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Lin TL, Chang PH, Liu YW, Lai WH, Chen YJ, Chen IL, Li WF, Wang CC, Lee IK. Gram-negative bacterial infections in surgical intensive care unit patients following abdominal surgery: high mortality associated with Stenotrophomonas maltophilia infection. Antimicrob Resist Infect Control 2024; 13:65. [PMID: 38886759 PMCID: PMC11184765 DOI: 10.1186/s13756-024-01411-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/12/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Stenotrophomonas maltophilia, a multidrug-resistant gram-negative bacteria (GNB), is an emerging nosocomial pathogen. This study assessed the clinical outcomes of GNB infections in surgical intensive care unit (SICU) patients post-abdominal surgery, focusing on the differences between S. maltophilia and other GNBs, including Pseudomonas aeruginosa. METHODS A retrospective study was conducted on SICU patients at Kaohsiung Chang Gung Memorial Hospital from 2010 to 2020, who developed GNB infections following abdominal surgery. RESULTS Of 442 patients, 237 had S. maltophilia and 205 had non-S. maltophilia GNB infections (including 81 with P. aeruginosa). The overall mortality rate was 44.5%, and S. maltophilia infection emerged as a significant contributor to the mortality rate in patients with GNB infections. S. maltophilia patients had longer mechanical ventilation and SICU stays, with a 30-day mortality rate of 35.4%, higher than the non-S. maltophilia GNB (22.9%) and P. aeruginosa (21%) groups. In-hospital mortality was also higher in the S. maltophilia group (53.2%) compared to the non-S. maltophilia GNB (34.6%) and P. aeruginosa groups (29.6%). Risk factors for acquiring S. maltophilia included a higher Sequential Organ Failure Assessment score and prior broad-spectrum antibiotics use. Older age, polymicrobial infections, and elevated bilirubin were associated with increased 30-day mortality in S. maltophilia patients. CONCLUSION S. maltophilia infections in post-abdominal surgery patients are linked to higher mortality than non-S. maltophilia GNB and P. aeruginosa infections, emphasizing the need for early diagnosis and treatment to improve outcomes.
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Affiliation(s)
- Ting-Lung Lin
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Hsun Chang
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yueh-Wei Liu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Hung Lai
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ying-Ju Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Ling Chen
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ing-Kit Lee
- Chang Gung University College of Medicine, Taoyuan, Taiwan.
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Yuan F, Li M, Wang X, Fu Y. Risk factors and mortality of carbapenem-resistant Pseudomonas aeruginosa bloodstream infection in haematology department: A 10-year retrospective study. J Glob Antimicrob Resist 2024; 37:150-156. [PMID: 38615882 DOI: 10.1016/j.jgar.2024.03.018] [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: 12/31/2023] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVES This study aims to investigate the risk factors for carbapenem-resistant Pseudomonas aeruginosa bloodstream infection (CRPA-BSI) and identify predictors of outcomes among patients with P. aeruginosa bloodstream infection (PA-BSI). METHODS A retrospective cohort study was conducted on patients with PA-BSI at Henan Cancer Hospital from 2013 to 2022. RESULTS Among the 503 incidences analysed, 15.1% of them were CRPA strains. Age, ANC < 100/mmc, receiving antifungal prophylaxis, exposure to carbapenems within the previous 90 days to onset of BSI, and allogeneic HSCT (allo-HSCT) were associated with the development of CRPA-BSI. CRPA-BSI patients experienced significantly higher 28-day mortality rates compared to those with carbapenem-susceptible P. aeruginosa bloodstream infection. Multivariate logistic regression analysis identified age at BSI, active stage of haematological disease, procalcitonin levels, prior corticosteroid treatment, isolation of CRPA, and septic shock as independent predictors of 28-day mortality. CONCLUSIONS Risk factors for CRPA-BSI include age, ANC < 100/mmc, antifungal prophylaxis, exposure to carbapenems, and allo-HSCT. Additionally, age at BSI, active haematological disease, procalcitonin levels, prior corticosteroid treatment, CRPA isolation, and septic shock contribute to increased mortality rates among patients with PA-BSI.
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Affiliation(s)
- Fangfang Yuan
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University& Henan Cancer Hospital, Zhengzhou, PR China
| | - Minghui Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University& Henan Cancer Hospital, Zhengzhou, PR China
| | - Xiaokun Wang
- Department of Laboratory Science, The Affiliated Cancer Hospital of Zhengzhou University& Henan Cancer Hospital, Zhengzhou, PR China
| | - Yuewen Fu
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University& Henan Cancer Hospital, Zhengzhou, PR China.
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Royo-Cebrecos C, Laporte-Amargós J, Peña M, Ruiz-Camps I, Garcia-Vidal C, Abdala E, Oltolini C, Akova M, Montejo M, Mikulska M, Martín-Dávila P, Herrera F, Gasch O, Drgona L, Morales HMP, Brunel AS, García E, Isler B, Kern WV, Palacios-Baena ZR, de la Calle GM, Montero MM, Kanj SS, Sipahi OR, Calik S, Márquez-Gómez I, Marin JI, Gomes MZR, Hemmatii P, Araos R, Peghin M, Del Pozo JL, Yáñez L, Tilley R, Manzur A, Novo A, Carratalà J, Gudiol C. Pseudomonas aeruginosa Bloodstream Infections Presenting with Septic Shock in Neutropenic Cancer Patients: Impact of Empirical Antibiotic Therapy. Microorganisms 2024; 12:705. [PMID: 38674650 PMCID: PMC11051800 DOI: 10.3390/microorganisms12040705] [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: 01/15/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
This large, multicenter, retrospective cohort study including onco-hematological neutropenic patients with Pseudomonas aeruginosa bloodstream infection (PABSI) found that among 1213 episodes, 411 (33%) presented with septic shock. The presence of solid tumors (33.3% vs. 20.2%, p < 0.001), a high-risk Multinational Association for Supportive Care in Cancer (MASCC) index score (92.6% vs. 57.4%; p < 0.001), pneumonia (38% vs. 19.2% p < 0.001), and infection due to multidrug-resistant P. aeruginosa (MDRPA) (33.8% vs. 21.1%, p < 0.001) were statistically significantly higher in patients with septic shock compared to those without. Patients with septic shock were more likely to receive inadequate empirical antibiotic therapy (IEAT) (21.7% vs. 16.2%, p = 0.020) and to present poorer outcomes, including a need for ICU admission (74% vs. 10.5%; p < 0.001), mechanical ventilation (49.1% vs. 5.6%; p < 0.001), and higher 7-day and 30-day case fatality rates (58.2% vs. 12%, p < 0.001, and 74% vs. 23.1%, p < 0.001, respectively). Risk factors for 30-day case fatality rate in patients with septic shock were orotracheal intubation, IEAT, infection due to MDRPA, and persistent PABSI. Therapy with granulocyte colony-stimulating factor and BSI from the urinary tract were associated with improved survival. Carbapenems were the most frequent IEAT in patients with septic shock, and the use of empirical combination therapy showed a tendency towards improved survival. Our findings emphasize the need for tailored management strategies in this high-risk population.
