain.,Department of Medicine, University of Seville, Seville, Spain
| | - José Antonio Lepe
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
| | - Younes Smani
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Seville, Spain.,Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, Seville, Spain
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Nagaoka R, Kitagawa H, Koba Y, Tadera K, Hara T, Kashiyama S, Nomura T, Omori K, Shigemoto N, Yokozaki M, Ohge H. Clinical and microbiological characteristics of Eggerthella lenta bacteremia at a Japanese tertiary hospital. J Infect Chemother 2021; 27:1261-1264. [PMID: 33853729 DOI: 10.1016/j.jiac.2021.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/06/2021] [Accepted: 03/25/2021] [Indexed: 12/30/2022]
Abstract
Eggerthella lenta is an important cause of anaerobic bloodstream infections and is associated with high mortality. However, there are few reports of E. lenta infection in Japan. This study aimed to evaluate the clinical and microbiological characteristics of bacteremia caused by E. lenta in Hiroshima, Japan. We retrospectively analyzed E. lenta bacteremia patients at the Hiroshima University Hospital between January 2012 and December 2020. During the study period, 14 patients with E. lenta bacteremia were identified. All E. lenta isolates were cultured in anaerobic bottles, and the median time to blood culture positivity was 52.9 h. In most cases (85.6%), the source of E. lenta bacteremia was associated with intra-abdominal infections, and colon perforation was the most frequent source of E. lenta bacteremia (42.9%, n = 6). Antimicrobial susceptibility testing showed high minimal inhibitory concentrations (MIC) of piperacillin-tazobactam (TZP) and 100% susceptibility to ampicillin-sulbactam, carbapenems, and metronidazole. This study demonstrates that E. lenta bacteremia is associated with intra-abdominal infections, particularly colon perforation, and a high MIC of TZP. When gram-positive anaerobes are detected in the blood cultures of patients with severe intra-abdominal infections, clinicians should suspect E. lenta, and it may be better to change antimicrobial agents from TZP.
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Affiliation(s)
- Rie Nagaoka
- Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Hiroki Kitagawa
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan; Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 734-8551, Japan.
| | - Yumiko Koba
- Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Kayoko Tadera
- Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Toshinori Hara
- Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Seiya Kashiyama
- Section of Infection Diseases Laboratory, Department of Clinical Support, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Toshihito Nomura
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Keitaro Omori
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Norifumi Shigemoto
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan; Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, 734-8551, Japan; Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 734-8551, Japan; Translational Research Center, Hiroshima University, Hiroshima, 734-8551, Japan
| | - Michiya Yokozaki
- Division of Clinical Laboratory Medicine, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
| | - Hiroki Ohge
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Hiroshima, 734-8551, Japan; Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, 734-8551, Japan
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Oñate J, Pallares Gutiérrez CJ, Esparza G, Jimenez A, Berrio Medina I, Osorio-Pinzón J, Cataño J, Alvarez- Moreno C, Rodriguez J, Guevara F, Mercado M, Zuluaga M, Becerra JS, Alvarez M, Coronel W, Ordonez K, Villegas M. Consensus Recommendations Based on Evidence for Abdominal Sepsis in the Pediatric and Adult Population of Colombia. INFECTIO 2021. [DOI: 10.22354/in.v25i4.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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232
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Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med 2021; 78:1-19. [PMID: 33840511 DOI: 10.1016/j.annemergmed.2021.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/12/2022]
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233
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Marques HS, Araújo GRL, da Silva FAF, de Brito BB, Versiani PVD, Caires JS, Milet TDC, de Melo FF. Tertiary peritonitis: A disease that should not be ignored. World J Clin Cases 2021; 9:2160-2169. [PMID: 33869592 PMCID: PMC8026831 DOI: 10.12998/wjcc.v9.i10.2160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/10/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023] Open
Abstract
Intra-abdominal infections can be classified into uncomplicated or complicated (peritonitis). Peritonitis is divided into primary, secondary, and tertiary. Tertiary peritonitis is the less common but the most severe among peritonitis stratifications, being defined as a recurrent intra-abdominal infection that occurs 48 h after a well-succeeded control of a secondary peritonitis. This disease has a complex pathogenesis that is closely related to the capacity of the peritoneal cavity to activate immunological processes. Patients who progress to persistent peritonitis are at an increased risk of developing several infectious complications such as sepsis and multiple organ failure syndrome. Moreover, tertiary peritonitis remains an important cause of hospital death mainly among patients with associated risk factors. The microbiological profile of organisms causing tertiary peritonitis is often different from that observed in other types of peritonitis. In addition, there is a high prevalence of multidrug-resistant pathogens causing this condition, and an appropriate and successful clinical management depends on an early diagnosis, which can be made easier with the use of clinical scores presenting a good prediction value during the intensive care unit admission. Complementarily, immediate therapy should be performed to control the infectious focus and to prevent new recurrences. In this sense, the treatment is based on initial antimicrobial therapy and well-performed peritoneal drainage.
