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Keikha M, Kamali H, Ghazvini K, Karbalaei M. Conceptual framework of antibiotic stewardship programs in reducing ESBL-producing Enterobacteriaceae: a systematic review and meta-analysis. J Chemother 2022; 34:483-491. [PMID: 35706130 DOI: 10.1080/1120009x.2022.2085473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Today, the phenomenon of antibiotic resistance has become one of the main concerns of health system around the world. Antimicrobial stewardship programs (ASPs) are considered as the most important strategy in optimizing antibiotic consumption, which in turn reduce the emergence of multidrug/extensively drug-resistant (MDR/XDR) microorganisms, as well as reducing mortality and healthcare costs. However, the effectiveness of APSs in controlling the spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae has not been investigated. The pooled odds ratio for the effectiveness of ASPs in reducing ESBL-producing Enterobacteriaceae was 0.82 (95% CI: 0.70-0.98; P value: 0.03); our results showed that in group with implemented ASPs, the prevalence of infection associated with these bacteria had been reduced by 11.8%. Overall, antimicrobial stewardship strategies are significantly effective in reducing ESBL-producing Enterobacteriaceae infections. The present study concluded that a comprehensive stewardship program will certainly reduce the mortality rate, as well as hospitalization stay and treatment costs. In general, our findings strongly support the performance of ASPs in healthcare centers.
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Affiliation(s)
- Masoud Keikha
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Kamali
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kiarash Ghazvini
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Karbalaei
- Department of Microbiology and Virology, Faculty of Medicine, Jiroft University of Medical Sciences, Jiroft, Iran
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Saharman YR, Karuniawati A, Sedono R, Aditianingsih D, Qi H, Verbrugh HA, Severin JA. Multimodal intervention to reduce acquisition of carbapenem-non-susceptible Gram-negative bacteria in intensive care units in the National Referral Hospital of Indonesia: An interrupted time series study. J Crit Care 2021; 64:237-244. [PMID: 34044188 DOI: 10.1016/j.jcrc.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 01/23/2023]
Abstract
PURPOSE To evaluate a low-cost multimodal intervention on the acquisition of carbapenem-non-susceptible Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa by patients in low-resource intensive care units. MATERIALS AND METHODS We performed a quasi-experimental study in a referral hospital in Jakarta, Indonesia: pre-intervention phase 1 (2013-2014), intervention phase 2 (2014-2015) and post-intervention phase 3 (2015-2016). The intervention was hand hygiene promotion and environmental cleaning and disinfection combined with patient disinfection and cohorting. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, which was assessed by active microbiological surveillance and analysed with a multilevel Poisson segmented regression model. RESULTS In phase 1 (387 patients), the acquisition rate was 4.3/100 days for carbapenem-non-susceptible A. baumannii versus 1.1/100 days for both K. pneumoniae and P. aeruginosa. There was a significant step change from phase 1 to phase 3 (361 patients) in the acquisition of carbapenem-non-susceptible strains, the incidence rate ratio (IRR) was 0.343 (99%CI: 0.164-0.717). This significant change was mainly due to reduced acquisitions of resistant A. baumannii (IRR 0.4, 99%CI: 0.181-1.061). Negative confounding was observed. CONCLUSION A multimodal intervention to prevent acquisition of resistant pathogens is feasible and may be effective in ICUs in lower-middle income countries.
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Affiliation(s)
- Yulia Rosa Saharman
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia; Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Anis Karuniawati
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Rudyanto Sedono
- Critical Care Division, Department of Anesthesia and Intensive Care, Faculty of Medicine, - Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Dita Aditianingsih
- Critical Care Division, Department of Anesthesia and Intensive Care, Faculty of Medicine, - Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Hongchao Qi
- Department of Biostatistics, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Henri A Verbrugh
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Khader K, Thomas A, Stevens V, Visnovsky L, Nevers M, Toth D, Keegan LT, Jones M, Rubin M, Samore MH. Association Between Contact Precautions and Transmission of Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Hospitals. JAMA Netw Open 2021; 4:e210971. [PMID: 33720369 PMCID: PMC7961311 DOI: 10.1001/jamanetworkopen.2021.0971] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The effectiveness and importance of contact precautions for endemic pathogens has long been debated, and their use has broad implications for infection control of other pathogens. OBJECTIVE To estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used mathematical models applied to data from a population-based sample of adults hospitalized in 108 VA acute care hospitals for at least 24 hours from January 1, 2008, to December 31, 2017. Data were analyzed from May 2, 2019, to December 11, 2020. EXPOSURES A positive MRSA test result, presumed to indicate contact precautions use according to the VA MRSA Prevention Initiative. MAIN OUTCOMES AND MEASURES The main outcome was the association between contact precautions and MRSA transmission, defined as the relative transmissibility attributed to contact precautions. A contact precaution effect estimate (<1 indicates a reduction in transmission associated with contact precautions) was estimated for each hospital and then pooled over time and across hospitals using meta-regression. RESULTS In this cohort study of 108 VA hospitals, more than 2 million unique individuals had over 5.6 million admissions, of which 14.1% were presumed to have contact precautions with more than 8.4 million MRSA surveillance tests. Pooled estimates found associations between contact precautions and transmission to be stable from 2008 to 2017, with estimated transmission reductions ranging from 43% (95% credible interval [CrI], 38%-48%) to 51% (95% CrI, 46%-55%). Over the entire 10-year study period, contact precautions reduced transmission 47% (95% CrI, 45%-49%), and the intrafacility autocorrelation coefficient estimate was 0.99, suggesting consistent estimates over time within facilities. Larger facilities and those with higher admission screening compliance observed additional reductions in transmission associated with contact precautions (relative rate, 0.84; 95% CI, 0.74-0.96 and 0.74; 95% CI, 0.58-0.96, respectively) compared with smaller facilities and those with lower admission screening compliance. Facilities in the southern US had a smaller transmission reduction attributable to contact precautions (relative rate, 1.14; 95% CI, 1.01-1.28) compared with facilities in other regions in the US. CONCLUSIONS AND RELEVANCE In this cohort study of adults in VA hospitals, transmissibility of MRSA was found to be reduced by approximately 50% among patients with contact precautions. These results provide an explanation for decreasing acquisition rates in VA hospitals since the MRSA Prevention Initiative.
