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Migiyama Y, Sakata S, Iyama S, Tokunaga K, Saruwatari K, Tomita Y, Saeki S, Okamoto S, Ichiyasu H, Sakagami T. Airway Pseudomonas aeruginosa density in mechanically ventilated patients: clinical impact and relation to therapeutic efficacy of antibiotics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:59. [PMID: 33573691 PMCID: PMC7876981 DOI: 10.1186/s13054-021-03488-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/04/2021] [Indexed: 01/31/2023]
Abstract
Background The bacterial density of Pseudomonas aeruginosa is closely related to its pathogenicity. We evaluated the effect of airway P. aeruginosa density on the clinical course of mechanically ventilated patients and the therapeutic efficacy of antibiotics. Methods We retrospectively analyzed data of mechanically ventilated ICU patients with P. aeruginosa isolated from endotracheal aspirates. Patients were divided into three groups according to the peak P. aeruginosa density during ICU stay: low (≤ 104 cfu/mL), moderate (105‒106 cfu/mL), and high (≥ 107 cfu/mL) peak density groups. The relationship between peak P. aeruginosa density and weaning from mechanical ventilation, risk factors for isolation of high peak density of P. aeruginosa, and antibiotic efficacy were investigated using multivariate and propensity score-matched analyses. Results Four-hundred-and-sixty-one patients were enrolled. Patients with high peak density of P. aeruginosa had higher inflammation and developed more severe respiratory infections. High peak density of P. aeruginosa was independently associated with few ventilator-free days on day 28 (P < 0.01) and increased ICU mortality (P = 0.047). Risk factors for high peak density of P. aeruginosa were prolonged mechanical ventilation (odd ratio [OR] 3.07 95% confidence interval [CI] 1.35‒6.97), non-antipseudomonal cephalosporins (OR 2.17, 95% CI 1.35‒3.49), hyperglycemia (OR 2.01, 95% CI 1.26‒3.22) during ICU stay, and respiratory diseases (OR 1.9, 95% CI 1.12‒3.23). Isolation of commensal colonizer was associated with lower risks of high peak density of P. aeruginosa (OR 0.43, 95% CI 0.26‒0.73). Propensity score-matched analysis revealed that antibiotic therapy for patients with ventilator-associated tracheobronchitis improved weaning from mechanical ventilation only in the high peak P. aeruginosa group. Conclusions Patients with high peak density of P. aeruginosa had worse ventilator outcome and ICU mortality. In patients with ventilator-associated tracheobronchitis, antibiotic therapy was associated with favorable ventilator weaning only in the high peak P. aeruginosa density group, and bacterial density could be a good therapeutic indicator for ventilator-associated tracheobronchitis due to P. aeruginosa.![]()
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Affiliation(s)
- Yohei Migiyama
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan. .,Demachi Naika, Kumamoto, Japan.