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Affiliation(s)
- Hanna Santos Marques
- Campus Vitória da Conquista, Universidade Estadual do Sudoeste da Bahia, Vitória da Conquista 45083-900, Bahia, Brazil
| | - Glauber Rocha Lima Araújo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Breno Bittencourt de Brito
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Paulo Victor Dias Versiani
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Jaqueline Silva Caires
- Department of Surgery, Hospital Geral de Vitória da Conquista, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Thiago de Carvalho Milet
- Department of Surgery, Hospital Geral de Vitória da Conquista, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Fabrício Freire de Melo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
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234
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Chiasson JM, Smith WJ, Jodlowski TZ, Kouma MA, Cutrell JB. Impact of a Rapid Blood Culture Diagnostic Panel on Time to Optimal Antimicrobial Therapy at a Veterans Affairs Medical Center. J Pharm Pract 2021; 35:722-729. [PMID: 33813935 DOI: 10.1177/08971900211000686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Utilization of rapid diagnostic testing alongside intensive antimicrobial stewardship interventions improves patient outcomes. We sought to determine the clinical impact of a rapid blood culture identification (BCID) panel in an established Antimicrobial Stewardship Program (ASP) with limited personnel resources. METHODS A single center retrospective pre- and post-intervention cohort study was performed following the implementation of a BCID panel on patients admitted with at least 1 positive blood culture during the study period. The primary outcome was time to optimal therapy from blood culture collection. Secondary outcomes included days of therapy (DOT), length of stay, and 30-day mortality and readmission rates. RESULTS 277 patients were screened with 180 patients included, with 82 patients in the pre-BCID and 98 in the post-BCID arms. Median time to optimal therapy was 73.8 hours (IQR; 1.1-79.6) in the pre-BCID arm and 34.7 hours (IQR; 10.9-71.6) in the post-BCID arm (p ≤ 0.001). Median DOT for vancomycin was 4 and 3 days (p ≤ 0.001), and for piperacillin-tazobactam was 3.5 and 2 days (p ≤ 0.007), for the pre-BCID and post-BCID arms, respectively. Median length of hospitalization was decreased from 11 to 9 days (p = 0.031). No significant change in 30-day readmission rate was noted, with a trend toward lower mortality (12% vs 5%; p = 0.086). CONCLUSION Introduction of BCID into the daily workflow resulted in a significant reduction in time to optimal therapy for bloodstream infections and DOT for select broad-spectrum antibiotics, highlighting the potential benefits of rapid diagnostics even in settings with limited personnel resources.
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Affiliation(s)
| | - Winter J Smith
- University of Texas at Tyler Fisch College of Pharmacy, Tyler, TX, USA
| | | | - Marcus A Kouma
- Dallas VA Medical Center, Pharmacy Service, Dallas, TX, USA
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Thattil SJ, Ajith TA. Emergence of Third Generation Cephalosporin Resistant Escherichia coli in Infants: Retrospective Study from a Tertiary Care Hospital in South India. ANTI-INFECTIVE AGENTS 2021; 19:215-219. [DOI: 10.2174/2211352518999200925153722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 07/31/2024]
Abstract
Aim:
This study was aimed to evaluate the emergence of third generation cephalosporin
resistant Escherichia coli isolated from the culture of various biological fluids of infants in a tertiary
care hospital.
Background:
Resistance to commonly used antibiotics is consistently increasing during the last decades
and it was found varying with time and geographical location.
Objectives:
To determine the prevalence of third generation cephalosporin sensitivity pattern of E.
coli isolated from urine, stool, and throat swab culture from laboratory records.
Methods:
The retrospective study included the laboratory report of antibiotic sensitivity conducted
on infants specimens during the period of 2 years. Third generation cephalosporin sensitivity patterns
of E. coli isolated from urine, stool, and throat swab culture were collected and data were statistically
analyzed.
Results:
Reports of 351 samples with positive E. coli were included in the study. More samples
were analyzed from infants above 6 months of age with female dominance (184/351). Among the
specimens tested, urine samples were highest 128/351 (35.0%). Cephalosporin resistant strain was
found in 243/351 samples (69.2%) (p=0.0463) with 218/243 (89.7%) isolated from infants above 6
months of age and 25/243 (10.2%) were from infants below 6 months of age (p=0.038). The frequency
of cephalosporin resistant E. coli in urine specimens of male and female infants was significant
(p=0.0001).
Conclusion:
Third generation cephalosporin resistant E. coli strain was found in 69.2% of isolates
and more in urine samples from female infants above 6 months of age. The clinicians should consider
the emergence of cephalosporin resistant E. coli while selecting antibiotics as empirical treatment.
