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Vintilă C, Coșeriu RL, Mare AD, Ciurea CN, Togănel RO, Simion A, Cighir A, Man A. Biofilm Formation and Antibiotic Resistance Profiles in Carbapenemase-Producing Gram-Negative Rods-A Comparative Analysis between Screening and Pathological Isolates. Antibiotics (Basel) 2024; 13:687. [PMID: 39199988 PMCID: PMC11350898 DOI: 10.3390/antibiotics13080687] [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: 06/29/2024] [Revised: 07/17/2024] [Accepted: 07/22/2024] [Indexed: 09/01/2024] Open
Abstract
(1) Background: Carbapenem-resistant (CR) bacteria pose a significant global public health challenge due to their ability to evade treatment with beta-lactam antibiotics, including carbapenems. This study investigates the biofilm-forming capabilities of CR clinical bacterial isolates and examines the impact of serum on biofilm formation. Additionally, the study evaluates the resistance profiles and genetic markers for carbapenemase production. (2) Methods: Bacterial isolates were collected from the microbiology laboratory of Mures County Clinical Hospital between October 2022 and September 2023. Pharyngeal and rectal swabs were screened for carbapenem-resistant bacteria using selective media. Lower respiratory tract samples were also analyzed for CR Gram-negative bacteria. The isolates were tested for their ability to form biofilms in the presence and absence of fetal bovine serum at 24 and 48 h. Carbapenemase production was detected phenotypically and confirmed via PCR for relevant genes. (3) Results: Out of 846 screened samples, 4.25% from pharyngeal swabs and 6.38% from rectal swabs tested positive for CR bacteria. Acinetobacter baumannii and Klebsiella pneumoniae were the most common species isolated. Biofilm formation varied significantly between clinical isolates and standard strains, with clinical isolates generally showing higher biofilm production. The presence of serum had no significant effect on biofilm formation in Klebsiella spp., but stimulated biofilm formation for Acinetobacter spp. Carbapenemase genes blaKPC, blaOXA-48-like, and blaNDM were detected in various isolates, predominantly in Klebsiella spp., but were not the main determinants of carbapenem resistance, at least in screening isolates. (4) Conclusions: This study highlights the variability in biofilm formation among CR clinical isolates and underscores the differences between the bacteria found as carriage versus infection. Both bacterial species and environmental factors variably influence biofilm formation. These insights are crucial for the development of effective treatment and infection control strategies in clinical settings.
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Affiliation(s)
- Camelia Vintilă
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540142 Târgu Mures, Romania
| | - Răzvan Lucian Coșeriu
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
| | - Anca Delia Mare
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
| | - Cristina Nicoleta Ciurea
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
| | - Radu Ovidiu Togănel
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540142 Târgu Mures, Romania
| | - Anastasia Simion
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540142 Târgu Mures, Romania
| | - Anca Cighir
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
| | - Adrian Man
- Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, 540142 Târgu Mures, Romania; (C.V.); (A.D.M.); (C.N.C.); (R.O.T.); (A.S.); (A.C.); (A.M.)
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Premachandra A, Moine P. Antibiotics in anesthesia and critical care. ANNALS OF TRANSLATIONAL MEDICINE 2024; 12:6. [PMID: 38304898 PMCID: PMC10777233 DOI: 10.21037/atm-22-5585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/06/2023] [Indexed: 02/03/2024]
Abstract
Sepsis is life-threatening organ dysfunction due to a dysregulated host response to an underlying acute infection. Sepsis is a major worldwide healthcare problem. An annual estimated 48.9 million incident cases of sepsis is reported, with 11 million (20%) sepsis-related deaths. Administration of appropriate antimicrobials is one of the most effective therapeutic interventions to reduce mortality. The severity of illness informs the urgency of antimicrobial administration. Nevertheless, even used properly, they cause adverse effects and contribute to the development of antibiotic resistance. Both inadequate and unnecessarily broad empiric antibiotics are associated with higher mortality and also select for antibiotic-resistant germs. In this narrative review, we will first discuss important factors and potential confounders which may influence the occurrence of surgical site infection (SSI) and which should be considered in the provision of perioperative antibiotic prophylaxis (PAP). Then, we will summarize recent advances and perspectives to optimize antibiotic therapy in the intensive care unit (ICU). Finally, the major role of the microbiota and the impact of antimicrobials on it will be discussed. While expert recommendations help guide daily practice in the operating theatre and ICU, a thorough knowledge of pharmacokinetic/pharmacodynamic (PK/PD) rules is critical to optimize the management of complex patients and minimize the emergence of multidrug-resistant organisms.