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Affiliation(s)
- Cristina Royo-Cebrecos
- Internal Medicine Department, Hospital Nostra Senyora de Meritxell, SAAS, AD700 Escaldes-Engordany, Andorra;
| | - Júlia Laporte-Amargós
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, 08907 Barcelona, Spain;
| | - Marta Peña
- Haematology Department, Institute Català d’Oncologia (ICO)–Hospital Duran i Reynals, IDIBELL, 08908 Barcelona, Spain;
| | - Isabel Ruiz-Camps
- Infectious Diseases Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic i Provincial, 08036 Barcelona, Spain;
| | - Edson Abdala
- Instituto do Cancer do Estado de São Paulo, Faculty of Medicine, Univesity of São Paulo, Sao Paulo 01246, Brazil;
| | - Chiara Oltolini
- Unit of Infectious and Tropical Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy;
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, 06100 Ankara, Turkey;
| | - Miguel Montejo
- Infectious Diseases Unit, Cruces University Hospital, 48903 Bilbao, Spain;
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Ospedale Policlinico San Martino, University of Genoa (DISSAL), 16132 Genoa, Italy;
| | - Pilar Martín-Dávila
- Infectious Diseases Department, Ramon y Cajal Hospital, 28034 Madrid, Spain;
| | - Fabián Herrera
- Infectious Diseases Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1430EFA, Argentina;
| | - Oriol Gasch
- Infectious Diseases Department, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208 Sabadell, Spain;
| | - Lubos Drgona
- Oncohematology Department, National Cancer Institute, Comenius University, 81499 Bratislava, Slovakia;
| | | | - Anne-Sophie Brunel
- Infectious Diseases and Medicine Department, Lausanne University Hospital, CHUV, 1011 Lausanne, Switzerland;
| | - Estefanía García
- Haematology Department, Reina Sofía University Hospital-IMIBIC-UCO, 14004 Córdoba, Spain;
| | - Burcu Isler
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Education and Research Hospital, 34668 Istanbul, Turkey;
| | - Winfried V. Kern
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University of Freiburg Medical Center, 79110 Freiburg, Germany;
| | - Zaira R. Palacios-Baena
- Unit of Infectious Diseases and Clinical Microbiology, Institute of Biomedicine of Seville (IBIS), Virgen Macarena University Hospital, 41013 Seville, Spain;
| | - Guillermo Maestr de la Calle
- Infectious Diseases Unit, Instituto de Investigación Hospital “12 de Octubre” (i + 12), School of Medicine, “12 de Octubre” University Hospital, Universidad Complutense, 28041 Madrid, Spain;
| | - Maria Milagro Montero
- Infectious Pathology and Antimicrobials Research Group (IPAR), Infectious Diseases Service, Hospital del Mar, Institut Hospital del Mar d’Investigations Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, 08003 Barcelona, Spain;
| | - Souha S. Kanj
- Infectious Diseases Division, American University of Beirut Medical Center, Beirut 110236, Lebanon;
| | - Oguz R. Sipahi
- Faculty of Medicine, Ege University, 35040 Izmir, Turkey;
| | - Sebnem Calik
- Department of Infectious Diseases and Clinical Microbiology, University of Health Science Izmir Bozyaka Training and Research Hospital, 35170 Izmir, Turkey;
| | | | - Jorge I. Marin
- Infectious Diseases and Clinical Microbiology Department, Clínica Maraya, Manizales 170001-17, Colombia;
| | - Marisa Z. R. Gomes
- Hospital Federal dos Servidores do Estado, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Ministério da Saúde, Rio de Janeiro 20221-161, Brazil;
| | - Philipp Hemmatii
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Academic Teaching Hospital of Charité University Medical School, 10117 Berlin, Germany;
| | - Rafael Araos
- Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago de Chile 12461, Chile;
| | - Maddalena Peghin
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, 21100 Varese, Italy;
| | - Jose L. Del Pozo
- Infectious Diseases and Microbiology Unit, Navarra University Clinic, 31008 Pamplona, Spain;
| | - Lucrecia Yáñez
- Haematology Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain;
| | - Robert Tilley
- Microbiology Department, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, UK;
| | - Adriana Manzur
- Infectious Diseases, Hospital Rawson, San Juan J5400, Argentina;
| | - Andrés Novo
- Haematology Department, Son Espases University Hospital, 07120 Palma de Mallorca, Spain;
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, 08907 Barcelona, Spain;
- Faculty of Medicine, Bellvitge Campus, University of Barcelona, carrer de la Feixa Llarga, s/n, 08907 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, 08907 Barcelona, Spain;
- Faculty of Medicine, Bellvitge Campus, University of Barcelona, carrer de la Feixa Llarga, s/n, 08907 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Unit, Catalan Institute of Oncology (ICO), Duran i Reynals Hospital, IDIBELL, 08908 Barcelona, Spain
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Ranganath N, Yetmar ZA, Saleh OA, Tande AJ, Shah AS. Risk factors for positive follow-up blood cultures in Gram-negative bacteremia among immunocompromised patients with neutropenia. Transpl Infect Dis 2024; 26:e14203. [PMID: 38010744 PMCID: PMC10922757 DOI: 10.1111/tid.14203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Gram-negative bacillary bloodstream infection (GN-BSI) is a frequent clinical challenge among immunocompromised hosts and is associated with a high mortality. The utility of follow-up blood cultures (FUBCs) for GN-BSI in this population, particularly in the setting of neutropenia, is poorly defined. METHODS We conducted a single-center, retrospective cohort study between the period of July 2018 and April 2022 to investigate the utility of FUBCs and delineate risk factors for positive cultures among neutropenic patients with monomicrobial GN-BSI. Univariate logistic regression was performed to assess risk factors associated with positive FUBCs. RESULTS Of 206 patients, 98% had FUBCs performed, and 9% were positive. Risk factors for positive FUBCs included multidrug-resistant GN infection (OR 3.26; 95% confidence interval [CI] 1.22-8.72) and vascular catheter source (OR 4.82; CI 1.76-13.17). Among patients lacking these risk factors, the prevalence of positive FUBCs was low (2.8%) and the negative predictive value was 92%. Those with positive and negative FUBCs had similar rates of all-cause mortality (16.7% vs. 16.6%; p = .942) and microbiologic relapse (11.1% vs. 6.0%; p = .401) within 90-days of treatment completion. However, positive FUBCs were associated with prolonged hospitalization and longer duration of antimicrobial therapy. CONCLUSION Positive FUBCs were infrequent in neutropenic patients with GN-BSI, and their occurrence did not significantly impact mortality or microbiologic relapse. Risk factors for positive FUBCs included multidrug resistant Gram-negative infection and vascular catheter source. Prospective studies will be necessary to elucidate the benefits and risks of FUBCs when managing GN-BSI in patients with underlying immune compromise.
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Affiliation(s)
- Nischal Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN USA
| | - Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN USA
| | - Omar Abu Saleh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN USA
| | - Aaron J. Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN USA
| | - Aditya S. Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN USA
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Chen J, Huang H, Liu C, Fu YQ. Risk factors for mortality in pseudomonas aeruginosa bacteremia in children. Pediatr Neonatol 2024; 65:31-37. [PMID: 37517970 DOI: 10.1016/j.pedneo.2023.03.012] [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: 10/08/2022] [Revised: 02/04/2023] [Accepted: 03/02/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND The incidence of Pseudomonas aeruginosa (P. aeruginosa) bacteremia in children ranks third to fourth among gram-negative bacilli bacteremia, which is one of the main conditional pathogens in hospitals. This study aimed to identify the clinical characteristics and risk factors of 60-day in-hospital mortality in children with P. aeruginosa bacteremia. METHODS This retrospective study was conducted in a tertiary pediatric hospital between January 2015 and December 2021 including children with P. aeruginosa bacteremia. Kaplan-Meier survival analysis was used to investigate the time-to-event outcomes. Logistic regression was used to explore the independent risk factors for 60-day mortality. RESULTS Overall, 75 patients with P. aeruginosa bacteremia episodes were identified. Immunosuppression (52%) was the most common underlying condition, followed by neutropenia (50.7%) and hematological malignancies (48%). Among 75 patients with P. aeruginosa bacteremia, 25 (33.3%) had septic shock, 30 (40%) had respiratory failure, and 20 (26.7%) had liver function impairment. The 60-day in-hospital mortality was 17.3%. In multivariate analysis, independent risk factors for 60-day mortality were respiratory failure [odds ratio (OR) 39.329; 95% CI:3.212-481.48, P = 0.004) and liver function impairment (OR 17.925; 95% CI:2.909-139.178, P = 0.002). CONCLUSION Respiratory failure and liver function impairment seem to be related to poor prognosis in children with P. aeruginosa bacteremia.