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Ahmed S, Brown R, Pettinger R, Vargas-Palacios A, Burke D, Kirby A. The CABI Trial: an Unblinded Parallel Group Randomised Controlled Feasibility Trial of Long-Course Antibiotic Therapy (28 Days) Compared with Short Course (≤ 10 Days) in the Prevention of Relapse in Adults Treated for Complicated Intra-Abdominal Infection. J Gastrointest Surg 2021; 25:1045-1052. [PMID: 32140989 DOI: 10.1007/s11605-020-04545-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/13/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Relapse after complicated intra-abdominal infection (cIAI) remains common after treatment. The optimal antibiotic treatment duration for cIAIs is uncertain, especially in cases where source control is not achieved. We hypothesised that in patients with cIAIs, regardless of source control intervention, there would be a lower relapse rate with long-course antibiotics (28 days) compared with short course (≤ 10 days). We piloted a trial comparing ≤ 10-day with 28-day antibiotic treatment for cIAI. METHODS A randomised controlled unblinded feasibility trial was conducted. Eligible participants were adult patients with a cIAI that were diagnosed ≤ 6 days prior to screening. Randomisation was to long-course (28 days) or short-course (≤10 days) antibiotic therapy. Choice of antibiotics was determined by the clinical team. Participants were followed up for 90 days. Primary outcomes were willingness of participants to be randomised and feasibility of trial procedures. RESULTS In total, 172 patients were screened, 84/172 (48.8%) were eligible, and 31/84 (36.9%) were randomised. Patients were assigned to either the short-course arm (18/31, 58.0%) or the long-course arm (13/31, 41.9%). One patient in the short-course arm withdrew after randomisation. In the short-course arm, 4/17 (23.5%) were treated for a cIAI relapse vs 0/13 (0.0%) relapses in the long-course arm. Protocol violations included deviations from protocol-assigned antibiotic duration and interruptions to antibiotic therapy. CONCLUSIONS This feasibility study identified opportunities to increase recruitment in a full trial. This study demonstrates completion of a randomised controlled trial to further evaluate if the optimum antibiotic duration for cIAIs is feasible. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03265834.
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Affiliation(s)
- Shadia Ahmed
- Microbiology Department, Old Medical School, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK. .,University of Leeds, Leeds, LS3 1EX, UK.
| | - Rory Brown
- Microbiology Department, Old Medical School, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Richard Pettinger
- Microbiology Department, Old Medical School, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | | | - Dermot Burke
- Microbiology Department, Old Medical School, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK.,University of Leeds, Leeds, LS3 1EX, UK
| | - Andrew Kirby
- Microbiology Department, Old Medical School, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK.,University of Leeds, Leeds, LS3 1EX, UK
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Ueda T, Takesue Y, Matsumoto T, Tateda K, Kusachi S, Mikamo H, Sato J, Hanaki H, Mizuguchi T, Morikane K, Kobayashi M, Harihara Y, Seki S, Ishida Y, Fukushima R, Hada M, Matsuo Y, Kubo S, Kimura Y, Hata H, Nakajima K, Ohge H, Akagi S, Takeda S, Fukui Y, Suzuki K, Okamoto K, Yanagihara K, Kawamura H. Change in antimicrobial susceptibility of pathogens isolated from surgical site infections over the past decade in Japanese nation-wide surveillance study. J Infect Chemother 2021; 27:931-939. [PMID: 33795192 DOI: 10.1016/j.jiac.2021.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 12/24/2022]
Abstract
Inappropriate antimicrobial therapy for surgical site infections (SSIs) can lead to poor outcomes and an increased risk of antibiotic resistance. A nationwide survey was conducted in Japan from 2018 to 2019 to investigate the antimicrobial susceptibility of pathogens isolated from SSIs. The data were compared with those obtained in 2010 and 2014-2015 surveillance studies. Although the rate of detection of extended-spectrum β-lactamase producing strains of Escherichia coli was increased from 9.5% in 2010 to 23% in 2014-2015, the incidence decreased to 8.7% in 2018-2019. Although high susceptibility rates were detected to piperacillin/tazobactam (TAZ), the geometric mean MICs were substantially higher than to meropenem (2.67 vs 0.08 μg/mL). By contrast, relatively low geometric mean MICs (0.397 μg/mL) were demonstrated for ceftolozane/TAZ. Although the MRSA incidence rate decreased from 72% in the first surveillance to 53% in the second, no further decrease was detected in 2018-2019. For the Bacteroides fragilis group species, low levels of susceptibility were observed for moxifloxacin (65.3%), cefoxitin (65.3%), and clindamycin (CLDM) (38.9%). In particular, low susceptibility against cefoxitin was demonstrated in non-fragilis Bacteroides, especially B. thetaiotaomicron. By contrast, low susceptibility rates against CLDM were demonstrated in both B. fragilis and non-fragilis Bacteroides species, and a steady decrease in susceptibility throughout was observed (59.3% in 2010, 46.9% in 2014-2015, and 38.9% in 2018-2019). In conclusion, Japanese surveillance data revealed no significant lowering of antibiotic susceptibility over the past decade in organisms commonly associated from SSIs, with the exception of the B. fragilis group.
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Affiliation(s)
- Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.