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Affiliation(s)
- Antoine Premachandra
- Department of Intensive Care, Hôpital Raymond Poincaré, Groupe Hospitalo-Universitaire GHU AP-HP, University Versailles Saint Quentin-University Paris-Saclay, Garches, France
| | - Pierre Moine
- Department of Intensive Care, Hôpital Raymond Poincaré, Groupe Hospitalo-Universitaire GHU AP-HP, University Versailles Saint Quentin-University Paris-Saclay, Garches, France
- Laboratory of Infection & Inflammation - U1173, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) - University Paris-Saclay - Institut National de la Santé et de la Recherche Médicale (INSERM), Garches, France
- Fédération Hospitalo-Universitaire FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), Garches, France
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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Xu J, Kong X, Li J, Mao H, Zhu Y, Zhu X, Xu Y. Pediatric intensive care unit treatment alters the diversity and composition of the gut microbiota and antimicrobial resistance gene expression in critically ill children. Front Microbiol 2023; 14:1237993. [PMID: 38029168 PMCID: PMC10679412 DOI: 10.3389/fmicb.2023.1237993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Common critical illnesses are a growing economic burden on healthcare worldwide. However, therapies targeting the gut microbiota for critical illnesses have not been developed on a large scale. This study aimed to investigate the changes in the characteristics of the gut microbiota in critically ill children after short-term pediatric intensive care unit (PICU) treatments. Methods Anal swab samples were prospectively collected from March 2021 to March 2022 from children admitted to the PICU of Xinhua Hospital who received broad-spectrum antibiotics on days 1 (the D1 group) and 7 (the D7 group) of the PICU treatment. The structural and functional characteristics of the gut microbiota of critically ill children were explored using metagenomic next-generation sequencing (mNGS) technology, and a comparative analysis of samples from D1 and D7 was conducted. Results After 7 days of PICU admission, a significant decrease was noted in the richness of the gut microbiota in critically ill children, while the bacterial diversity and the community structure between groups remained stable to some extent. The relative abundance of Bacilli and Lactobacillales was significantly higher, and that of Campylobacter hominis was significantly lower in the D7 group than in the D1 group. The random forest model revealed that Prevotella coporis and Enterobacter cloacae were bacterial biomarkers between groups. LEfSe revealed that two Gene Ontology entries, GO:0071555 (cell wall organization) and GO:005508 (transmembrane transport), changed significantly after the short-term treatment in the PICU. In addition, 30 KEGG pathways were mainly related to the activity of enzymes and proteins during the processes of metabolism, DNA catabolism and repair, and substance transport. Finally, 31 antimicrobial resistance genes had significantly different levels between the D7 and D1 groups. The top 10 up-regulated genes were Erm(A), ErmX, LptD, eptB, SAT-4, tetO, adeJ, adeF, APH(3')-IIIa, and tetM. Conclusion The composition, gene function, and resistance genes of gut microbiota of critically ill children can change significantly after short PICU treatments. Our findings provide a substantial basis for a better understanding of the structure and function of gut microbiota and their role in critical illnesses.