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Affiliation(s)
- Jian Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Haixin Huang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Yue-Qiang Fu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China.
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Chumbita M, Puerta-Alcalde P, Yáñez L, Angeles Cuesta M, Chinea A, Español-Morales I, Fernandez-Abellán P, Gudiol C, González-Sierra P, Rojas R, Sánchez-Pina JM, Vadillo IS, Sánchez M, Varela R, Vázquez L, Guerreiro M, Monzo P, Lopera C, Aiello TF, Peyrony O, Soriano A, Garcia-Vidal C. High Rate of Inappropriate Antibiotics in Patients with Hematologic Malignancies and Pseudomonas aeruginosa Bacteremia following International Guideline Recommendations. Microbiol Spectr 2023; 11:e0067423. [PMID: 37367629 PMCID: PMC10434044 DOI: 10.1128/spectrum.00674-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Optimal coverage of Pseudomonas aeruginosa is challenging in febrile neutropenic patients due to a progressive increase in antibiotic resistance worldwide. We aimed to detail current rates of resistance to antibiotics recommended by international guidelines for P. aeruginosa isolated from bloodstream infections (BSI) in patients with hematologic malignancies. Secondarily, we aimed to describe how many patients received inappropriate empirical antibiotic treatment (IEAT) and its impact on mortality. We conducted a retrospective, multicenter cohort study of the last 20 BSI episodes caused by P. aeruginosa in patients with hematologic malignancies from across 14 university hospitals in Spain. Of the 280 patients with hematologic malignancies and BSI caused by P. aeruginosa, 101 (36%) had strains resistant to at least one of the β-lactam antibiotics recommended in international guidelines, namely, cefepime, piperacillin-tazobactam, and meropenem. Additionally, 21.1% and 11.4% of the strains met criteria for MDR and XDR P. aeruginosa, respectively. Even if international guidelines were followed in most cases, 47 (16.8%) patients received IEAT and 66 (23.6%) received inappropriate β-lactam empirical antibiotic treatment. Thirty-day mortality was 27.1%. In the multivariate analysis, pulmonary source (OR 2.22, 95% CI 1.14 to 4.34) and IEAT (OR 2.67, 95% CI 1.37 to 5.23) were factors independently associated with increased mortality. We concluded that P. aeruginosa-causing BSI in patients with hematologic malignancies is commonly resistant to antibiotics recommended in international guidelines, which is associated with frequent IEAT and higher mortality. New therapeutic strategies are needed. IMPORTANCE Bloodstream infection (BSI) caused by P. aeruginosa is related with an elevated morbidity and mortality in neutropenic patients. For this reason, optimal antipseudomonal coverage has been the basis of all historical recommendations in the empirical treatment of febrile neutropenia. However, in recent years the emergence of multiple types of antibiotic resistances has posed a challenge in treating infections caused by this microorganism. In our study we postulated that P. aeruginosa-causing BSI in patients with hematologic malignancies is commonly resistant to antibiotics recommended in international guidelines. This observation is associated with frequent IEAT and increased mortality. Consequently, there is a need for a new therapeutic strategy.
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Affiliation(s)
- Mariana Chumbita
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lucrecia Yáñez
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | | | | | - Carlota Gudiol
- Hospital Universitario de Bellvitge, Institut Català d'Oncologia, IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Rafael Rojas
- Hospital Universitario Reina Sofia, Córdoba, Spain
| | | | | | | | | | - Lourdes Vázquez
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Patricia Monzo
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Carlos Lopera
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | | | - Oliver Peyrony
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alex Soriano
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Barcelona, Spain
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Fontana L, Strasfeld L, Hakki M. Pseudomonas aeruginosa ExoU-associated virulence in HCT recipients and patients with hematologic malignancies. Blood Adv 2023; 7:4035-4038. [PMID: 37216281 PMCID: PMC10410125 DOI: 10.1182/bloodadvances.2023009806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 04/01/2023] [Indexed: 05/24/2023] Open
Affiliation(s)
- Lauren Fontana
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Lynne Strasfeld
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR
| | - Morgan Hakki
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR
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8
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Yuan Q, Guo L, Li B, Zhang S, Feng H, Zhang Y, Yu M, Hu H, Chen H, Yang Q, Qu T. Risk factors and outcomes of inpatients with carbapenem-resistant Pseudomonas aeruginosa bloodstream infections in China: a 9-year trend and multicenter cohort study. Front Microbiol 2023; 14:1137811. [PMID: 37260693 PMCID: PMC10227572 DOI: 10.3389/fmicb.2023.1137811] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023] Open
Abstract
Objective Bacteremia caused by carbapenem-resistant Pseudomonas aeruginosa (CRPA) has high mortality, threatening the healthcare quality worldwide. Analysis is required to update the epidemiological data of CRPA bloodstream infections (BSI) and evaluate the prevalent strains in China. Moreover, it is necessary to clarify the risk factors associated with the development and mortality of CRPA bacteremia. Methods This is a 9-year multicenter retrospective study, enrolling 137 patients with CRPA BSI and 137 carbapenem-susceptible P. aeruginosa (CSPA) BSI during January 2012 and December 2020. Antimicrobials susceptibility between the two groups were compared. Risk factors of CRPA BSI were identified by binary logistic regression for development and cox regression for mortality. The Kaplan-Meier method was used to compare time to mortality. CRPA and difficult-to-treat resistant P. aeruginosa (DTRPA) detection rate was analyzed year-by-year in ZYH. Results A total of 7,384 P. aeruginosa clinical samples were cultured in ZYH during 9 years, and notable increase of CRPA and DTRPA detection rate in P. aeruginosa BSI was identified (from 17 to 60%; from 2.1 to 25%). Multivariate analysis revealed that prior ICU hospitalization, immunosuppressive therapy and exposure to carbapenems were independent risk factors for development of CRPA BSI. The 30-day crude mortality of 137 CRPA BSI was 39%. A total of 46 DTRPA were identified, and the 30-day mortality for patients infected by DTRPA was 50%. The 30-day crude mortality of CRPA BSI was independently associated with multiple organ failure and higher Pitt bacteremia score, whereas receipt appropriate therapy improved prognosis. Conclusion A significant increase in the detection rate of CRPA and DTRPA in P. aeruginosa BSI was identified. Strict policies for carbapenems usage, cautious decisions regarding the usage of immunosuppressive agent and standard care for patients with prior ICU hospitalization are necessary for CRPA BSI management.