| | - Yoshio Takesue
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan; Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tetsuya Matsumoto
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan
| | - Kazuhiro Tateda
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan
| | - Shinya Kusachi
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan
| | - Hiroshige Mikamo
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan; Department of Clinical Infectious Diseases, Aichi Medical University, Aichi, Japan
| | - Junko Sato
- The Surveillance Committee of Japanese Society of Cemotherapy (JSC), The Japanese Association for Infectious Disease (JAID) and the Japanese Society for Clinical Microbiology (JSCM), Tokyo, Japan
| | - Hideaki Hanaki
- Infection Control Research Center, Kitasato University, Tokyo, Japan
| | - Toru Mizuguchi
- Department of Nursing, Surgical Science, Sapporo Medical University, Hokkaido Japan
| | - Keita Morikane
- Division of Clinical Laboratory and Infection Control, Yamagata University Hospital, Yamagata, Japan
| | | | | | - Shiko Seki
- Department of Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuichi Ishida
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoji Fukushima
- Department of Surgery, Teikyo University Hospital, Tokyo, Japan
| | - Masahiro Hada
- Department of Surgery, Kouseiren Takaoka Hospital, Toyama, Japan
| | - Yoichi Matsuo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Hospital, Osaka, Japan
| | - Hiroaki Hata
- Department of Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Akagi
- Department of Surgery, Mazda Hospital, Mazda Motor Corporation, Hiroshima, Japan
| | - Shigeru Takeda
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuo Fukui
- Department of Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Katsunori Suzuki
- University of Occupational and Environmental Health Japan, Fukuoka, Japan
| | - Kohji Okamoto
- Department of Surgery, Gastroenterology and Hepatology Center, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | | | - Hideki Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
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Luo X, Li L, Xuan J, Zeng Z, Zhao H, Cai S, Huang Q, Guo X, Chen Z. Risk Factors for Enterococcal Intra-Abdominal Infections and Outcomes in Intensive Care Unit Patients. Surg Infect (Larchmt) 2021; 22:845-853. [PMID: 33769911 DOI: 10.1089/sur.2020.417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: To investigate the risk factors for enterococcal intra-abdominal infections (EIAIs) and the association between EIAIs and outcomes in intensive care unit (ICU) patients. Methods: We reviewed retrospectively the records of patients with intra-abdominal infections admitted to the Department of Critical Care Medicine at Nanfang Hospital, Southern Medical University, China, from January 2011 to December 2018. Patients with intra-abdominal infections were divided into enterococcal and non-enterococcal groups based on whether enterococci were isolated from intra-abdominal specimens. Results: A total of 431 patients with intra-abdominal infections were included, of whom 119 were infected with enterococci and 312 were infected with non-enterococci. Enterococci were isolated in 27.6% of patients, accounting for 24.5% (129/527) of all clinical bacterial isolates. Post-operative abdominal infection (adjusted odds ratio [OR], 2.361; p = 0.004), intestinal infection (adjusted OR, 2.703; p < 0.001), Mannheim Peritonitis Index score (MPI; adjusted OR, 1.052; p = 0.015), and use of antibiotic agents within the previous 90 days (adjusted OR, 1.880; p = 0.025) were associated with an increased risk of EIAIs. Compared with patients without enterococcal infection, ICU patients with enterococcal infection had a higher risk of failure of initial clinical therapy (49.6% vs. 24.2%; p < 0.001) and longer hospital stays (33 days [19, 48] vs. 18 days [12, 29]; p < 0.001). Enterococcal infection was associated with increased 28-day mortality, in-hospital mortality, and ICU mortality. However, no difference was found in length of ICU stay between the two groups. Additionally, there was no difference in ICU mortality, hospital mortality, or 28-day mortality in patients infected with enterococcus who did or did not receive empirical anti-enterococcal therapy. Conclusion: Post-operative abdominal infection, intestinal infection, MPI score, and use of antibiotic agents within the previous 90 days were independent risk factors for enterococcal infection. Enterococcal infection was associated with reduced short-term survival in ICU patients.
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Affiliation(s)
- Xingzheng Luo
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
- Department of Critical Care Medicine, XiaoLan Hospital of Southern Medical University, Zhongshan, Guangdong, P.R. China
| | - Lulan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Jiabin Xuan
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Hengrui Zhao
- Department of Clinical Laboratory, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Shumin Cai
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
| | - Qiaobing Huang
- Guangdong Provincial Key Laboratory of Shock and Microcirculation Research, Department of Pathophysiology, Southern Medical University, Guangzhou, P.R. China
| | - Xiaohua Guo
- Guangdong Provincial Key Laboratory of Shock and Microcirculation Research, Department of Pathophysiology, Southern Medical University, Guangzhou, P.R. China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R. China
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Clostridium difficile: Diagnosis and the Consequence of Over Diagnosis. Infect Dis Ther 2021; 10:687-697. [PMID: 33770398 PMCID: PMC8116462 DOI: 10.1007/s40121-021-00417-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading cause of healthcare-associated infections, accounting for significant disease burden and mortality. The clinical spectrum of C. difficile ranges from asymptomatic colonization to toxic megacolon and fulminant colitis. CDI is characterized by new onset of ≥ 3 unformed stools in 24 h and is confirmed by laboratory test for the presence of toxigenic C. difficile. Currently, laboratory tests to diagnose CDI include toxigenic culture, glutamate dehydrogenase (GDH), nucleic acid amplification test (NAAT), and toxins A/B enzyme immunoassay (EIA). The sensitivities of these tests are variable with toxin EIA ranging from 53 to 60% and with NAAT at about 95%. Overall, the specificity is > 90% for these methods. However, the positive predictive value (PPV) depends on the disease prevalence with lower CDI rates associated with lower PPVs. Notably, the widespread use of the highly sensitive NAAT and its relatively lower clinical specificity have led to overdiagnosis of C. difficile by identifying carriers when NAAT is used as the sole diagnostic method. Overdiagnosis of C. difficile has resulted in unwarranted treatment, possibly attributing to resistance to metronidazole and vancomycin, increased risk for overgrowth of vancomycin-resistant enterococci strains in stool specimens, and increased hospitalization thereby impacting patient safety and healthcare costs. Strategies to optimize the clinical sensitivity and specificity of current laboratory tests are critical to differentiate the clinical CDI from colonization. To achieve high diagnostic yield, if preagreed institutional criteria for stool submission are not used, a multistep approach to CDI diagnosis is recommended, such as either GDH or NAAT followed by toxins A/B EIA in conjunction with laboratory stewardship by evaluating C. difficile test orders for appropriateness and providing feedback. Furthermore, antimicrobial stewardship, along with provider education on appropriate testing for C. difficile, is vital to differentiate CDI from colonization.