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Affiliation(s)
| | | | | | | | | | | | - Yaya Xu
- Department of Pediatric Intensive Care Medicine, Xinhua Hospital, Affiliated to the Medical School, Shanghai Jiao Tong University, Shanghai, China
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Roson-Calero N, Ballesté-Delpierre C, Fernández J, Vila J. Insights on Current Strategies to Decolonize the Gut from Multidrug-Resistant Bacteria: Pros and Cons. Antibiotics (Basel) 2023; 12:1074. [PMID: 37370393 DOI: 10.3390/antibiotics12061074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
In the last decades, we have witnessed a steady increase in infections caused by multidrug-resistant (MDR) bacteria. These infections are associated with higher morbidity and mortality. Several interventions should be taken to reduce the emergence and spread of MDR bacteria. The eradication of resistant pathogens colonizing specific human body sites that would likely cause further infection in other sites is one of the most conventional strategies. The objective of this narrative mini-review is to compile and discuss different strategies for the eradication of MDR bacteria from gut microbiota. Here, we analyse the prevalence of MDR bacteria in the community and the hospital and the clinical impact of gut microbiota colonisation with MDR bacteria. Then, several strategies to eliminate MDR bacteria from gut microbiota are described and include: (i) selective decontamination of the digestive tract (SDD) using a cocktail of antibiotics; (ii) the use of pre and probiotics; (iii) fecal microbiota transplantation; (iv) the use of specific phages; (v) engineered CRISPR-Cas Systems. This review intends to provide a state-of-the-art of the most relevant strategies to eradicate MDR bacteria from gut microbiota currently being investigated.
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Affiliation(s)
- Natalia Roson-Calero
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Clara Ballesté-Delpierre
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, 08036 Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure (EF-Clif), 08021 Barcelona, Spain
| | - Jordi Vila
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical Microbiology, Biomedical Diagnostic Center, Hospital Clinic, 08036 Barcelona, Spain
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Biemond JJ, McDonald B, Haak BW. Leveraging the microbiome in the treatment of sepsis: potential pitfalls and new perspectives. Curr Opin Crit Care 2023; 29:123-129. [PMID: 36762681 DOI: 10.1097/mcc.0000000000001019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW This review aims to provide an overview of the current knowledge about microbiota-targeted therapies in sepsis, and calls out - despite recent negative studies - not to halt our efforts of translating these tools into regular medical practice. RECENT FINDINGS The intestinal microbiome has an important role in shaping our immune system, and microbiota-derived metabolites prime innate and adaptive inflammatory responses to infectious pathogens. Microbiota composition is severely disrupted during sepsis, which has been linked to increased risk of mortality and secondary infections. However, efforts of using these microbes as a tool for prognostic or therapeutic purposes have been unsuccessful so far, and recent trials studying the impact of probiotics in critical illness did not improve patient outcomes. Despite these negative results, researchers must continue their attempts of harnessing the microbiome to improve sepsis survival in patients with a high risk of clinical deterioration. Promising research avenues that could potentially benefit sepsis patients include the development of next-generation probiotics, use of the microbiome as a theranostic tool to direct therapy, and addressing the restoration of microbial communities following ICU discharge. SUMMARY Although research focused on microbiome-mediated therapy in critically ill patients has not yielded the results that were anticipated, we should not abandon our efforts to translate promising preclinical findings into clinical practice.