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Affiliation(s)
- Karim Khader
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Alun Thomas
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Vanessa Stevens
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lindsay Visnovsky
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - McKenna Nevers
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Damon Toth
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lindsay T. Keegan
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Makoto Jones
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael Rubin
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Matthew H. Samore
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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Khader K, Thomas A, Huskins WC, Stevens V, Keegan LT, Visnovsky L, Samore MH. Effectiveness of Contact Precautions to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in Intensive Care Units. Clin Infect Dis 2021; 72:S42-S49. [PMID: 33512528 PMCID: PMC7844588 DOI: 10.1093/cid/ciaa1603] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are under increasing scrutiny, in part due to limited clinical trial evidence. METHODS We retrospectively analyzed data from the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial to model the use of contact precautions in individual intensive care units (ICUs). Data included admission and discharge times and surveillance test results. We used a transmission model to estimate key epidemiological parameters, including the effect of contact precautions on transmission. Finally, we performed multivariate meta-regression to identify ICU-level factors associated with contact precaution effects. RESULTS We found that 21% of admissions (n = 2194) were placed on contact precautions, with most for MRSA and VRE. We found little evidence that contact precautions reduced MRSA transmission. The estimated change in transmission attributed to contact precautions was -16% (95% credible interval, -38% to 15%). VRE transmission was higher than MRSA transmission due to contact precautions, but not significantly. In our meta-regression, we did not identify associations between ICU-level factors and estimated contact precaution effects. Importation and transmission were higher for VRE than for MRSA, but clearance rates were lower for VRE than for MRSA. CONCLUSIONS We found little evidence that contact precautions implemented during the STAR*ICU trial reduced transmission of MRSA or VRE. We did find important differences in the transmission dynamics between MRSA and VRE. Differences in organism and healthcare setting may impact the efficacy of contact precautions.
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Affiliation(s)
- Karim Khader
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alun Thomas
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - W Charles Huskins
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vanessa Stevens
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lindsay T Keegan
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lindsay Visnovsky
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew H Samore
- Informatics, Decision-Enhancement, and Analytical Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Saharman YR, Karuniawati A, Severin JA, Verbrugh HA. Infections and antimicrobial resistance in intensive care units in lower-middle income countries: a scoping review. Antimicrob Resist Infect Control 2021; 10:22. [PMID: 33514432 PMCID: PMC7844809 DOI: 10.1186/s13756-020-00871-x] [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: 06/04/2020] [Accepted: 12/22/2020] [Indexed: 01/18/2023] Open
Abstract
Background Intensive care units (ICUs) in lower-middle income countries (LMICs) are suspected to constitute a special risk for patients of acquiring infection due to multiple antibiotic resistant organisms. The aim of this systematic scoping review was to present the data published on ICU-acquired infections and on antimicrobial resistance observed in ICUs in LMICs over a 13-year period. A systematic scoping review was conducted according to the PRISMA extension guideline for scoping reviews and registered in the Open Science Framework.