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Affiliation(s)
- Qing Yuan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Lei Guo
- Department of Infection Control, Wenzhou Medical University of the Second Affiliated Hospital, Wenzhou, Zhejiang, China
| | - Bin Li
- Department of Infectious Diseases, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Sheng Zhang
- Infection Control Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiting Feng
- Infection Control Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yan Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Meihong Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Hangbin Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Hongchao Chen
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qing Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tingting Qu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, Zhejiang, China
- Infection Control Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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9
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Cruz-Vargas SA, García-Muñoz L, Cuervo-Maldonado SI, Álvarez-Moreno CA, Saavedra-Trujillo CH, Álvarez-Rodríguez JC, Arango-Gutiérrez A, Gómez-Rincón JC, García-Guzman K, Leal AL, Garzón-Herazo J, Martínez-Vernaza S, Guevara FO, Jiménez-Cetina LP, Mora LM, Saavedra SY, Cortés JA. Molecular and Clinical Data of Antimicrobial Resistance in Microorganisms Producing Bacteremia in a Multicentric Cohort of Patients with Cancer in a Latin American Country. Microorganisms 2023; 11:microorganisms11020359. [PMID: 36838324 PMCID: PMC9960769 DOI: 10.3390/microorganisms11020359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
Patients with cancer have a higher risk of severe bacterial infections. This study aims to determine the frequency, susceptibility profiles, and resistance genes of bacterial species involved in bacteremia, as well as risk factors associated with mortality in cancer patients in Colombia. In this prospective multicenter cohort study of adult patients with cancer and bacteremia, susceptibility testing was performed and selected resistance genes were identified. A multivariate regression analysis was carried out for the identification of risk factors for mortality. In 195 patients, 206 microorganisms were isolated. Gram-negative bacteria were more frequently found, in 142 cases (68.9%): 67 Escherichia coli (32.5%), 36 Klebsiella pneumoniae (17.4%), and 21 Pseudomonas aeruginosa (10.1%), and 18 other Gram-negative isolates (8.7%). Staphylococcus aureus represented 12.4% (n = 25). Among the isolates, resistance to at least one antibiotic was identified in 63% of them. Genes coding for extended-spectrum beta-lactamases and carbapenemases, blaCTX-M and blaKPC, respectively, were commonly found. Mortality rate was 25.6% and it was lower in those with adequate empirical antibiotic treatment (22.0% vs. 45.2%, OR: 0.26, 95% CI: 0.1-0.63, in the multivariate model). In Colombia, in patients with cancer and bacteremia, bacteria have a high resistance profile to beta-lactams, with a high incidence of extended-spectrum beta-lactamases and carbapenemases. Adequate empirical treatment diminishes mortality, and empirical selection of treatment in this environment of high resistance is of key importance.
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Affiliation(s)
- Sergio Andrés Cruz-Vargas
- Department of Internal Medicine, Universidad Nacional de Colombia, Sede Bogotá, Bogotá 111321, Colombia
| | - Laura García-Muñoz
- Department of Internal Medicine, Universidad Nacional de Colombia, Sede Bogotá, Bogotá 111321, Colombia
| | - Sonia Isabel Cuervo-Maldonado
- Department of Internal Medicine, Universidad Nacional de Colombia, Sede Bogotá, Bogotá 111321, Colombia
- Infectious Diseases Group, Instituto Nacional de Cancerología-ESE, Bogotá 111511, Colombia
- Research Group in Cancer Infectious Diseases and Hematological Alterations (GREICAH), Bogotá 111321, Colombia
| | - Carlos Arturo Álvarez-Moreno
- Department of Internal Medicine, Universidad Nacional de Colombia, Sede Bogotá, Bogotá 111321, Colombia
- Clínica Universitaria Colombia, Bogota 111321, Colombia
| | | | - José Camilo Álvarez-Rodríguez
- Infectious Diseases Group, Instituto Nacional de Cancerología-ESE, Bogotá 111511, Colombia
- Research Group in Cancer Infectious Diseases and Hematological Alterations (GREICAH), Bogotá 111321, Colombia
- Hospital Universitario Clínica San Rafael, Bogotá 110111, Colombia
| | | | | | | | - Aura Lucía Leal
- Department of Microbiology, Universidad Nacional de Colombia, Bogotá 111321, Colombia
| | - Javier Garzón-Herazo
- Infectious Diseases Unit, Hospital Universitario San Ignacio, Bogotá 110231, Colombia
| | - Samuel Martínez-Vernaza
- Infectious Diseases Unit, Hospital Universitario San Ignacio, Bogotá 110231, Colombia
- Research Group in Infectious Diseases, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | | | | | - Liliana Marcela Mora
- Microbiology Laboratory, Instituto Nacional de Cancerología-ESE, Bogotá 111511, Colombia
| | | | - Jorge Alberto Cortés
- Department of Internal Medicine, Universidad Nacional de Colombia, Sede Bogotá, Bogotá 111321, Colombia
- Diseases Unit, Hospital Universitario Nacional, Bogotá 111321, Colombia
- Correspondence:
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10
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Antimicrobial Treatment of Pseudomonas aeruginosa Severe Sepsis. Antibiotics (Basel) 2022; 11:antibiotics11101432. [PMID: 36290092 PMCID: PMC9598900 DOI: 10.3390/antibiotics11101432] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Pseudomonas aeruginosa is a pathogen often encountered in a healthcare setting. It has consistently ranked among the most frequent pathogens seen in nosocomial infections, particularly bloodstream and respiratory tract infections. Aside from having intrinsic resistance to many antibiotics, it rapidly acquires resistance to novel agents. Given the high mortality of pseudomonal infections generally, and pseudomonal sepsis particularly, and with the rise of resistant strains, treatment can be very challenging for the clinician. In this paper, we will review the latest evidence for the optimal treatment of P. aeruginosa sepsis caused by susceptible as well as multidrug-resistant strains including the difficult to treat pathogens. We will also discuss the mode of drug infusion, indications for combination therapy, along with the proper dosing and duration of treatment for various conditions with a brief discussion of the use of non-antimicrobial agents.
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11
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Royo-Cebrecos C, Laporte-Amargós J, Peña M, Ruiz-Camps I, Puerta-Alcalde P, Abdala E, Oltolini C, Akova M, Montejo M, Mikulska M, Martín-Dávila P, Herrera F, Gasch O, Drgona L, Morales HMP, Brunel AS, García E, Isler B, Kern WV, Palacios-Baena ZR, de la Calle GM, Montero MM, Kanj SS, Sipahi OR, Calik S, Márquez-Gómez I, Marin JI, Gomes MZR, Hemmatti P, Araos R, Peghin M, del Pozo JL, Yáñez L, Tilley R, Manzur A, Novo A, Carratalà J, Gudiol C. Pseudomonas aeruginosa Bloodstream Infections in Patients with Cancer: Differences between Patients with Hematological Malignancies and Solid Tumors. Pathogens 2022; 11:pathogens11101132. [PMID: 36297188 PMCID: PMC9610728 DOI: 10.3390/pathogens11101132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: To assess the clinical features and outcomes of Pseudomonas aeruginosa bloodstream infection (PA BSI) in neutropenic patients with hematological malignancies (HM) and with solid tumors (ST), and identify the risk factors for 30-day mortality. Methods: We performed a large multicenter, retrospective cohort study including onco-hematological neutropenic patients with PA BSI conducted across 34 centers in 12 countries (January 2006−May 2018). Episodes occurring in hematologic patients were compared to those developing in patients with ST. Risk factors associated with 30-day mortality were investigated in both groups. Results: Of 1217 episodes of PA BSI, 917 occurred in patients with HM and 300 in patients with ST. Hematological patients had more commonly profound neutropenia (0.1 × 109 cells/mm) (67% vs. 44.6%; p < 0.001), and a high risk Multinational Association for Supportive Care in Cancer (MASCC) index score (32.2% vs. 26.7%; p = 0.05). Catheter-infection (10.7% vs. 4.7%; p = 0.001), mucositis (2.4% vs. 0.7%; p = 0.042), and perianal infection (3.6% vs. 0.3%; p = 0.001) predominated as BSI sources in the hematological patients, whereas pneumonia (22.9% vs. 33.7%; p < 0.001) and other abdominal sites (2.8% vs. 6.3%; p = 0.006) were more common in patients with ST. Hematological patients had more frequent BSI due to multidrug-resistant P. aeruginosa (MDRPA) (23.2% vs. 7.7%; p < 0.001), and were more likely to receive inadequate initial antibiotic therapy (IEAT) (20.1% vs. 12%; p < 0.001). Patients with ST presented more frequently with septic shock (45.8% vs. 30%; p < 0.001), and presented worse outcomes, with increased 7-day (38% vs. 24.2%; p < 0.001) and 30-day (49% vs. 37.3%; p < 0.001) case-fatality rates. Risk factors for 30-day mortality in hematologic patients were high risk MASCC index score, IEAT, pneumonia, infection due to MDRPA, and septic shock. Risk factors for 30-day mortality in patients with ST were high risk MASCC index score, IEAT, persistent BSI, and septic shock. Therapy with granulocyte colony-stimulating factor was associated with survival in both groups. Conclusions: The clinical features and outcomes of PA BSI in neutropenic cancer patients showed some differences depending on the underlying malignancy. Considering these differences and the risk factors for mortality may be useful to optimize their therapeutic management. Among the risk factors associated with overall mortality, IEAT and the administration of granulocyte colony-stimulating factor were the only modifiable variables.