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Affiliation(s)
- Jason J Biemond
- Center for Experimental and Molecular Medicine (CEMM)
- Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Braedon McDonald
- The Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Bastiaan W Haak
- Center for Experimental and Molecular Medicine (CEMM)
- Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Ventilator-Associated Pneumonia in COVID-19 Patients Admitted in Intensive Care Units: Relapse, Therapeutic Failure and Attributable Mortality-A Multicentric Observational Study from the OutcomeRea Network. J Clin Med 2023; 12:jcm12041298. [PMID: 36835834 PMCID: PMC9961155 DOI: 10.3390/jcm12041298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/24/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction: Ventilator-associated pneumonia (VAP) incidence is high among critically ill COVID-19 patients. Its attributable mortality remains underestimated, especially for unresolved episodes. Indeed, the impact of therapeutic failures and the determinants that potentially affect mortality are poorly evaluated. We assessed the prognosis of VAP in severe COVID-19 cases and the impact of relapse, superinfection, and treatment failure on 60-day mortality. Methods: We evaluated the incidence of VAP in a multicenter prospective cohort that included adult patients with severe COVID-19, who required mechanical ventilation for ≥48 h between March 2020 and June 2021. We investigated the risk factors for 30-day and 60-day mortality, and the factors associated with relapse, superinfection, and treatment failure. Results: Among 1424 patients admitted to eleven centers, 540 were invasively ventilated for 48 h or more, and 231 had VAP episodes, which were caused by Enterobacterales (49.8%), P. aeruginosa (24.8%), and S. aureus (22%). The VAP incidence rate was 45.6/1000 ventilator days, and the cumulative incidence at Day 30 was 60%. VAP increased the duration of mechanical ventilation without modifying the crude 60-day death rate (47.6% vs. 44.7% without VAP) and resulted in a 36% increase in death hazard. Late-onset pneumonia represented 179 episodes (78.2%) and was responsible for a 56% increase in death hazard. The cumulative incidence rates of relapse and superinfection were 45% and 39.5%, respectively, but did not impact death hazard. Superinfection was more frequently related to ECMO and first episode of VAP caused by non-fermenting bacteria. The risk factors for treatment failure were an absence of highly susceptible microorganisms and vasopressor need at VAP onset. Conclusions: The incidence of VAP, mainly late-onset episodes, is high in COVID-19 patients and associated with an increased risk of death, similar to that observed in other mechanically ventilated patients. The high rate of VAP due to difficult-to-treat microorganisms, pharmacokinetic alterations induced by renal replacement therapy, shock, and ECMO likely explains the high cumulative risk of relapse, superinfection, and treatment failure.
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Patrier J, Villageois-Tran K, Szychowiak P, Ruckly S, Gschwind R, Wicky PH, Gueye S, Armand-Lefevre L, Marzouk M, Sonneville R, Bouadma L, Petitjean M, Lamara F, de Montmollin E, Timsit JF, Ruppé E. Oropharyngeal and intestinal concentrations of opportunistic pathogens are independently associated with death of SARS-CoV-2 critically ill adults. Crit Care 2022; 26:300. [PMID: 36192756 PMCID: PMC9527714 DOI: 10.1186/s13054-022-04164-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The composition of the digestive microbiota may be associated with outcome and infections in patients admitted to the intensive care unit (ICU). The dominance by opportunistic pathogens (such as Enterococcus) has been associated with death. However, whether this association remains all throughout the hospitalization are lacking. METHODS We performed a single-center observational prospective cohort study in critically ill patients admitted with severe SARS-CoV-2 infection. Oropharyngeal and rectal swabs were collected at admission and then twice weekly until discharge or death. Quantitative cultures for opportunistic pathogens were performed on oropharyngeal and rectal swabs. The composition of the intestinal microbiota was assessed by 16S rDNA sequencing. Oropharyngeal and intestinal concentrations of opportunistic pathogens, intestinal richness and diversity were entered into a multivariable Cox model as time-dependent covariates. The primary outcome was death at day 90. RESULTS From March to September 2020, 95 patients (765 samples) were included. The Simplified Acute Physiology Score 2 (SAPS 2) at admission was 33 [24; 50] and a Sequential Organ Failure Assessment score (SOFA score) at 6 [4; 8]. Day 90 all-cause mortality was 44.2% (42/95). We observed that the oropharyngeal and rectal concentrations of Enterococcus spp., Staphylococcus aureus and Candida spp. were associated with a higher risk of death. This association remained significant after adjustment for prognostic covariates (age, chronic disease, daily antimicrobial agent use and daily SOFA score). A one-log increase in Enterococcus spp., S. aureus and Candida spp. in oropharyngeal or rectal swabs was associated with a 17% or greater increase in the risk of death. CONCLUSION We found that elevated oropharyngeal/intestinal Enterococcus spp. S. aureus and Candida spp. concentrations, assessed by culture, are associated with mortality, independent of age, organ failure, and antibiotic therapy, opening prospects for simple and inexpensive microbiota-based markers for the prognosis of critically ill SARS-CoV-2 patients.