| | - Shinya Sakata
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Shinji Iyama
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Kentaro Tokunaga
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan.,Department of Critical Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Koichi Saruwatari
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yusuke Tomita
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Sho Saeki
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Shinichiro Okamoto
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Takuro Sakagami
- Department of Respiratory Medicine, Kumamoto University Hospital, Kumamoto, Japan
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Cooley LF, Cohen JE, Chen L, Schaeffer AJ. Algorithms to Enhance Empiric Antimicrobial Choice for Outpatients With Afebrile Complicated Cystitis Reflects Importance of Status of the Urinary Tract and Patient Place of Residence. Urology 2020; 145:127-133. [DOI: 10.1016/j.urology.2020.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/15/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022]
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Lodise TP, Berger A, Altincatal A, Wang R, Bhagnani T, Gillard P, Bonine NG. Antimicrobial Resistance or Delayed Appropriate Therapy-Does One Influence Outcomes More Than the Other Among Patients With Serious Infections Due to Carbapenem-Resistant Versus Carbapenem-Susceptible Enterobacteriaceae? Open Forum Infect Dis 2019; 6:ofz194. [PMID: 31198817 PMCID: PMC6546203 DOI: 10.1093/ofid/ofz194] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 04/18/2019] [Indexed: 12/20/2022] Open
Abstract
Background The relative contribution of antimicrobial resistance versus delayed appropriate treatment to the clinical and economic burden of Enterobacteriaceae infections is not well understood. Methods Using a large US hospital database, we identified all admissions between July 2011 and September 2014 with evidence of serious Enterobacteriaceae infection. The "index date" was the earliest date on which a culture positive for Enterobacteriaceae was drawn. Infections were classified as carbapenem-resistant (CRE) or carbapenem-susceptible (CSE). Receipt of antimicrobials with activity against all index pathogens on the index date or ≤2 days thereafter was deemed as "timely"; all other instances were "delayed." Associations between CRE status and delayed appropriate therapy on outcomes were estimated using inverse probability weighting and multivariate regression models (ie, logistic model for discharge destination and composite mortality [in-hospital death or discharge to hospice] or generalized linear model for duration of antibiotic therapy, hospital length of stay [LOS], and costs). Results A total of 50 069 patients met selection criteria; 514 patients (1.0%) had CRE. Overall, 67.5% of CSE patients (vs 44.6%, CRE) received timely appropriate therapy (P < .01). Irrespective of CRE status, patients who received delayed appropriate therapy had longer durations of antibiotic therapy and LOS, higher costs, lower likelihood of discharge to home, and greater likelihood of the composite mortality outcome (P for trend < .01). Conclusions Delayed appropriate therapy is a more important driver of outcomes than CRE, although the 2 factors are somewhat synergistic. Better methods of early CRE identification may improve outcomes in this patient population.
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Affiliation(s)
- Thomas P Lodise
- Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York
| | - Ariel Berger
- Real-World Evidence, Evidera, Waltham, Massachusetts
| | | | - Rosa Wang
- Real-World Evidence, Evidera, Waltham, Massachusetts
| | | | - Patrick Gillard
- Global Health Outcomes Strategy & Research, Allergan plc, Madison, New Jersey
| | - Nicole G Bonine
- Global Health Outcomes Strategy & Research, Allergan plc, Madison, New Jersey
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Lee KS, Kim TJ, Peck KR, Han J. Infectious pneumonia in immunocompetent patients: updates in clinical and imaging features. PRECISION AND FUTURE MEDICINE 2018. [DOI: 10.23838/pfm.2018.00079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Du W, Chen H, Xiao S, Tang W, Shi G. New insight on antimicrobial therapy adjustment strategies for gram-negative bacterial infection: A cohort study. Medicine (Baltimore) 2017; 96:e6439. [PMID: 28353572 PMCID: PMC5380256 DOI: 10.1097/md.0000000000006439] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/18/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023] Open
Abstract
Gram-negative bacterial infections, especially multidrug-resistant (MDR) bacterial infection, are becoming a serious threat to public health. Although it is widely accepted that both appropriate initial empirical therapy and targeted therapy are important, but for patients needing therapy adjustment, few studies have explored whether adjustment strategy based on microbiologic susceptibility test (MST) brings better outcome compared with empirical adjustment.A total of 320 patients with gram-negative bacterial infection (airway, blood, or pleural effusion) were selected and a prospective cohort study was conducted. Baseline characteristics and outcomes (microbiologic, clinical, and economic) were documented during follow-up.MDR and nosocomial infections were common among subjects. Initial therapies consistent with MST could result in reduced in-hospital mortality, treatment failure rate, infection-related death, percentages of patients needing therapy adjustment, and daily hospitalization cost with increased successful treatment rate compared with inconsistent with MST, and microbiologic outcomes were also better with appropriate therapies.For patients needing therapy adjustment, relying on MST gained no significant benefit on mortality, clinical, or microbiologic outcomes compared with depending on clinical experience. But for patients with MDR infection, adjustment relying on MST gained more benefit than non-MDR infection.Appropriate initial therapy significantly improved the prognosis of patients with gram-negative bacterial infections, but improvement was not that obvious for patients needing therapy adjustment which was based on MST compared with clinical experience, and more beneficial effects of adjustment relying on MST were obtained for patients with MDR bacterial infection.