Main body of the abstract Articles were sought that reported on ICU-acquired infection in LMICs between 2005 and 2018. Two reviewers parallelly reviewed 1961 titles and abstracts retrieved from five data banks, found 274 eligible and finally included 51. Most LMICs had not produced reports in Q1 or Q2 journals in this period, constituting a large gap in knowledge. However, from the reported evidence it is clear that the rate of ICU-acquired infections was comparable, albeit approximately 10% higher, in LMICs compared to high income countries. In contrast, ICU mortality was much higher in LMICs (33.6%) than in high income countries (< 20%). Multidrug-resistant Gram-negative species, especially Acinetobacter baumannii and Pseudomonas aeruginosa, and Klebsiella pneumoniae played a much more dominant role in LMIC ICUs than in those in high income countries. However, interventions to improve this situation have been shown to be feasible and effective, even cost-effective. Conclusions Compared to high income countries the burden of ICU-acquired infection is higher in LMICs, as is the level of antimicrobial resistance; the pathogen distribution is also different. However, there is evidence that interventions are feasible and may be quite effective in these settings. Protocol Registration The protocol was registered with Open Science Framework (https://osf.io/c8vjk)
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Affiliation(s)
- Yulia Rosa Saharman
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Anis Karuniawati
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Henri A Verbrugh
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Campbell JI, Pham TT, Le T, Dang TTH, Chandonnet CJ, Truong TH, Duong H, Nguyen DD, Le TH, Tran TH, Nguyen TKO, Ho TMT, Le KN, Pollack TM, Sandora TJ. Facilitators and barriers to a family empowerment strategy to improve healthcare worker hand hygiene in a resource-limited setting. Am J Infect Control 2020; 48:1485-1490. [PMID: 32492500 DOI: 10.1016/j.ajic.2020.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The World Health Organization recommends empowering patients/families to remind healthcare workers (HCWs) to perform hand hygiene (HH). We sought to understand acceptability of a family empowerment strategy in a Vietnamese pediatric intensive care unit (PICU). METHODS With end-user input, we designed a tool to help families in a PICU in Vietnam to remind HCWs to perform HH. We conducted 3 preliminary focus group discussions (FGDs) with patients' family members (n = 8), physicians (n = 9), and nurses (n = 8) to understand acceptability of preliminary tools, attitudes towards HH and barriers to HH. Tools were then modified and implemented in a 5-week intervention study. We then conducted 3 more FGDs with families (n = 7), physicians (n = 7), and nurses (n = 8). Discussions were analyzed using qualitative directed content analysis. Families who used the tool were asked to complete written surveys. FINDINGS Both family members and HCWs felt that HCWs had a responsibility to perform HH. Barriers to performing HH were identified, including forgetfulness and time constraints. Family members felt shy reminding HCWs to perform HH. However, the HH reminder tool was acceptable, and some felt it could overcome barriers to reminding HCWs to perform HH. HCWs felt embarrassed when reminded to perform HH, but felt that the reminder was useful. Nearly all (99%) survey respondents felt that family members should speak up if they noticed HCWs omitting HH. CONCLUSIONS A tool given to families to remind HCWs to perform HH was largely acceptable in a pediatric ICU in Vietnam. Perceived benefits of improving HH were felt to surmount barriers to tool use.
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Affiliation(s)
- Jeffrey I Campbell
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | - Thanh Thuy Pham
- Department of Medicine, Beth Israel Deaconess Medical Center, and The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Trang Le
- Department of Medicine, Beth Israel Deaconess Medical Center, and The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Thi Thu Huong Dang
- Department of Infection Prevention and Control, Vietnam National Children's Hospital, Hanoi, Vietnam
| | | | - Thi Hoa Truong
- Department of Cardiology, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Hao Duong
- Department of Medicine, Beth Israel Deaconess Medical Center, and The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Duc Duat Nguyen
- Department of Medicine, Beth Israel Deaconess Medical Center, and The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Thi Huyen Le
- The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Thi Ha Tran
- The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Thi Kim Oanh Nguyen
- Department of Infection Prevention and Control, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Thi Minh Than Ho
- Department of Infection Prevention and Control, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Kien Ngai Le
- Department of Infection Prevention and Control, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Todd M Pollack
- Department of Medicine, Beth Israel Deaconess Medical Center, and The Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Thomas J Sandora
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Gut Microbiota, Antibiotic Therapy and Antimicrobial Resistance: A Narrative Review. Microorganisms 2020; 8:microorganisms8020269. [PMID: 32079318 PMCID: PMC7074698 DOI: 10.3390/microorganisms8020269] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/08/2020] [Accepted: 02/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial resistance is a major concern. Epidemiological studies have demonstrated direct relationships between antibiotic consumption and emergence/dissemination of resistant strains. Within the last decade, authors confounded spectrum activity and ecological effects and did not take into account several other factors playing important roles, such as impact on anaerobic flora, biliary elimination and sub-inhibitory concentration. The ecological impact of antibiotics on the gut microbiota by direct or indirect mechanisms reflects the breaking of the resistance barrier to colonization. To limit the impact of antibiotic therapy on gut microbiota, consideration of the spectrum of activity and route of elimination must be integrated into the decision. Various strategies to prevent (antimicrobial stewardship, action on residual antibiotics at colonic level) or cure dysbiosis (prebiotic, probiotic and fecal microbiota transplantation) have been introduced or are currently being developed.