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240
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Barreto EF, Rule AD, Alshaer MH, Roberts JA, Abdul Aziz MH, Scheetz MH, Mara KC, Jannetto PJ, Gajic O, O'Horo JC, Boehmer KR. Provider perspectives on beta-lactam therapeutic drug monitoring programs in the critically ill: a protocol for a multicenter mixed-methods study. Implement Sci Commun 2021; 2:34. [PMID: 33762025 PMCID: PMC7992791 DOI: 10.1186/s43058-021-00134-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Beta-lactams (i.e., penicillins, cephalosporins, carbapenems, monobactams) are the most widely used class of antibiotics in critically ill patients. There is substantial interpatient variability in beta-lactam pharmacokinetics which renders their effectiveness and safety largely unpredictable. One strategy to ensure achievement of therapeutic concentrations is drug level testing (“therapeutic drug monitoring”; TDM). While studies have suggested promise with beta-lactam TDM, it is not yet widely available or implemented. This protocol presents a mixed-methods study designed to examine healthcare practitioners’ perspectives on the use and implementation of beta-lactam TDM in the critically ill. Methods An explanatory sequential mixed-methods design will be used [QUANT → qual]. First, quantitative data will be collected through a web-based questionnaire directed at clinicians at three academic medical centers at different phases of beta-lactam TDM implementation (not yet implemented, partially implemented, fully implemented). The sampling frame will include providers from a variety of disciplines that interact with drug level testing and interpretation in the critical care environment including pharmacists, intensivists, infectious diseases experts, medical/surgical trainees, and advanced practice providers. Second, approximately 30 individuals will be purposively sampled from survey respondents to conduct in-depth qualitative interviews to explain and expand upon the results from the quantitative strand. Normalization Process Theory and the Consolidated Framework for Implementation Science will be used to guide data analysis. Discussion These data will be used to answer two specific questions: “What are ICU practitioners’ perspectives on implementing beta-lactam TDM?” and “What factors contribute to the success of beta-lactam TDM program implementation?” Results of this study will be used to design future implementation strategies for beta-lactam TDM programs in the critically ill. Trial registration NCT04755777. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00134-9.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Andrew D Rule
- Division of Epidemiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA.,Pharmacometrics Center of Excellence, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - John C O'Horo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Infectious Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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241
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Sinha A, Bagga A, Banerjee S, Mishra K, Mehta A, Agarwal I, Uthup S, Saha A, Mishra OP. Steroid Sensitive Nephrotic Syndrome: Revised Guidelines. Indian Pediatr 2021. [PMID: 33742610 PMCID: PMC8139225 DOI: 10.1007/s13312-021-2217-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Justification Steroid sensitive nephrotic syndrome (SSNS) is one of the most common chronic kidney diseases in children. These guidelines update the existing Indian Society of Pediatric Nephrology recommendations on its management. Objective To frame revised guidelines on diagnosis, evaluation, management and supportive care of patients with the illness. Process The guidelines combine evidence-based recommendations and expert opinion. Formulation of key questions was followed by review of literature and evaluation of evidence by experts in two face-to-face meetings. Recommendations The initial statements provide advice for evaluation at onset and follow up and indications for kidney biopsy. Subsequent statements provide recommendations for management of the first episode of illness and of disease relapses. Recommendations on the use of immunosuppressive strategies in patients with frequent relapses and steroid dependence are accompanied by suggestions for step-wise approach and plan of monitoring. Guidance is also provided regarding the management of common complications including edema, hypovolemia and serious infections. Advice on immunization and transition of care is given. The revised guideline is intended to improve the management and outcomes of patients with SSNS, and provide directions for future research.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Correspondence to: Dr. Arvind Bagga, Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Amarjeet Mehta
- Department of Pediatrics, Sawai Man Singh Medical College, Jaipur, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Susan Uthup
- Department of Pediatrics, Trivandrum Medical College, Thiruvananthapuram, India
| | - Abhijeet Saha
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Om Prakash Mishra
- Department of Pediatrics, Institute of Medical Sciences, Benaras Hindu University, Varanasi, India
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242