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Affiliation(s)
- Wei Du
- Department of Pulmonary Medicine
| | | | - Shuzhen Xiao
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Tang
- Department of Pulmonary Medicine
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Marcus G, Levy S, Salhab G, Mengesha B, Tzuman O, Shur S, Burke E, Mayeda RC, Cochavi L, Perluk I, Zaidenstein R, Lazarovitch T, Dadon M, Marchaim D. Intra-abdominal Infections: The Role of Anaerobes, Enterococci, Fungi, and Multidrug-Resistant Organisms. Open Forum Infect Dis 2016; 3:ofw232. [PMID: 28018930 PMCID: PMC5170494 DOI: 10.1093/ofid/ofw232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 10/30/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Intra-abdominal infections (IAI) constitute a common reason for hospitalization. However, there is lack of standardization in empiric management of (1) anaerobes, (2) enterococci, (3) fungi, and (4) multidrug-resistant organisms (MDRO). The recommendation is to institute empiric coverage for some of these organisms in "high-risk community-acquired" or in "healthcare-associated" infections (HCAI), but exact definitions are not provided. METHODS Epidemiological study of IAI was conducted at Assaf Harofeh Medical Center (May-November 2013). Logistic and Cox regressions were used to analyze predictors and outcomes of IAI, respectively. The performances of established HCAI definitions to predict MDRO-IAI upon admission were calculated by receiver operating characteristic (ROC) curve analyses. RESULTS After reviewing 8219 discharge notes, 253 consecutive patients were enrolled (43 [17%] children). There were 116 patients with appendicitis, 93 biliary infections, and 17 with diverticulitis. Cultures were obtained from 88 patients (35%), and 44 of them (50%) yielded a microbiologically confirmed IAI: 9% fungal, 11% enterococcal, 25% anaerobic, and 34% MDRO. Eighty percent of MDRO-IAIs were present upon admission, but the area under the ROC curve of predicting MDRO-IAI upon admission by the commonly used HCAI definitions were low (0.73 and 0.69). Independent predictors for MDRO-IAI were advanced age and active malignancy. CONCLUSIONS Multidrug-resistant organism-IAIs are common, and empiric broad-spectrum coverage is important among elderly patients with active malignancy, even if the infection onset was outside the hospital setting, regardless of current HCAI definitions. Outcomes analyses suggest that empiric regimens should routinely contain antianaerobes (except for biliary IAI); however, empiric antienterococcal or antifungals regimens are seldom needed.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Tsilia Lazarovitch
- Clinical Microbiology Laboratory, Assaf Harofeh Medical Center , Zerifin , Israel
| | | | - Dror Marchaim
- Unit of Infectious Diseases,; Sackler School of Medicine, Tel-Aviv University, Israel
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Cerceo E, Deitelzweig SB, Sherman BM, Amin AN. Multidrug-Resistant Gram-Negative Bacterial Infections in the Hospital Setting: Overview, Implications for Clinical Practice, and Emerging Treatment Options. Microb Drug Resist 2016; 22:412-31. [PMID: 26866778 DOI: 10.1089/mdr.2015.0220] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The increasing prevalence of infections due to multidrug-resistant (MDR) gram-negative bacteria constitutes a serious threat to global public health due to the limited treatment options available and the historically slow pace of development of new antimicrobial agents. Infections due to MDR strains are associated with increased morbidity and mortality and prolonged hospitalization, which translates to a significant burden on healthcare systems. In particular, MDR strains of Enterobacteriaceae (especially Klebsiella pneumoniae and Escherichia coli), Pseudomonas aeruginosa, and Acinetobacter baumannii have emerged as particularly serious concerns. In the United States, MDR strains of these organisms have been reported from hospitals throughout the country and are not limited to a small subset of hospitals. Factors that have contributed to the persistence and spread of MDR gram-negative bacteria include the following: overuse of existing antimicrobial agents, which has led to the development of adaptive resistance mechanisms by bacteria; a lack of good antimicrobial stewardship such that use of multiple broad-spectrum agents has helped perpetuate the cycle of increasing resistance; and a lack of good infection control practices. The rising prevalence of infections due to MDR gram-negative bacteria presents a significant dilemma in selecting empiric antimicrobial therapy in seriously ill hospitalized patients. A prudent initial strategy is to initiate treatment with a broad-spectrum regimen pending the availability of microbiological results allowing for targeted or narrowing of therapy. Empiric therapy with newer agents that exhibit good activity against MDR gram-negative bacterial strains such as tigecycline, ceftolozane-tazobactam, ceftazidime-avibactam, and others in the development pipeline offer promising alternatives to existing agents.