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A family empowerment strategy is associated with increased healthcare worker hand hygiene in a resource-limited setting. Infect Control Hosp Epidemiol 2019; 41:202-208. [PMID: 31822321 DOI: 10.1017/ice.2019.312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Guidelines recommend empowering patients and families to remind healthcare workers (HCWs) to perform hand hygiene (HH). The effectiveness of empowerment tools for patients and their families in Southeast Asia is unknown. METHODS We performed a prospective study in a pediatric intensive care unit (PICU) of a Vietnamese pediatric referral hospital. With family and HCW input, we developed a visual tool for families to prompt HCW HH. We used direct observation to collect baseline HH data. We then enrolled families to receive the visual tool and education on its use while continuing prospective collection of HH data. Multivariable logistic regression was used to identify independent predictors of HH in baseline and implementation periods. RESULTS In total, 2,014 baseline and 2,498 implementation-period HH opportunities were observed. During the implementation period, 73 families were enrolled. Overall, HCW HH was 46% preimplementation, which increased to 73% in the implementation period (P < .001). The lowest HH adherence in both periods occurred after HCW contact with patient surroundings: 16% at baseline increased to 24% after implementation. In multivariable analyses, the odds of HCW HH during the implementation period were significantly higher than baseline (adjusted odds ratio [aOR], 2.94; 95% confidence interval [CI], 2.54-3.41; P < .001) after adjusting for observation room, HCW type, time of observation (weekday business hours vs evening or weekend), and HH moment. CONCLUSIONS The introduction of a visual empowerment tool was associated with significant improvement in HH adherence among HCWs in a Vietnamese PICU. Future research should explore acceptability and barriers to use of similar tools in low- and middle-income settings.
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Varghese S, Ramakrishnan D, Rajahamsan J, Balakrishnan SK, Mercybai IR, Valamparampil MJ, Mohan A, Rajeevan A. Staphylococcus aureus carrier state among surgery and orthopedics health care personnel of a tertiary care center. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2018. [DOI: 10.1016/j.cegh.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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A Systematic Review of the Burden of Multidrug-Resistant Healthcare-Associated Infections Among Intensive Care Unit Patients in Southeast Asia: The Rise of Multidrug-Resistant Acinetobacter baumannii. Infect Control Hosp Epidemiol 2018; 39:525-533. [PMID: 29580299 DOI: 10.1017/ice.2018.58] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVETo summarize the clinical burden (cumulative incidence, prevalence, case fatality rate and length of stay) and economic burden (healthcare cost) of healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDROs) among patients in intensive care units (ICUs) in Southeast Asia.DESIGNSystematic review.METHODSWe conducted a comprehensive literature search in PubMed, EMBASE, CINAHL, EconLit, and the Cochrane Library databases from their inception through September 30, 2016. Clinical and economic burdens and study quality were assessed for each included study.RESULTSIn total, 41 studies met our inclusion criteria; together, 22,876 ICU patients from 7 Southeast Asian countries were included. The cumulative incidence of HAI caused by A. baumannii (AB) in Southeast Asia is substantially higher than has been reported in other regions, especially carbapenem-resistant AB (CRAB; 64.91%) and multidrug-resistant AB (MDR-AB) (58.51%). Evidence of a dose-response relationship between different degrees of drug resistance and excess mortality due to AB infections was observed. Adjusted odds ratios were 1.23 (95% confidence interval [CI], 0.51-3.00) for MDR-AB, 1.72 (95% CI, 0.77-3.80) for extensively drug-resistant AB (XDR-AB), and 1.82 (95% CI, 0.55-6.00) for pandrug-resistant AB (PDR-AB). There is, however, a paucity of published data on additional length of stay and costs attributable to MDROs.CONCLUSIONSThis review highlights the challenges in addressing MDROs in Southeast Asia, where HAIs caused by MDR gram-negative bacteria are abundant and have a strong impact on society. With our findings, we hope to draw the attention of clinicians and policy makers to the problem of antibiotic resistance and to issue a call for action in the management of MDROs.Infect Control Hosp Epidemiol 2018;39:525-533.
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Teerawattanapong N, Kengkla K, Dilokthornsakul P, Saokaew S, Apisarnthanarak A, Chaiyakunapruk N. Prevention and Control of Multidrug-Resistant Gram-Negative Bacteria in Adult Intensive Care Units: A Systematic Review and Network Meta-analysis. Clin Infect Dis 2018; 64:S51-S60. [PMID: 28475791 DOI: 10.1093/cid/cix112] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background This study evaluated the relative efficacy of strategies for the prevention of multidrug-resistant gram-negative bacteria (MDR-GNB) in adult intensive care units (ICUs). Methods A systematic review and network meta-analysis was performed; searches of the Cochrane Library, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) included all randomized controlled trials and observational studies conducted in adult patients hospitalized in ICUs and evaluating standard care (STD), antimicrobial stewardship program (ASP), environmental cleaning (ENV), decolonization methods (DCL), or source control (SCT), simultaneously. The primary outcomes were MDR-GNB acquisition, colonization, and infection; secondary outcome was ICU mortality. Results Of 3805 publications retrieved, 42 met inclusion criteria (5 randomized controlled trials and 37 observational studies), involving 62068 patients (median age, 58.8 years; median APACHE [Acute Physiology and Chronic Health Evaluation] II score, 18.9). The majority of studies reported extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and MDR Acinetobacter baumannii. Compared with STD, a 4-component strategy composed of STD, ASP, ENV, and SCT was the most effective intervention (rate ratio [RR], 0.05 [95% confidence interval {CI}, .01-.38]). When ENV was added to STD+ASP or SCT was added to STD+ENV, there was a significant reduction in the acquisition of MDR A. baumannii (RR, 0.28 [95% CI, .18-.43] and 0.48 [95% CI, .35-.66], respectively). Strategies with ASP as a core component showed a statistically significant reduction the acquisition of ESBL-producing Enterobacteriaceae (RR, 0.28 [95% CI, .11-.69] for STD+ASP+ENV and 0.23 [95% CI, .07-.80] for STD+ASP+DCL). Conclusions A 4-component strategy was the most effective intervention to prevent MDR-GNB acquisition. As some strategies were differential for certain bacteria, our study highlighted the need for further evaluation of the most effective prevention strategies.