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Hawkins BK, Wingler MJB, Cretella DA, Barber KE, Stover KR, Wagner JL. An evaluation of antipseudomonal dosing on the incidence of treatment failure. SAGE Open Med 2021; 9:20503121211000927. [PMID: 33796294 PMCID: PMC7968010 DOI: 10.1177/20503121211000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Significant mortality is associated with delays in appropriate antibiotic therapy in Pseudomonas aeruginosa infections. The impact of empiric dosing on clinical outcomes has been largely unreported. Methods This retrospective cohort compared treatment failure in patients receiving guideline-concordant or guideline-discordant empiric therapy with cefepime, meropenem, or piperacillin/tazobactam. Patients with culture-positive P. aeruginosa between 1 July 2013 and 31 July 2019 were eligible for inclusion. Patients with cystic fibrosis, polymicrobial infection, and urinary or pulmonary colonization were excluded. The composite primary outcome was treatment failure, defined as (1) therapy modification due to resistance/perceived treatment failure, (2) increased/unchanged qSOFA, or (3) persistent fever 48 h after initiating appropriate therapy. Secondary outcomes included rate of infectious diseases consultation, all-cause inpatient mortality, mechanical ventilation requirement, and infection-related intensive care unit and hospital lengths of stay. Results In total, 198 patients were included: 90 guideline-concordant and 108 guideline-discordant. Baseline characteristics were balanced. Treatment failure was more common in the guideline-discordant than the guideline-concordant group (62% versus 48%; p = 0.04). This remained significant when adjusting for supratherapeutic dosing (p = 0.02). Infectious diseases consultation was higher in the guideline-discordant group (46% versus 29%, p = 0.01), while intensive care unit length of stay was longer in the guideline-concordant group (4.5 versus 3 days, p = 0.03). Additional secondary outcomes were similar. Conclusion Treatment failure was significantly higher in patients receiving guideline-discordant empiric antipseudomonal dosing. Guideline-directed dosing, disease states, and patient-specific factors should be assessed when considering empiric antipseudomonal dosing.
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Affiliation(s)
- Brandon K Hawkins
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary Joyce B Wingler
- Antimicrobial Stewardship Program, University of Mississippi Medical Center, Jackson, MS, USA
| | - David A Cretella
- Antimicrobial Stewardship Program, University of Mississippi Medical Center, Jackson, MS, USA
| | - Katie E Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA.,Department of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS, USA
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243
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McCreery RJ, Florescu DF, Kalil AC. Sepsis in Immunocompromised Patients Without Human Immunodeficiency Virus. J Infect Dis 2021; 222:S156-S165. [PMID: 32691837 DOI: 10.1093/infdis/jiaa320] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Sepsis remains among the most common complications from infectious diseases worldwide. The morbidity and mortality rates associated with sepsis range from 20% to 50%. The advances in care for patients with an immunocompromised status have been remarkable over the last 2 decades, but sepsis continues to be a major cause of death in this population Immunocompromised patients who are recipients of a solid organ or hematopoietic stem cell transplant are living longer with a better quality of life. However, some of these patients need lifelong treatment with immunosuppressive medications to maintain their transplant status. A consequence of the need for this permanent immunosuppression is the high risk of opportunistic, community, and hospital-acquired infections, all of which can lead to sepsis. In addition, the detection of serious infections may be more challenging owing to patients' lower ability to mount the clinical symptoms that usually accompany sepsis. This article provides an update on the current knowledge of sepsis in immunocompromised patients without human immunodeficiency virus. It reviews the most pertinent causes of sepsis in this population, and addresses the specific diagnostic and therapeutic challenges in neutropenia and solid organ and hematopoietic stem cell transplantation.
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Affiliation(s)
- Randy J McCreery
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Diana F Florescu
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
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244
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Sansotta N, De Luca E, Nicastro E, Tebaldi A, Ferrari A, D’Antiga L. Incidence of Cholangitis and Sepsis Associated with Percutaneous Transhepatic Cholangiography in Pediatric Liver Transplant Recipients. Antibiotics (Basel) 2021; 10:antibiotics10030282. [PMID: 33801816 PMCID: PMC8001276 DOI: 10.3390/antibiotics10030282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/28/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background. Percutaneous transhepatic cholangiography (PTC) is an established treatment in the management of biliary strictures. The aim of our study was to determine the incidence of PTC-related infectious complications in transplanted children, and identify their precise aetiol-ogy. Methods. We retrospectively reviewed all PTC performed from January 2017 to October 2020 in our center. Before the procedure, all patients received antibiotic prophylaxis defined as first line, while second line was used in case of previously microbiological isolation. Cholangitis was defined as fever (>38.5°) and elevated inflammatory markers after PTC, while sepsis included hemodynamic instability in addition to cholangitis. Results. One hundred and fifty-seven PTCs from 50 pediatric recipients were included. The overall incidence of cholangitis and sepsis after PTC was 44.6% (70/157) and 3.2% (5/157), respectively, with no fatal events. Blood cultures yielded positive results in 15/70 cases (21.4%). Enterococcus faecium and Pseudomonas aeruginosa were the most common isolated pathogens. Multidrug-resistant (MDR) pathogens were found in 11/50 patients (22%). Conclusion. PTC is associated with a relatively high rate of post-procedural cholangitis, although with low rate of sepsis and no fatal events. Blood cultures allowed to find a precise aetiology in roughly a quarter of the cases, showing prevalence of Enterococcus faecium and Pseudomonas aeruginosa.