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Affiliation(s)
- Cristina Royo-Cebrecos
- Internal Medicine Department, Hospital Nostra Senyora de Meritxell, Andorra Health Services (SAAS), AD700 Escaldes-Engordany, Andorra
| | - Julia Laporte-Amargós
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, 08907 Barcelona, Spain
- Institut Català d’Oncologia (ICO), Hospital Duran i Reynals, IDIBELL, 08907 Barcelona, Spain
| | - Marta Peña
- Hematology Department, Institut Català d’Oncologia (ICO)–Hospital Duran i Reynals, IDIBELL, 08907 Barcelona, Spain
| | - Isabel Ruiz-Camps
- Infectious Diseases Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Infectious Diseases Department, Hospital Clínic i Provincial, 08035 Barcelona, Spain
| | - Edson Abdala
- Instituto do Câncer do Estado de São Paulo, Faculty of Medicine, Univesity of São Paulo, Sao Paulo 01246, Brazil
| | - Chiara Oltolini
- Unit of Infectious and Tropical Diseases, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, 06230 Ankara, Turkey
| | - Miguel Montejo
- Infectious Diseases Unit, Cruces University Hospital, 48903 Bilbao, Spain
| | - Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | | | - Fabian Herrera
- Infectious Diseases Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1430EFA, Argentina
| | - Oriol Gasch
- Infectious Diseases Department, Parc Taulí University Hospital, 08208 Sabadell, Spain
| | - Lubos Drgona
- Oncohematology Department, Comenius University and National Cancer Institute, 81499 Bratislava, Slovakia
| | | | - Anne-Sophie Brunel
- Infectious Diseases Department, Department of Medicine, Lausanne University Hospital, (CHUV), 1011 Lausanne, Switzerland
| | - Estefanía García
- Hematology Department, Reina Sofía University Hospital-IMIBIC-UCO, Córdoba 14004, Argentina
| | - Burcu Isler
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Education and Research Hospital, 34668 Istanbul, Turkey
| | - Winfried V. Kern
- Division of Infectious Diseases, Department of Medicine II, University of Freiburg Medical Center and Faculty of Medicine, 79106 Freiburg, Germany
| | - Zaira R. Palacios-Baena
- Unit of Infectious Diseases and Clinical Microbiology, Virgen Macarena University Hospital, Institute of Biomedicine of Seville (IBIS), 41013 Seville, Spain
| | - Guillermo Maestro de la Calle
- Infectious Diseases Unit, Instituto de Investigación Hospital “12 de Octubre” (i+12), “12 de Octubre”, University Hospital, School of Medicine, Universidad Complutense, 28041 Madrid, Spain
| | - Maria Milagro Montero
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigations Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, 08003 Barcelona, Spain
| | - Souha S. Kanj
- Infectious Diseases Division, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Oguz R. Sipahi
- Faculty of Medicine, Ege University, 35040 Izmir, Turkey
| | - Sebnem Calik
- University of Health Science Izmir Bozyaka Training and Research Hospital, 35170 Izmir, Turkey
| | | | - Jorge I. Marin
- Infectious Diseases and Clinical Microbiology Department, Clínica Maraya, Pereira, Colombia. Critical Care and Clinical Microbiology Department, Manizales 170001-17, Colombia
| | - Marisa Z. R. Gomes
- Hospital Federal dos Servidores do Estado, and Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Ministério da Saúde, Rio de Janeiro 20221-161, Brazil
| | - Philipp Hemmatti
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Academic Teaching Hospital, Charité University Medical School, 10117 Berlin, Germany
| | - Rafael Araos
- Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago de Chile 12461, Chile, and Millennium Initiative for Collaborative Research on Bacterial Resistance (MICROB-R)
| | - Maddalena Peghin
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata in Udine, and Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, 33100 Udine, Italy
| | - José Luis del Pozo
- Infectious Diseases and Microbiology Unit, Navarra University Clinic, 31008 Pamplona, Spain
| | - Lucrecia Yáñez
- Hematology Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Robert Tilley
- Microbiology Department, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, UK
| | - Adriana Manzur
- Infectious Diseases, Hospital Rawson, San Juan J5400, Argentina
| | - Andrés Novo
- Hematology Department, Son Espases University Hospital, 07120 Palma de Mallorca, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, 08907 Barcelona, Spain
- University of Barcelona, 08007 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, 08907 Barcelona, Spain
- Institut Català d’Oncologia (ICO), Hospital Duran i Reynals, IDIBELL, 08907 Barcelona, Spain
- University of Barcelona, 08007 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-932607625; Fax: +34-932607637
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12
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Dey P, Ray Chaudhuri S. Cancer-Associated Microbiota: From Mechanisms of Disease Causation to Microbiota-Centric Anti-Cancer Approaches. BIOLOGY 2022; 11:757. [PMID: 35625485 PMCID: PMC9138768 DOI: 10.3390/biology11050757] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori infection is the only well-established bacterial cause of cancer. However, due to the integral role of tissue-resident commensals in maintaining tissue-specific immunometabolic homeostasis, accumulated evidence suggests that an imbalance of tissue-resident microbiota that are otherwise considered as commensals, can also promote various types of cancers. Therefore, the present review discusses compelling evidence linking tissue-resident microbiota (especially gut bacteria) with cancer initiation and progression. Experimental evidence supporting the cancer-causing role of gut commensal through the modulation of host-specific processes (e.g., bile acid metabolism, hormonal effects) or by direct DNA damage and toxicity has been discussed. The opportunistic role of commensal through pathoadaptive mutation and overcoming colonization resistance is discussed, and how chronic inflammation triggered by microbiota could be an intermediate in cancer-causing infections has been discussed. Finally, we discuss microbiota-centric strategies, including fecal microbiota transplantation, proven to be beneficial in preventing and treating cancers. Collectively, this review provides a comprehensive understanding of the role of tissue-resident microbiota, their cancer-promoting potentials, and how beneficial bacteria can be used against cancers.