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Affiliation(s)
| | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and
| | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and.,Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor.,School of Pharmacy, University of Wisconsin- Madison ; and.,School of Population Health, University of Queensland, Brisbane, Australia
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12
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Phu VD, Nadjm B, Duy NHA, Co DX, Mai NTH, Trinh DT, Campbell J, Khiem DP, Quang TN, Loan HT, Binh HS, Dinh QD, Thuy DB, Lan HNP, Ha NH, Bonell A, Larsson M, Hoan HM, Tuan ĐQ, Hanberger H, Minh HNV, Yen LM, Van Hao N, Binh NG, Chau NVV, Van Kinh N, Thwaites GE, Wertheim HF, van Doorn HR, Thwaites CL. Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology. J Intensive Care 2017; 5:69. [PMID: 29276607 PMCID: PMC5738227 DOI: 10.1186/s40560-017-0266-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 11/27/2017] [Indexed: 01/16/2023] Open
Abstract
Background Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available. Methods We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission. Results Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients’ data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75–3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14–1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806–7824) vs 3131 USD (IQR 2108–7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75–6.75, p = 0.15). Conclusions VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed. Electronic supplementary material The online version of this article (10.1186/s40560-017-0266-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vu Dinh Phu
- National Hospital for Tropical Diseases, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | | | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - James Campbell
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Quynh-Dao Dinh
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Duong Bich Thuy
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Huong Nguyen Phu Lan
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Ana Bonell
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | | | | | | | | | | | - Lam Minh Yen
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Heiman F Wertheim
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, Netherlands
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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13
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A one-year prospective study of colonization with antimicrobial-resistant organisms on admission to a Vietnamese intensive care unit. PLoS One 2017; 12:e0184847. [PMID: 28910379 PMCID: PMC5599024 DOI: 10.1371/journal.pone.0184847] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/31/2017] [Indexed: 12/03/2022] Open
Abstract
There is a paucity of data regarding initial bacterial colonization on admission to Intensive Care Units (ICUs) in low and middle-income countries (LMICs). Patients admitted to ICUs in LMICs are at high-risk of subsequent infection with antimicrobial-resistant organisms (AROs). We conducted a prospective, observational study at the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam from November 2014 to January 2016 to assess the colonization and antimicrobial susceptibility of Staphylococcus aureus, Escherichia coli, Klebsiella spp., Pseudomonas spp. and Acinetobacter spp. among adult patients within 48 hours of ICU admission. We found the admission colonization prevalence (with at least one of the identified organisms) was 93.7% (785/838) and that of AROs was 63.1% (529/838). The colonization frequency with AROs among patients admitted from the community was comparable to those transferred from other hospitals (62.2% vs 63.8%). Staphylococcus aureus was the most commonly isolated bacteria from nasal swabs (13.1%, 110/838) and the methicillin-resistant Staphylococcus aureus nasal colonization prevalence was 8.6% (72/838). We isolated Escherichia coli from rectal swabs from almost all enrolled patients (88.3%, 740/838) and 52.1% (437/838) of patients were colonized by extended spectrum β-lactamase producing Escherichia coli. Notably, Klebsiella pneumoniae was the most frequently isolated bacteria from the tracheal swabs (11.8%, 18/153). Vietnamese ICU patients have a high rate of colonization with AROs and are thus at risk of subsequent infections with these organisms if good infection control practices are not in place.
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14
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Beardmore RE, Peña-Miller R, Gori F, Iredell J. Antibiotic Cycling and Antibiotic Mixing: Which One Best Mitigates Antibiotic Resistance? Mol Biol Evol 2017; 34:802-817. [PMID: 28096304 PMCID: PMC5400377 DOI: 10.1093/molbev/msw292] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Can we exploit our burgeoning understanding of molecular evolution to slow the progress of drug resistance? One role of an infection clinician is exactly that: to foresee trajectories to resistance during antibiotic treatment and to hinder that evolutionary course. But can this be done at a hospital-wide scale? Clinicians and theoreticians tried to when they proposed two conflicting behavioral strategies that are expected to curb resistance evolution in the clinic, these are known as “antibiotic cycling” and “antibiotic mixing.” However, the accumulated data from clinical trials, now approaching 4 million patient days of treatment, is too variable for cycling or mixing to be deemed successful. The former implements the restriction and prioritization of different antibiotics at different times in hospitals in a manner said to “cycle” between them. In antibiotic mixing, appropriate antibiotics are allocated to patients but randomly. Mixing results in no correlation, in time or across patients, in the drugs used for treatment which is why theorists saw this as an optimal behavioral strategy. So while cycling and mixing were proposed as ways of controlling evolution, we show there is good reason why clinical datasets cannot choose between them: by re-examining the theoretical literature we show prior support for the theoretical optimality of mixing was misplaced. Our analysis is consistent with a pattern emerging in data: neither cycling or mixing is a priori better than the other at mitigating selection for antibiotic resistance in the clinic. Key words: antibiotic cycling, antibiotic mixing, optimal control, stochastic models.