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Affiliation(s)
- Naire Sansotta
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
- Correspondence:
| | - Ester De Luca
- Department of Pediatrics, University of Milano Bicocca, 20126 Milan, Italy;
| | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Alessandra Tebaldi
- Infectious Diseases Unit, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Alberto Ferrari
- FROM Research Foundation, Statistics, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Lorenzo D’Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
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245
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The Need of Enterococcal Coverage in Severe Intra-Abdominal Infection: Evidence from Animal Study. J Clin Med 2021; 10:jcm10051027. [PMID: 33801494 PMCID: PMC7958860 DOI: 10.3390/jcm10051027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 11/17/2022] Open
Abstract
Intra-abdominal infection (IAI) is a common and important cause of infectious mortality in intensive care units. Adequate source control and appropriate antimicrobial regimens are key in the management of IAI. In community-acquired IAI, guidelines recommend the use of different antimicrobial regimens according to severity. However, the evidence for this is weak. We investigated the effect of enterococcal coverage in antimicrobial regimens in a severe polymicrobial IAI model. We investigated the effects of imipenem/cilastatin (IMP) and ceftriaxone with metronidazole (CTX + M) in a rat model of severe IAI. We observed the survival rate and bacterial clearance rate. We identified the bacteria in blood culture. We measured lactate, alanine aminotransferase (ALT), creatinine, interleukin (IL)-6, IL-10, and reactive oxygen species (ROS) in the blood. Endotoxin tolerance of peripheral blood mononuclear cells (PBMCs) was also estimated to determine the level of immune suppression. In the severe IAI model, IMP improved survival and bacterial clearance compared to CTX + M. Enterococcus spp. were more frequently isolated in the CTX + M group. IMP also decreased plasma lactate, cytokine, and ROS levels. ALT and creatinine levels were lower in IMP group. In the mild-to-moderate IAI model, however, there was no survival difference between the groups. Immune suppression of PBMCs was observed in IAI model, and it was more prominent in the severe IAI model. Compared to CTX + M, IMP improved the outcome of rats in severe IAI model.
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246
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Magill SS, O’Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR, Chea N, Neuhauser MM. Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4:e212007. [PMID: 33734417 PMCID: PMC7974639 DOI: 10.1001/jamanetworkopen.2021.2007] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.
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Affiliation(s)
- Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin O’Leary
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Lantana Consulting Group, Thetford, Vermont
| | - Susan M. Ray
- Department of Medicine, Emory University, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur
| | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Infectious Diseases, Western Health, Melbourne, Victoria, Australia
| | | | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Medical Epidemiology Consulting, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver
| | | | - Tolulope Oyewumi
- Colorado Department of Public Health and Environment, Denver
- Department of Healthcare Management, University of Denver, Colorado
| | | | | | - Linn Warnke
- Minnesota Department of Health, St Paul
- Hennepin County Public Health, Minneapolis, Minnesota
| | | | - Deborah L. Thompson
- New Mexico Department of Health, Santa Fe
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Shamima Sharmin
- New Mexico Department of Health, Santa Fe
- Infection Prevention and Control Department, University of New Mexico Hospital, Albuquerque
| | | | | | | | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven
| | - Samantha Greissman
- Connecticut Emerging Infections Program, Hartford and New Haven
- Department of Medicine, Columbia–New York Presbyterian Hospital
| | - Lucy E. Wilson
- Maryland Department of Health, Baltimore
- University of Maryland Baltimore County, Baltimore
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester Medical Center, Rochester, New York
| | - Jonathan R. Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Chea
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melinda M. Neuhauser
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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247
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Endoscopic ultrasound-guided drainage of a fungal liver abscess using a lumen-apposing metal stent: case report and literature review. ACTA ACUST UNITED AC 2021; 59:93-98. [PMID: 33170145 DOI: 10.2478/rjim-2020-0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 11/20/2022]
Abstract
Liver abscesses are rare entities for which percutaneous drainage is traditionally employed. The technique is simple, but associated with a significant rate of side effects and patient discomfort. We herein report a case of fungal left liver lobe abscess that was successfully treated by using EUS-guided drainage, with insertion of a large caliber lumen-apposing metal stent. The literature review we performed on the topic seems to favor, at least for abscess in the left and/or caudate liver lobes, EUS as compared to percutaneous drainage.