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Affiliation(s)
- Elizabeth Cerceo
- 1 Division of Hospital Medicine, Cooper Medical School of Rowan University , Camden, New Jersey
| | - Steven B Deitelzweig
- 2 Department of Hospital Medicine, Ochsner Clinical School, Ochsner Health Center , New Orleans, Louisiana
| | | | - Alpesh N Amin
- 4 Department of Medicine, University of California , Irvine, California
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Sartelli M, Griffiths EA, Nestori M. The challenge of post-operative peritonitis after gastrointestinal surgery. Updates Surg 2015; 67:373-81. [DOI: 10.1007/s13304-015-0324-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/11/2015] [Indexed: 12/13/2022]
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Kaman WE, Andrinopoulou ER, Hays JP. Perceptions of point-of-care infectious disease testing among European medical personnel, point-of-care test kit manufacturers, and the general public. Patient Prefer Adherence 2013; 7:559-77. [PMID: 23814465 PMCID: PMC3693915 DOI: 10.2147/ppa.s44889] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The proper development and implementation of point-of-care (POC) diagnostics requires knowledge of the perceived requirements and barriers to their implementation. To determine the current requirements and perceived barriers to the introduction of POC diagnostics in the field of medical microbiology (MM)-POC a prospective online survey (TEMPOtest-QC) was established. METHODS AND RESULTS The TEMPOtest-QC survey was online between February 2011 and July 2012 and targeted the medical community, POC test diagnostic manufacturers, general practitioners, and the general public. In total, 293 individuals responded to the survey, including 91 (31%) medical microbiologists, 39 (13%) nonmedical microbiologists, 25 (9%) employees of POC test manufacturers, and 138 (47%) members of the general public. Responses were received from 18 different European countries, with the largest percentage of these living in The Netherlands (52%). The majority (>50%) of medical specialists regarded the development of MM-POC for blood culture and hospital acquired infections as "absolutely necessary", but were much less favorable towards their use in the home environment. Significant differences in perceptions between medical specialists and the general public included the: (1) Effect on quality of patient care; (2) Ability to better monitor patients; (3) Home testing and the doctor-patient relationship; and (4) MM-POC interpretation. Only 34.7% of the general public is willing to pay more than a€10 ($13) for a single MM-POC test, with 85.5% preferring to purchase their MM-POC test from a pharmacy. CONCLUSION The requirements for the proper implementation of MM-POC were found to be generally similar between medical specialists and POC test kit manufacturers. The general public was much more favorable with respect to a perceived improvement in the quality of healthcare that these tests would bring to the hospital and home environment.
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Affiliation(s)
- Wendy E Kaman
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
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Russett F. Recent Publications on Medications and Pharmacy. Hosp Pharm 2012. [DOI: 10.1310/hpj4703-245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly. Suggestions or comments may be addressed to Flint Russett, St. Claire Regional Medical Center, 222 Medical Circle, Morehead, KY 40351, or e-mail: FSRussett@st-claire.org .
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Affiliation(s)
- Flint Russett
- Department of Pharmacy and Drug Information, St. Claire Regional Medical Center, Morehead, Kentucky
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