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Affiliation(s)
| | - Rafael Peña-Miller
- Center for Genomic Sciences, Universidad Nacional Autonóma de México, Cuernavaca, Mexico
| | - Fabio Gori
- Biosciences University of Exeter, Devon, United Kingdom
| | - Jonathan Iredell
- Westmead Clinical School, Westmead Hospital, The University of Sydney, Australia
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15
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Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2017. [PMID: 28629876 DOI: 10.1016/s1473-3099(17)30325-0] [Citation(s) in RCA: 463] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic stewardship programmes have been shown to reduce antibiotic use and hospital costs. We aimed to evaluate evidence of the effect of antibiotic stewardship on the incidence of infections and colonisation with antibiotic-resistant bacteria. METHODS For this systematic review and meta-analysis, we searched PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Web of Science for studies published from Jan 1, 1960, to May 31, 2016, that analysed the effect of antibiotic stewardship programmes on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients. Two authors independently assessed the eligibility of trials and extracted data. Studies involving long-term care facilities were excluded. The main outcomes were incidence ratios (IRs) of target infections and colonisation per 1000 patient-days before and after implementation of antibiotic stewardship. Meta-analyses were done with random-effect models and heterogeneity was calculated with the I2 method. FINDINGS We included 32 studies in the meta-analysis, comprising 9 056 241 patient-days and 159 estimates of IRs. Antibiotic stewardship programmes reduced the incidence of infections and colonisation with multidrug-resistant Gram-negative bacteria (51% reduction; IR 0·49, 95% CI 0·35-0·68; p<0·0001), extended-spectrum β-lactamase-producing Gram-negative bacteria (48%; 0·52, 0·27-0·98; p=0·0428), and meticillin-resistant Staphylococcus aureus (37%; 0·63, 0·45-0·88; p=0·0065), as well as the incidence of C difficile infections (32%; 0·68, 0·53-0·88; p=0·0029). Antibiotic stewardship programmes were more effective when implemented with infection control measures (IR 0·69, 0·54-0·88; p=0·0030), especially hand-hygiene interventions (0·34, 0·21-0·54; p<0·0001), than when implemented alone. Antibiotic stewardship did not affect the IRs of vancomycin-resistant enterococci and quinolone-resistant and aminoglycoside-resistant Gram-negative bacteria. Significant heterogeneity between studies was detected, which was partly explained by the type of interventions and co-resistance patterns of the target bacteria. INTERPRETATION Antibiotic stewardship programmes significantly reduce the incidence of infections and colonisation with antibiotic-resistant bacteria and C difficile infections in hospital inpatients. These results provide stakeholders and policy makers with evidence for implementation of antibiotic stewardship interventions to reduce the burden of infections from antibiotic-resistant bacteria. FUNDING German Center for Infection Research.
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16
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Caudill L, Lawson B. A unified inter-host and in-host model of antibiotic resistance and infection spread in a hospital ward. J Theor Biol 2017; 421:112-126. [PMID: 28365293 DOI: 10.1016/j.jtbi.2017.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 03/14/2017] [Accepted: 03/25/2017] [Indexed: 11/24/2022]
Abstract
As the battle continues against hospital-acquired infections and the concurrent rise in antibiotic resistance among many of the major causative pathogens, there is a dire need to conduct controlled experiments, in order to compare proposed control strategies. However, cost, time, and ethical considerations make this evaluation strategy either impractical or impossible to implement with living patients. This paper presents a multi-scale model that offers promise as the basis for a tool to simulate these (and other) controlled experiments. This is a "unified" model in two important ways: (i) It combines inter-host and in-host dynamics into a single model, and (ii) it links two very different modeling approaches - agent-based modeling and differential equations - into a single model. The potential of this model as an instrument to combat antibiotic resistance in hospitals is demonstrated with numerical examples.
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Affiliation(s)
- Lester Caudill
- Department of Mathematics and Computer Science, University of Richmond, Virginia 23173 USA.