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Affiliation(s)
- Priyankar Dey
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Patiala 147004, India
| | - Saumya Ray Chaudhuri
- Council of Scientific and Industrial Research (CSIR), Institute of Microbial Technology, Chandigarh 160036, India;
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13
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Promising Photocytotoxicity of Water-Soluble Phtalocyanine against Planktonic and Biofilm Pseudomonas aeruginosa Isolates from Lower Respiratory Tract and Chronic Wounds. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12083707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Alternative methods of killing microbes have been extensively researched in connection with the widespread appearance of antibiotic resistance among pathogenic bacteria. In this study, we report on in vitro antimicrobial phototoxicity research of cationic phthalocyanine with 2-(4-N-methylmorpholin-4-ium-4-yl)ethoxy substituents against selected clinical strains of Pseudomonas aeruginosa isolated from the lower respiratory tract and chronic wounds. The microorganisms tested in the research were analyzed in terms of drug resistance and biofilm formation. The photocytotoxic effect of phthalocyanine was determined by the reduction factor of bacteria. The studied cationic phthalocyanine at a concentration of 1.0 × 10−4 M, when activated by light, revealed a significant reduction factor, ranging from nearly 4 to 6 log, of P. aeruginosa cells when compared to the untreated control group. After single irradiation, a decrease in the number of bacteria in biofilm ranging from 1.3 to 4.2 log was observed, whereas the second treatment significantly improved the bacterial reduction factor from 3.4 to 5.5 log. It is worth mentioning that a boosted cell-death response was observed after the third irradiation, with a bacterial reduction factor ranging from 4.6 to 6.4 log. According to the obtained results, the tested photosensitizer can be considered as a potential antimicrobial photodynamic therapy against multidrug-resistant P. aeruginosa.
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14
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Effect of Combination Antibiotic Empirical Therapy on Mortality in Neutropenic Cancer Patients with Pseudomonas aeruginosa Pneumonia. Microorganisms 2022; 10:microorganisms10040733. [PMID: 35456784 PMCID: PMC9027680 DOI: 10.3390/microorganisms10040733] [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: 02/24/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
To assess the effect of combination antibiotic empirical therapy on 30-day case-fatality rate in neutropenic cancer patients with Pseudomonas aeruginosa (PA) bacteremic pneumonia. This was a multinational, retrospective cohort study of neutropenic onco-hematological patients with PA bloodstream infection (BSI) (2006−2018). The effect of appropriate empirical combination therapy, appropriate monotherapy and inappropriate empirical antibiotic therapy [IEAT] on 30-day case-fatality was assessed only in patients with PA bacteremic pneumonia. Among 1017 PA BSI episodes, pneumonia was the source of BSI in 294 (28.9%). Among those, 52 (17.7%) were caused by a multidrug-resistant (MDR) strain and 68 (23.1%) received IEAT, mainly when the infection was caused by an MDR strain [38/52 (73.1%) vs. 30/242 (12.4%); p < 0.001]. The 30-day case-fatality rate was higher in patients with PA bacteremic pneumonia than in those with PA BSI from other sources (55.1% vs. 31.4%; p < 0.001). IEAT was associated with increased 30-day case-fatality (aHR 1.44 [95%CI 1.01−2.03]; p = 0.042), whereas the use of appropriate combination empirical treatment was independently associated with improved survival (aHR 0.46 [95%CI 0.27−0.78]; p = 0.004). Appropriate empirical monotherapy was not associated with improved overall survival (aHR 1.25 [95%CI 0.76−2.05]; p = 0.39). Combination antibiotic empirical therapy should be administered promptly in febrile neutropenic patients with suspected pneumonia as the source of infection.
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15
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Kishimoto K, Kasai M, Kawamura N, Otake S, Hasegawa D, Kosaka Y. Clinical characteristics and risk factors for mortality in children with Pseudomonas aeruginosa bacteraemia: A retrospective review at a paediatric tertiary centre. J Paediatr Child Health 2021; 57:1976-1980. [PMID: 34169605 DOI: 10.1111/jpc.15634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/08/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
AIM The objective of this study was to describe clinical features and to assess the risk factors associated with mortality in Pseudomonas aeruginosa bacteraemia in a tertiary Japanese paediatric care hospital. METHODS Patients diagnosed with P. aeruginosa bacteraemia at our hospital between 2007 and 2018 were analysed in a retrospective case series. Inadequate initial therapy for P. aeruginosa bacteraemia was defined as initial treatment without antipseudomonal antibiotics or an administration of antipseudomonal agent to which the causative strain was resistant. Bacteraemia-related death was defined as all deaths occurring within 7 days after the onset of bacteraemia. RESULTS Overall, 41 patients with 42 P. aeruginosa bacteraemia episodes were identified. The most common underlying condition was malignancy (27%), followed by congenital heart disease (20%) and preterm birth (17%). Among the 42 P. aeruginosa clinical isolates, 24% were resistant to at least one of the antipseudomonal agents and 10% were resistant to more than one agent. The susceptibility levels for piperacillin, fourth-generation cephalosporins and ciprofloxacin were higher than that for carbapenems. Bacteraemia-related death was observed in 43% of episodes. The 30-day all-cause mortality was 50% (standard error 8%). Neonates, intensive care, mechanical ventilation, afebrile episodes, septic shock, hypoxia, renal injury and inadequate initial therapy were associated with bacteraemia-related death episodes. CONCLUSIONS We found that childhood P. aeruginosa bacteraemia is still a high mortality disease. Our results imply the importance of the identification of high-risk patients and the establishment of adequate empirical antibiotic therapy.
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Affiliation(s)
- Kenji Kishimoto
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Masashi Kasai
- Department of Infectious Disease, Kobe Children's Hospital, Kobe, Japan
| | - Noriko Kawamura
- Department of Clinical Laboratory, Kobe Children's Hospital, Kobe, Japan
| | - Shogo Otake
- Department of Infectious Disease, Kobe Children's Hospital, Kobe, Japan
| | - Daiichiro Hasegawa
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
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16
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The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update. Drugs 2021; 81:2117-2131. [PMID: 34743315 PMCID: PMC8572145 DOI: 10.1007/s40265-021-01635-6] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 12/20/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have
identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.
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17
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Fontana L, Hakki M. Emergence of non-susceptibility during persistent Pseudomonas aeruginosa bacteraemia in haematopoietic cell transplant recipients and haematological malignancy patients. JAC Antimicrob Resist 2021; 3:dlab125. [PMID: 34661107 PMCID: PMC8519295 DOI: 10.1093/jacamr/dlab125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/18/2021] [Indexed: 01/13/2023] Open
Abstract
Background Systematic studies pertaining to the emergence of resistance during therapy
of Pseudomonas aeruginosa bloodstream infections (BSIs) in
haematopoietic cell transplant (HCT) recipients and haematological
malignancy (HM) patients are lacking. Objectives To determine how frequently non-susceptibility emerges during therapy of
P. aeruginosa BSIs and to compare these findings with
non-HCT/HM patients. Patients and methods P. aeruginosa BSIs that occurred at our institution between
1 July 2012 and 31 October 2019 in HCT/HM patients and non-HCT/HM patients
were identified. Episodes in which bacteraemia persisted while on
appropriate therapy (‘persistent BSI’) were evaluated for
emergence of non-susceptibility during therapy. Results In total, 96 BSI episodes among 86 HCT/HM patients were analysed. Eight
persistent BSI episodes (8.3%) occurred in eight patients
(9.3%). Repeat susceptibility testing was performed in seven
(87.5%) of these episodes. Non-susceptibility to the treatment agent
emerged in five (71.4%) episodes and to any antipseudomonal agent in
seven (100%) episodes. The 21 day mortality rate associated
with persistent BSI was 87.5% (seven of eight), and it was 80%
(four of five) among persistent BSI episodes in which non-susceptibility to
the treatment agent emerged on therapy. Non-susceptibility to any
antipseudomonal agent during persistent BSI emerged significantly more
frequently in HCT/HM patients compared with non-HCT/HM patients. Conclusions Non-susceptibility emerges frequently during persistent P.
aeruginosa BSIs in HCT/HM patients, and this is associated with
a high mortality rate. Our findings have implications for the management of
persistent P. aeruginosa BSIs in these patients. Larger
studies are needed to confirm and expand on our findings.