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Affiliation(s)
- Juliette Patrier
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France
| | - Khanh Villageois-Tran
- grid.411599.10000 0000 8595 4540AP-HP, Service de Microbiologie, Hôpital Beaujon, 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Piotr Szychowiak
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Stéphane Ruckly
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Rémi Gschwind
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Paul-Henri Wicky
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France
| | - Signara Gueye
- grid.411119.d0000 0000 8588 831XAP-HP, Service de Bactériologie, Hôpital Bichat-Claude Bernard, 75018 Paris, France
| | - Laurence Armand-Lefevre
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.411119.d0000 0000 8588 831XAP-HP, Service de Bactériologie, Hôpital Bichat-Claude Bernard, 75018 Paris, France
| | - Mehdi Marzouk
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France
| | - Romain Sonneville
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Lila Bouadma
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Marie Petitjean
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Fariza Lamara
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Etienne de Montmollin
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Jean-Francois Timsit
- grid.411119.d0000 0000 8588 831XAP-HP, Bichat Hospital, Medical and Infectious Diseases ICU (MI2), 75018 Paris, France ,grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.508487.60000 0004 7885 7602OUTCOME REA Research Network, IAME, INSERM, Université de Paris, 75018 Paris, France
| | - Etienne Ruppé
- grid.508487.60000 0004 7885 7602IAME, INSERM, Université de Paris, 75018 Paris, France ,grid.411119.d0000 0000 8588 831XAP-HP, Service de Bactériologie, Hôpital Bichat-Claude Bernard, 75018 Paris, France
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Dono A, Esquenazi Y, Choi HA. Gut microbiome and neurocritically ill patients. JOURNAL OF NEUROCRITICAL CARE 2022. [DOI: 10.18700/jnc.220058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Since the times of Rokitansky and Cushing, we have been fascinated by the connections between the gut and the brain. Recent advances in next-generation sequencing techniques have shown that this relationship is even more complex and integral to our sense of self than previously imagined. As these techniques refine our understanding of the abundance and diversity of the gut bacterial microbiome, the relationship between the gut and the brain has been redefined. Now, this is understood as a complex symbiotic network with bidirectional communication, the gut-brain axis. The implication of this communication involves an intense focus of research on a variety of chronic psychiatric, neurological, neurodegenerative, and neuro-oncological diseases. Recently, the gut-brain axis has been studied in neurologically ill patients requiring intensive care. Preliminary studies have shown that acute brain injury changes the bacterial phenotype from one that is symbiotic with the host human to one that is pathologic, termed the “pathobiome.” This can contribute to nosocomial pneumonia and sepsis. The first studies in neurologically ill patients in the neurointensive care unit (NeuroICU) demonstrated changes in the gut microbiome between neuroICU patients and healthy matched subjects. Specifically, a decrease in short-chain fatty acid-producing bacteria and increase in harmful gut microbes have been associated with mortality and decreased function at discharge. Although these preliminary findings are exciting and have opened a new field of research in the complex NeuroICU population, there are several limitations and challenges. Further investigation is needed to confirm these correlations and understand their implications on patients in a complex intensive care environment.