| | - Barry Lawson
- Department of Mathematics and Computer Science, University of Richmond, Virginia 23173 USA
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17
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Khader K, Thomas A, Huskins WC, Leecaster M, Zhang Y, Greene T, Redd A, Samore MH. A Dynamic Transmission Model to Evaluate the Effectiveness of Infection Control Strategies. Open Forum Infect Dis 2017; 4:ofw247. [PMID: 28702465 PMCID: PMC5499871 DOI: 10.1093/ofid/ofw247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The advancement of knowledge about control of antibiotic resistance depends on the rigorous evaluation of alternative intervention strategies. The STAR*ICU trial examined the effects of active surveillance and expanded barrier precautions on acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) in intensive care units. We report a reanalyses of the STAR*ICU trial using a Bayesian transmission modeling framework. METHODS The data included admission and discharge times and surveillance test times and results. Markov chain Monte Carlo stochastic integration was used to estimate the transmission rate, importation, false negativity, and clearance separately for MRSA and VRE. The primary outcome was the intervention effect, which when less than (or greater than) zero, indicated a decreased (or increased) transmission rate attributable to the intervention. RESULTS The transmission rate increased in both arms from pre- to postintervention (by 20% and 26% for MRSA and VRE). The estimated intervention effect was 0.00 (95% confidence interval [CI], -0.57 to 0.56) for MRSA and 0.05 (95% CI, -0.39 to 0.48) for VRE. Compared with MRSA, VRE had a higher transmission rate (preintervention, 0.0069 vs 0.0039; postintervention, 0.0087 vs 0.0046), higher importation probability (0.22 vs 0.17), and a lower clearance rate per colonized patient-day (0.016 vs 0.035). CONCLUSIONS Transmission rates in the 2 treatment arms were statistically indistinguishable from the pre- to postintervention phase, consistent with the original analysis of the STAR*ICU trial. Our statistical framework was able to disentangle transmission from importation and account for imperfect testing. Epidemiological differences between VRE and MRSA were revealed.
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Affiliation(s)
- Karim Khader
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
| | - Alun Thomas
- Genetic Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - W Charles Huskins
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Molly Leecaster
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
| | - Yue Zhang
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
| | - Tom Greene
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
| | - Andrew Redd
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
| | - Matthew H Samore
- Informatics, Decision Enhancement, and Analytical Sciences 2.0 Center, VA Salt Lake City Health Care System, City, Utah.,Divisions of Epidemiology
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18
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The Role of Mathematical Modeling in Designing and Evaluating Antimicrobial Stewardship Programs. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0074-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Schultz MB, Pham Thanh D, Tran Do Hoan N, Wick RR, Ingle DJ, Hawkey J, Edwards DJ, Kenyon JJ, Phu Huong Lan N, Campbell JI, Thwaites G, Thi Khanh Nhu N, Hall RM, Fournier-Level A, Baker S, Holt KE. Repeated local emergence of carbapenem-resistant Acinetobacter baumannii in a single hospital ward. Microb Genom 2016; 2:e000050. [PMID: 28348846 PMCID: PMC5320574 DOI: 10.1099/mgen.0.000050] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/12/2016] [Indexed: 12/20/2022] Open
Abstract
We recently reported a dramatic increase in the prevalence of carbapenem-resistant Acinetobacter baumannii infections in the intensive care unit (ICU) of a Vietnamese hospital. This upsurge was associated with a specific oxa23-positive clone that was identified by multilocus VNTR analysis. Here, we used whole-genome sequence analysis to dissect the emergence of carbapenem-resistant A. baumannii causing ventilator-associated pneumonia (VAP) in the ICU during 2009–2012. To provide historical context and distinguish microevolution from strain introduction, we compared these genomes with those of A. baumannii asymptomatic carriage and VAP isolates from this same ICU collected during 2003–2007. We identified diverse lineages co-circulating over many years. Carbapenem resistance was associated with the presence of oxa23, oxa40, oxa58 and ndm1 genes in multiple lineages. The majority of resistant isolates were oxa23-positive global clone GC2; fine-scale phylogenomic analysis revealed five distinct GC2 sublineages within the ICU that had evolved locally via independent chromosomal insertions of oxa23 transposons. The increase in infections caused by carbapenem-resistant A. baumannii was associated with transposon-mediated transmission of a carbapenemase gene, rather than clonal expansion or spread of a carbapenemase-harbouring plasmid. Additionally, we found evidence of homologous recombination creating diversity within the local GC2 population, including several events resulting in replacement of the capsule locus. We identified likely donors of the imported capsule locus sequences amongst the A. baumannii isolated on the same ward, suggesting that diversification was largely facilitated via reassortment and sharing of genetic material within the localized A. baumannii population.