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Affiliation(s)
- Lauren Fontana
- Division of Infectious Diseases, University of Minnesota, Minneapolis, MN, USA
| | - Morgan Hakki
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA
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18
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Antibiotic-Resistant Infections and Treatment Challenges in the Immunocompromised Host: An Update. Infect Dis Clin North Am 2021; 34:821-847. [PMID: 33131573 DOI: 10.1016/j.idc.2020.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This article reviews antibiotic resistance and treatment of bacterial infections in the growing number of patients who are immunocompromised: solid organ transplant recipients, the neutropenic host, and persons with human immunodeficiency virus and AIDS. Specific mechanisms of resistance in both gram-negative and gram-positive bacteria, as well as newer treatment options are addressed elsewhere and are only briefly discussed in the context of the immunocompromised host.
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19
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Changing epidemiology of catheter-related bloodstream infections in neutropenic oncohematological patients. PLoS One 2021; 16:e0251010. [PMID: 33930068 PMCID: PMC8087001 DOI: 10.1371/journal.pone.0251010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/18/2021] [Indexed: 12/02/2022] Open
Abstract
Background We aimed to describe the epidemiology of catheter-related bloodstream infections (CRBSIs) in onco-hematological neutropenic patients during a 25-year study period, to evaluate the risk factors for Gram-negative bacilli (GNB) CRBSI, as well as rates of inappropriate empirical antibiotic treatments (IEAT) and mortality. Materials/Methods All consecutive episodes of CRBSIs were prospectively collected (1994–2018). Changing epidemiology was evaluated comparing five-year time spans. A multivariate regression model was built to evaluate risk factors for GNB CRBSIs. Results 482 monomicrobial CRBSIs were documented. The proportion of CRBSIs among all BSIs decreased over time from 41.2% to 15.8% (p<0.001). CRBSIs epidemiology has been changing: the rate of GNB increased over time (from 11.9% to 29.4%; p<0.001), as well as the absolute number and rate of multidrug-resistant (MDR) GNB (from 9.5% to 40.0%; p = 0.039). P. aeruginosa increased and comprised up to 40% of all GNB. Independent factors related with GNB-CRBSIs were: longer duration of in-situ catheter (OR 1.007; 95%CI 1.004–1.011), older age (OR 1.016; 95%CI 1.001–1.033), prior antibiotic treatment with penicillins (OR 2.716; 95%CI 1.306–5.403), and current antibiotic treatment with glycopeptides (OR 1.931; 95%CI 1.001–3.306). IEATs were administered to 30.7% of patients, with the highest percentage among MDR P. aeruginosa (76.9%) and S. maltophillia (92.9%). Mortality rate was greater among GNB than GPC-CRBSI (14.4% vs 5.4%; p = 0.002), with mortality increasing over time (from 4.5% to 11.2%; p = 0.003). Conclusion A significant shift towards GNB-CRBSIs was observed. Secondarily, and coinciding with an increasing number of GNB-MDR infections, mortality increased over time.
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20
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Gudiol C, Albasanz-Puig A, Cuervo G, Carratalà J. Understanding and Managing Sepsis in Patients With Cancer in the Era of Antimicrobial Resistance. Front Med (Lausanne) 2021; 8:636547. [PMID: 33869250 PMCID: PMC8044357 DOI: 10.3389/fmed.2021.636547] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/08/2021] [Indexed: 12/23/2022] Open
Abstract
Sepsis is a frequent complication in immunosuppressed cancer patients and hematopoietic stem cell transplant recipients that is associated with high morbidity and mortality rates. The worldwide emergence of antimicrobial resistance is of special concern in this population because any delay in starting adequate empirical antibiotic therapy can lead to poor outcomes. In this review, we aim to address: (1) the mechanisms involved in the development of sepsis and septic shock in these patients; (2) the risk factors associated with a worse prognosis; (3) the impact of adequate initial empirical antibiotic therapy given the current era of widespread antimicrobial resistance; and (4) the optimal management of sepsis, including adequate and early source control of infection, optimized antibiotic use based on the pharmacokinetic and pharmacodynamics changes in these patients, and the role of the new available antibiotics.
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Affiliation(s)
- Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospital Duran i Reynals, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Adaia Albasanz-Puig
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
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21
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Zhang Y, Li Y, Zeng J, Chang Y, Han S, Zhao J, Fan Y, Xiong Z, Zou X, Wang C, Li B, Li H, Han J, Liu X, Xia Y, Lu B, Cao B. Risk Factors for Mortality of Inpatients with Pseudomonas aeruginosa Bacteremia in China: Impact of Resistance Profile in the Mortality. Infect Drug Resist 2020; 13:4115-4123. [PMID: 33209041 PMCID: PMC7669529 DOI: 10.2147/idr.s268744] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Pseudomonas aeruginosa bacteremia presents a severe challenge to hospitalized patients. However, to date, the risk factors for mortality among inpatients with P. aeruginosa bacteremia in China remain unclear. Patients and Methods This retrospective multicenter study was performed to analyze 215 patients with culture-confirmed P. aeruginosa bacteremia in five healthcare centers in China during the years 2012–2019. Results Of 215 patients with P. aeruginosa bacteremia, 61 (28.4%) died during the study period. Logistic multivariable analysis revealed that cardiovascular disease (OR=3.978, P=0.001), blood transfusion (OR=5.855, P<0.001) and carbapenem-resistant P. aeruginosa (CRPA) phenotype (OR=4.485, P=0.038) constituted the independent risk factors of mortality. Furthermore, both CRPA and multidrug-resistant P. aeruginosa (MDRPA) phenotypes were found to be significantly associated with 5-day mortality (Log-rank, P<0.05). Conclusion This study revealed a high mortality rate amongst hospitalized patients with P. aeruginosa bacteremia, and those with cardiovascular diseases, CRPA and MDRPA phenotypes, should be highlighted and given appropriate management in China.
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Affiliation(s)
- Yulin Zhang
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Yi Li
- Department of Laboratory Medicine, Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Ji Zeng
- Department of Laboratory Medicine, Wuhan Pu Ai Hospital of Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yanzi Chang
- Department of Laboratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, People's Republic of China
| | - Shouhua Han
- Department of Laboratory Medicine, Weifang No.2 People's Hospital, Weifang, People's Republic of China
| | - Jiankang Zhao
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Yanyan Fan
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Zhujia Xiong
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Xiaohui Zou
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Chunlei Wang
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Binbin Li
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Haibo Li
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Jiajing Han
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Xinmeng Liu
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Yudi Xia
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Binghuai Lu
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases, Center for Respiratory Diseases, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing 100029, People's Republic of China.,Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, People's Republic of China.,Tsinghua University-Peking University, Joint Center for Life Sciences, Beijing, People's Republic of China
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22
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Peseski AM, McClean M, Green SD, Beeler C, Konig H. Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert Rev Anti Infect Ther 2020; 19:359-378. [PMID: 32892669 DOI: 10.1080/14787210.2020.1820863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Febrile neutropenia represents one of the most common treatment-associated complications in the management of acute myeloid leukemia (AML) and is considered an oncologic emergency. Rapid and detailed workup as well as the initiation of empiric broad-spectrum antibiotic therapy are critical to avoid sepsis and to reduce mortality. Although a definitive source of infection is frequently not identified, the severely immunosuppressed status of the AML patient undergoing cytotoxic therapy results in a high risk for a wide array of bacterial, fungal, and viral etiologies. AREAS COVERED The authors herein review the diagnostic and therapeutic approach to the neutropenic leukemia patient based on the current knowledge. Special consideration is given to the rapidly changing therapeutic landscape in AML, creating new challenges in the management of infectious complications. EXPERT OPINION Multidrug-resistant organisms pose a major challenge in the management of neutropenic fever patients with hematologic malignancies - including AML. Future directions to improve outcomes demand innovative treatment approaches as well as advances in biomarker research to facilitate diagnosis and disease monitoring. Recent achievements in AML-targeted therapy led to an increased incidence of differentiation syndrome, a potentially life-threatening side effect that frequently resembles clinical infection and requires prompt recognition and aggressive intervention.