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Garnacho-Montero J, Amaya-Villar R. The problem of multi-resistance in gram-negative bacilli in intensive care units: Treatment and prevention strategies. Med Intensiva 2022; 46:326-335. [PMID: 35545496 DOI: 10.1016/j.medine.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 06/15/2023]
Abstract
The rise of infections caused by multi-resistant gram-negative bacilli (MR-GNB), which includes carbapenems, represents one of the major current challenges worldwide. These MR-GNB include extended spectrum β-lactamase-producing Enterobacterales, derepressed AmpC-producing or carbapenemase-producing Enterobacterales as well as non-fermenting Gram-negative bacilli such as Pseudomonas aeruginosa or Acinetobacter baumannii. P. aeruginosa predominantly exhibits other resistance mechanisms different to β-lactamases such as expulsion pumps or loss of porins. A. baumannii frequently presents several of these resistance mechanisms. Mortality is high especially if empirical treatment is inadequate. In this review, treatment strategies are revised, describing the tools available to identify patients in whom empirical antibiotic treatment would be justified to cover MR-GNB, the importance of optimizing the administration of these antibiotics, as well as prevention strategies to avoid its spread from patients colonized or infected by a MR-GNB.
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Affiliation(s)
- J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain.
| | - R Amaya-Villar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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11
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Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”. Antibiotics (Basel) 2022; 11:antibiotics11030359. [PMID: 35326822 PMCID: PMC8944836 DOI: 10.3390/antibiotics11030359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/26/2022] Open
Abstract
Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.
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Garnacho-Montero J, Amaya-Villar R. El problema de la multi-resistencia en bacilos gram-negativos en las unidades de cuidados intensivos: estrategias de tratamiento y prevención. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Szychowiak P, Villageois-Tran K, Patrier J, Timsit JF, Ruppé É. The role of the microbiota in the management of intensive care patients. Ann Intensive Care 2022; 12:3. [PMID: 34985651 PMCID: PMC8728486 DOI: 10.1186/s13613-021-00976-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.
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Affiliation(s)
- Piotr Szychowiak
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, 37000, Tours, France
| | - Khanh Villageois-Tran
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Laboratoire de Bactériologie, AP-HP, Hôpital Beaujon, 92110, Paris, France
| | - Juliette Patrier
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Jean-François Timsit
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Étienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.
- Laboratoire de Bactériologie, AP-HP, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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14
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Kollef MH, Shorr AF, Bassetti M, Timsit JF, Micek ST, Michelson AP, Garnacho-Montero J. Timing of antibiotic therapy in the ICU. Crit Care 2021; 25:360. [PMID: 34654462 PMCID: PMC8518273 DOI: 10.1186/s13054-021-03787-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Severe or life threatening infections are common among patients in the intensive care unit (ICU). Most infections in the ICU are bacterial or fungal in origin and require antimicrobial therapy for clinical resolution. Antibiotics are the cornerstone of therapy for infected critically ill patients. However, antibiotics are often not optimally administered resulting in less favorable patient outcomes including greater mortality. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is now recognized as one of the most important determinants of survival for this population. Individuals who have a delay in the administration of antibiotic therapy for serious infections can have a doubling or more in their mortality. Additionally, the timing of an appropriate antibiotic regimen, one that is active against the offending pathogens based on in vitro susceptibility, also influences survival. Thus not only is early empiric antibiotic administration important but the selection of those agents is crucial as well. The duration of antibiotic infusions, especially for β-lactams, can also influence antibiotic efficacy by increasing antimicrobial drug exposure for the offending pathogen. However, due to mounting antibiotic resistance, aggressive antimicrobial de-escalation based on microbiology results is necessary to counterbalance the pressures of early broad-spectrum antibiotic therapy. In this review, we examine time related variables impacting antibiotic optimization as it relates to the treatment of life threatening infections in the ICU. In addition to highlighting the importance of antibiotic timing in the ICU we hope to provide an approach to antimicrobials that also minimizes the unnecessary use of these agents. Such approaches will increasingly be linked to advances in molecular microbiology testing and artificial intelligence/machine learning. Such advances should help identify patients needing empiric antibiotic therapy at an earlier time point as well as the specific antibiotics required in order to avoid unnecessary administration of broad-spectrum antibiotics.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA.