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248
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Lodise TP, Mistry R, Young K, LaPensee K. Decision Analysis: Omadacycline Relative to Moxifloxacin Among Hospitalized Community-Acquired Bacterial Pneumonia Patients at Risk of Clostridioides difficile Infection. Clin Drug Investig 2021; 41:269-275. [PMID: 33604769 PMCID: PMC8079290 DOI: 10.1007/s40261-021-01005-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE: Omadacycline is an aminomethylcycline antibiotic approved in the USA as once-daily intravenous/oral monotherapy for adults with community-acquired bacterial pneumonia (CABP). Omadacycline demonstrated noninferiority to the fluoroquinolone moxifloxacin in a phase III CABP trial; adverse-event rates were similar between treatment groups except for Clostridioides difficile infection (CDI), which occurred in 2% of moxifloxacin-treated patients and 0% of patients on omadacycline. Conceptual healthcare-decision analytic models were developed to better understand the economic implications of antibiotic selection and CDI risk in acute-care facilities. METHODS A conceptual healthcare-decision analytic model was created to estimate incremental costs associated with treating 100 hospitalized CABP patients with an initial 5-day inpatient regimen of omadacycline instead of moxifloxacin. The underlying model assumption was that treatment with omadacycline has the potential to reduce CDI events relative to moxifloxacin. The model included excess costs associated with each treatment group from admission through discharge. Attributable CDI cost per case in the moxifloxacin group varied from $15,000 to $45,000 (US$). Omadacycline acquisition cost was $300-600/day for 5 days. RESULTS At a CDI attributable cost per case of $30,000 (base-case analyses), the incremental treatment cost (US$) per 100 patients ranged from $300,000 to $- 120,000 (cost savings). The excess CDI incidence in moxifloxacin-treated patients would need to be 5-10% for omadacycline to be cost-saving, assuming the attributable CDI cost is approximately $30,000. CONCLUSION Targeted omadacycline use may reduce economic burden associated with hospitalized CABP patients treated with moxifloxacin if it can reduce excess cases of moxifloxacin-associated CDI.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and the Health Sciences, 106 New Scotland Avenue, Albany, NY, 12189, USA.
| | | | - Kate Young
- PAREXEL Access Consulting, Waltham, MA, USA
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Chawki S, Sokal A, Duprilot M, Henry A, Leflon-Guibout V, Nicolas-Chanoine MH, Fantin B, de Lastours V. Temocillin as an alternative treatment for acute bacterial cholangitis: a retrospective microbiology susceptibility-based study of 140 episodes. Eur J Clin Microbiol Infect Dis 2021; 40:1773-1777. [PMID: 33609262 DOI: 10.1007/s10096-021-04158-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/07/2021] [Indexed: 12/07/2022]
Abstract
With rising antibiotic resistance, alternatives to carbapenems are needed for acute cholangitis (AC). Temocillin reaches high biliary concentrations with limited impact on microbiota. We retrospectively included 140 AC episodes and assessed the efficacy of temocillin using microbiology susceptibility testing from blood cultures. Considering all bacteria collected by episode, resistance to temocillin, PIP/TAZ and 3GC occurred in 27/140 (26%), 32 (22.8%) and 31 (22%) episodes, respectively (p = 0.7). After documentation, temocillin could have spared PIP/TAZ or carbapenems in 14/26 and 4/11 episodes. Temocillin may constitute an alternative treatment after microbiological documentation by sparing carbapenems and/or PIP/TAZ, but not as an empirical therapeutic option.
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Affiliation(s)
- Sylvain Chawki
- Service de Médecine Interne, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France
| | - Aurélien Sokal
- Service de Médecine Interne, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France
| | - Marion Duprilot
- Laboratoire de Microbiologie, Hôpital Beaujon, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France.,IAME Research Group, UMR 1137, Université de Paris and INSERM, 75018, Paris, France
| | - Amandine Henry
- Service de Médecine Interne, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France
| | - Véronique Leflon-Guibout
- Laboratoire de Microbiologie, Hôpital Beaujon, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France
| | - Marie-Hélène Nicolas-Chanoine
- Laboratoire de Microbiologie, Hôpital Beaujon, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France.,IAME Research Group, UMR 1137, Université de Paris and INSERM, 75018, Paris, France
| | - Bruno Fantin
- Service de Médecine Interne, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France.,IAME Research Group, UMR 1137, Université de Paris and INSERM, 75018, Paris, France
| | - Victoire de Lastours
- Service de Médecine Interne, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, 92100, Clichy, Paris, France. .,IAME Research Group, UMR 1137, Université de Paris and INSERM, 75018, Paris, France.
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250
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Bull KE, Gainey AB, Cox CL, Burch AK, Durkin M, Daniels R. Evaluation of Time to Resolution of Medical Necrotizing Enterocolitis Using Severity-Guided Management in a Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2021; 26:179-186. [PMID: 33603582 DOI: 10.5863/1551-6776-26.2.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE No studies, to our knowledge, have determined the relationship between symptom resolution and timing of antimicrobial discontinuation in necrotizing enterocolitis (NEC). Our study seeks to determine the period to NEC resolution by using severity-guided management, based on surrogate markers used in the diagnosis of NEC. METHODS This retrospective, observational review included patients in our NICU with NEC from June 1, 2012, to June 1, 2018. Patients were excluded for surgical NEC, a positive blood culture or transfer from an outside institution at the time of NEC, presence of a peritoneal drain, or death prior to NEC resolution. The primary outcome was time to resolution of NEC, measured by return to baseline of surrogate markers used in the diagnosis of NEC. RESULTS The median times to resolution in days, based on our institution's NEC severity group, were as follows: mild 3 (range, 1-4); moderate 4 (range, 1-17); severe 9 (range, 5-21). No difference in NEC recurrence was found based on antibiotic duration (OR 0.803; 95% CI, 0.142-4.225). CONCLUSIONS Time to resolution of NEC differs by severity group, suggesting a need for different treatment durations. Recurrence of NEC did not differ between groups, suggesting that shorter antibiotic durations do not lead to an increased incidence of NEC recurrence. Further exploration of the optimal antimicrobial treatment duration for NEC is warranted.
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