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Affiliation(s)
- Mark B Schultz
- 2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia.,1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Duy Pham Thanh
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nhu Tran Do Hoan
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ryan R Wick
- 1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia.,2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Danielle J Ingle
- 1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia.,2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Jane Hawkey
- 1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia.,2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - David J Edwards
- 1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia.,2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Johanna J Kenyon
- 4School of Molecular Bioscience, University of Sydney, New South Wales, Australia.,5School of Biomedical Science, Queensland University of Technology, Queensland, Australia
| | - Nguyen Phu Huong Lan
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,6Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, London, UK
| | - James I Campbell
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Khanh Nhu
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,6Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, London, UK
| | - Ruth M Hall
- 4School of Molecular Bioscience, University of Sydney, New South Wales, Australia
| | | | - Stephen Baker
- 3The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,6Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, London, UK
| | - Kathryn E Holt
- 1Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Parkville, Victoria 3010, Australia.,2Centre for Systems Genomics, University of Melbourne, Parkville, Victoria 3010, Australia
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20
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Prevention and control of multi-drug-resistant Gram-negative bacteria: recommendations from a Joint Working Party. J Hosp Infect 2015; 92 Suppl 1:S1-44. [PMID: 26598314 DOI: 10.1016/j.jhin.2015.08.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Indexed: 12/25/2022]
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21
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Otter JA, Mutters NT, Tacconelli E, Gikas A, Holmes AH. Controversies in guidelines for the control of multidrug-resistant Gram-negative bacteria in EU countries. Clin Microbiol Infect 2015; 21:1057-66. [PMID: 26435462 DOI: 10.1016/j.cmi.2015.09.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 12/16/2022]
Abstract
The various guidelines that are available for multidrug-resistant Gram-negative bacteria are useful, and contain broad areas of agreement. However, there are also important areas of controversy between the guidelines in terms of the details of applying contact precautions, single-room isolation and active surveillance cultures, differences in the approach to environmental cleaning and disinfection, and whether or not to perform staff and patient cohorting, healthcare worker screening or patient decolonization. The evidence-base is extremely limited and further research is urgently required to inform an evidence-based approach to multidrug-resistant Gram-negative bacteria prevention and control.
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Affiliation(s)
- J A Otter
- Imperial College Healthcare NHS Trust, London, UK.
| | - N T Mutters
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
| | - E Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
| | - A Gikas
- Department of Internal Medicine, Infectious Diseases Unit, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - A H Holmes
- Imperial College Healthcare NHS Trust, London, UK; Imperial College London, UK
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22
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Le Minh V, Thi Khanh Nhu N, Vinh Phat V, Thompson C, Huong Lan NP, Thieu Nga TV, Thanh Tam PT, Tuyen HT, Hoang Nhu TD, Van Hao N, Thi Loan H, Minh Yen L, Parry CM, Trung Nghia HD, Campbell JI, Hien TT, Thwaites L, Thwaites G, Van Vinh Chau N, Baker S. In vitro activity of colistin in antimicrobial combination against carbapenem-resistant Acinetobacter baumannii isolated from patients with ventilator-associated pneumonia in Vietnam. J Med Microbiol 2015; 64:1162-1169. [PMID: 26297024 PMCID: PMC4755130 DOI: 10.1099/jmm.0.000137] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Acinetobacter baumannii has become one of the major infection threats in intensive care units (ICUs) globally. Since 2008, A. baumannii has been the leading cause of ventilator-associated pneumonia (VAP) in our ICU at an infectious disease hospital in southern Vietnam. The emergence of this pathogen in our setting is consistent with the persistence of a specific clone exhibiting resistance to carbapenems. Antimicrobial combinations may be a strategy to treat infections caused by these carbapenem-resistant A. baumannii. Therefore, we assessed potential antimicrobial combinations against local carbapenem-resistant A. baumannii by measuring in vitro interactions of colistin with four antimicrobials that are locally certified for treating VAP. We first performed antimicrobial susceptibility testing and multilocus variable number tandem repeat analysis (MLVA) genotyping on 74 A. baumannii isolated from quantitative tracheal aspirates from patients with VAP over an 18-month period. These 74 isolates could be subdivided into 21 main clusters by MLVA and >80 % were resistant to carbapenems. We selected 56 representative isolates for in vitro combination synergy testing. Synergy was observed in four (7 %), seven (13 %), 20 (36 %) and 38 (68 %) isolates with combinations of colistin with ceftazidime, ceftriaxone, imipenem and meropenem, respectively. Notably, more carbapenem-resistant A. baumannii isolates (36/43; 84 %) exhibited synergistic activity with a combination of colistin and meropenem than carbapenem-susceptible A. baumannii isolates (2/13; 15 %) (P = 0.023; Fisher's exact test). Our findings suggest that combinations of colistin and meropenem should be considered when treating carbapenem-resistant A. baumannii infections in Vietnam, and we advocate clinical trials investigating combination therapy for VAP.
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Affiliation(s)
- Vien Le Minh
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Division of Infectious Diseases, Department of Medicine, University of California San Francisco, CA, USA
| | - Nguyen Thi Khanh Nhu
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia
| | - Voong Vinh Phat
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Corinne Thompson
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK
| | - Nguyen Phu Huong Lan
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Vu Thieu Nga
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Pham Thi Thanh Tam
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ha Thanh Tuyen
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Do Hoang Nhu
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Christopher M Parry
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK.,Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - James I Campbell
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK
| | - Tran Tinh Hien
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK
| | - Louise Thwaites
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK
| | - Guy Thwaites
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK
| | | | - Stephen Baker
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, UK.,London School of Hygiene and Tropical Medicine, London, UK.,Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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Timsit JF, Citerio G, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Hernandez G, Herridge M, Jaber S, Joannidis M, Papazian L, Peters M, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Azoulay E. Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics. Intensive Care Med 2014; 40:471-83. [PMID: 24519574 PMCID: PMC7095429 DOI: 10.1007/s00134-014-3235-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Jean-Francois Timsit
- Medical and Infectious Diseases ICU, Bichat Hospital, Paris Diderot University, Paris, France,
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