| | - Andrew F Shorr
- Pulmonary and Critical Care Medicine, Medstar Washington Hospital, Washington, DC, USA
| | - Matteo Bassetti
- Infectious Diseases Unit, Department of Health Sciences, San Martino Policlinico Hospital - IRCCS, University of Genoa, Genoa, Italy
| | - Jean-Francois Timsit
- AP-HP, Bichat Claude Bernard Hospital, Medical and Infectious Diseases ICU (MI2), IAME, INSERM, Université de Paris, Paris, France
| | - Scott T Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA
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Martin-Loeches I, Metersky M, Kalil A, Pezzani MD, Torres A. Strategies for implementation of a multidisciplinary approach to the treatment of nosocomial infections in critically ill patients. Expert Rev Anti Infect Ther 2020; 19:759-767. [PMID: 33249874 DOI: 10.1080/14787210.2021.1857730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Intensive Care Units (ICU) are among the hospital wards exhibiting the highest prevalence of antimicrobial resistance (AMR), and resulting impact on patient outcomes. Antimicrobial resistance surveillance and antimicrobial stewardship (AMS) programs play a pivotal role in promoting interventions tailored to optimize infection diagnosis and treatment in the final attempt to limit unnecessary antimicrobial use and development of resistance. AREAS COVERED A narrative review of the literature was carried out to summarize the available evidence and develop a set of actions that should be considered for integration into the ICU stewardship framework. Four questions were addressed: how AMR surveillance can inform antibiotic policy in ICU; whether pharmacokinetic and pharmacodynamic (PK/PD) principles and the use of procalcitonin should be incorporated as a standard practice in ICU AMS programs to optimize antibiotic treatment and to drive antibiotic discontinuation; which criteria should drive treatment duration of ICU-associated infections. EXPERT OPINION In this review we aim to highlight that the ICU must be considered in its own right. Each ICU has its own characteristics depending on the country, on the local antibiotic resistance profile, on the patients feature and the severity of infection.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad De Barcelona, CIBERES, Barcelona, Spain
| | - Mark Metersky
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Andre Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Maria Diletta Pezzani
- Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona Italy
| | - Antoni Torres
- Hospital Clinic, IDIBAPS, Universidad De Barcelona, CIBERES, Barcelona, Spain
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Semiquantitative Kulturen von ESBL-Enterobacterales können VAP-Risiko vorhersagen. Anasthesiol Intensivmed Notfallmed Schmerzther 2020. [DOI: 10.1055/a-1258-1734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Relationship between the composition of the intestinal microbiota and the tracheal and intestinal colonization by opportunistic pathogens in intensive care patients. PLoS One 2020; 15:e0237260. [PMID: 32857755 PMCID: PMC7454957 DOI: 10.1371/journal.pone.0237260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/22/2020] [Indexed: 12/05/2022] Open
Abstract
Objective Infections caused by multidrug-resistant Gram-negative bacilli (MDR-GNB) are a major issue in intensive care. The intestinal and oropharyngeal microbiota being the reservoir of MDR-GNB. Our main objective was to assess the link between the composition of the intestinal microbiota and the tracheal and intestinal colonization by MDR-GNB, and also by Enterococcus spp. and yeasts. Methods We performed a 2-month prospective, monocentric cohort study in the medical intensive care unit of our hospital. Patients ventilated >3 days and spontaneously passing feces were included. A fecal sample and an endotracheal aspiration (EA) were collected twice a week. MDR-GNB but also Enterococcus faecium and yeasts (as potential dysbiosis surrogate markers) were detected by culture methods. The composition of the intestinal microbiota was assessed by 16S profiling. Results We collected 62 couples of feces and EA from 31 patients, including 18 feces and 9 EA positive for MDR-GNB. Forty-eight fecal samples were considered for 16S profiling. We did not observe a link between the diversity and the richness of the intestinal microbiota and the MDR-GNB intestinal relative abundance (RA). Conversely, we observed a negative link between the intestinal diversity and richness and the RA of Enterococcus spp. (p<0.001). Conclusion The fecal MDR-GNB RA was not associated to the diversity nor the richness of the intestinal microbiota, but that of Enterococcus spp. was.
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