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Affiliation(s)
- Andrew M Peseski
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mitchell McClean
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven D Green
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cole Beeler
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heiko Konig
- Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
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23
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Pseudomonas aeruginosa bloodstream infections in children: a 9-year retrospective study. Eur J Pediatr 2020; 179:1247-1254. [PMID: 32080759 DOI: 10.1007/s00431-020-03598-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
P. aeruginosa bloodstream infection (BSI) is associated with high hospital mortality. Empirical combination therapy is commonly used, but its benefit remains debated. The purpose of this study was to describe in a paediatric population, demographical characteristics and outcome of children treated for P. aeruginosa BSI receiving either a combined or single antibacterial therapy. We performed a retrospective, single-centre, cohort study of hospitalized children with P. aeruginosa BSI from 2007 to 2015. A total of 118 bloodstream infections (BSI) were analysed (102 (86.4%) hospital-acquired, including 52 (44.1%) hospitalized in intensive care unit). In immunocompromised children, 52% of BSI episodes were recorded. Recent medical history revealed that 68% were hospitalized, 31% underwent surgery and 67% had a prior antibiotic therapy within the last 3 months. In-hospital mortality was similar for patients receiving single or combined anti-Pseudomonas therapy (p = 0.78). In multivariate analysis, independent risk factors for in-hospital mortality were neutropenia (OR = 6.23 [1.94-20.01], hospitalization in ICU (OR = 5.24 [2.04-13.49]) and urinary tract infection (OR = 4.40 [1.02-19.25]).Conclusion: P. aeruginosa BSI mainly occurred in immunocompromised children. Most infections were hospital-acquired and associated with high mortality. Combination therapy did not improve survival. What is Known: • P. aeruginosa bloodstream infection (BSI) is associated with high hospital mortality. Empirical combination therapy is commonly used but its benefit remains debated. What is New: • This is the largest cohort of Pseudomonas aeruginosa bacteraemia in children ever published. P. aeruginosa Bloodstream mainly occurred in immunocompromised children. Most infections were hospital-acquired and associated with high mortality. Combination therapy did not improve survival.
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24
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Lalaoui R, Javelle E, Bakour S, Ubeda C, Rolain JM. Infections Due to Carbapenem-Resistant Bacteria in Patients With Hematologic Malignancies. Front Microbiol 2020; 11:1422. [PMID: 32765433 PMCID: PMC7379235 DOI: 10.3389/fmicb.2020.01422] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
In developed countries, hematological malignancies (HM) account for 8 to 10% of cancers diagnosed annually and one-third of patients with HM (HMP) are expected to die from their disease. The former wide spectrum “magic bullet,” imipenem, has been ousted by the emergence of carbapenem resistant (CR) pathogens. In endemic areas, infections with CR-bacteria occur in vulnerable patients, notably in HMP, who suffer from high mortality related to infectious complications. In this work, we reviewed epidemiologic and clinical factors associated with CR-infections in adult HMP and data on CR-related mortality and antibiotic treatments in this population. We found that resistance profile of strains involved in HMP infections, mainly bacteremia, reflect local epidemiology. Significant risk factors for infections with CR-bacteria include sex male, age around 50 years old, acute leukemia, selvage chemotherapy, neutropenia, and digestive colonization by CR-bacteria. Mortality rate is high in HMP infected with CR-Enterobacteriaceae, more particularly in case of acute myeloid leukemia and unresolved neutropenia, due to inappropriate empiric management and delayed administration of targeted antibiotics, such as tigecycline, colistin, or new associations of active drugs. Thus, we developed an algorithm for clinicians, assessing the incremental risk for CR-bacterial infection occurrence and mortality in febrile HMP, to guide decisions related to empirical therapeutic strategies.
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Affiliation(s)
- Rym Lalaoui
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Emilie Javelle
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France.,Laveran Military Teaching Hospital, Marseille, France
| | - Sofiane Bakour
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Carles Ubeda
- Centro Superior de Investigación en Salud Pública, FISABIO, Valencia, Spain.,Centers of Biomedical Research Network (CIBER), Epidemiology and Public Health, Madrid, Spain
| | - Jean-Marc Rolain
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
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25
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Jiang AM, Shi X, Liu N, Gao H, Ren MD, Zheng XQ, Fu X, Liang X, Ruan ZP, Yao Y, Tian T. Nosocomial infections due to multidrug-resistant bacteria in cancer patients: a six-year retrospective study of an oncology Center in Western China. BMC Infect Dis 2020; 20:452. [PMID: 32600270 PMCID: PMC7324970 DOI: 10.1186/s12879-020-05181-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Bacterial infections are the most frequent complications in patients with malignancy, and the epidemiology of nosocomial infections among cancer patients has changed over time. This study aimed to evaluate the characteristics, antibiotic resistance patterns, and prognosis of nosocomial infections due to multidrug-resistant (MDR) bacteria in cancer patients. METHODS This retrospective observational study analyzed cancer patients with nosocomial infections caused by MDR from August 2013 to May 2019. The extracted clinical data were recorded in a standardized form and compared based on the survival status of the patients after infection and during hospitalization. The data were analyzed using independent samples t-test, Chi-square test, and binary logistic regression. P-values < 0.05 were considered significant. RESULTS One thousand eight patients developed nosocomial infections during hospitalization, with MDR strains detected in 257 patients. Urinary tract infection (38.1%), respiratory tract infection (26.8%), and bloodstream infection (BSI) (12.5%) were the most common infection types. Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-PE) (72.8%) members were the most frequently isolated MDR strains, followed by Acinetobacter baumannii (11.7%), and Stenotrophomonas maltophilia (6.2%). The results of multivariate regression analysis revealed that smoking history, intrapleural/abdominal infusion history within 30 days, the presence of an indwelling urinary catheter, length of hospitalization, and hemoglobin were independent factors for in-hospital mortality in the study population. The isolated MDR bacteria exhibited high rates of sensitivity to amikacin, meropenem, and imipenem. CONCLUSIONS The burden of nosocomial infections due to MDR bacteria is considerably high in oncological patients, with ESBL-PE being the most predominant causative pathogen. Our findings suggest that amikacin and carbapenems actively against more than 89.7% of MDR isolates. The precise management of MDR bacterial infections in cancer patients may improve the prognosis of these individuals.
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Affiliation(s)
- Ai-Min Jiang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xin Shi
- School of Public Health, Xi'an Jiaotong University Health Science Center, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Na Liu
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Huan Gao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Meng-Di Ren
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiao-Qiang Zheng
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiao Fu
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xuan Liang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Zhi-Ping Ruan
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Yu Yao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Tao Tian
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China.
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26
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An eleven-year cohort of bloodstream infections in 552 febrile neutropenic patients: resistance profiles of Gram-negative bacteria as a predictor of mortality. Ann Hematol 2020; 99:1925-1932. [PMID: 32564194 DOI: 10.1007/s00277-020-04144-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 06/14/2020] [Indexed: 02/03/2023]
Abstract
Antimicrobial stewardship is of major importance in patients with febrile neutropenia (FN). In this study, we aimed to investigate the trends in resistance and the relationship with mortality rates in patients with FN. The single-center surveillance data of inpatients with FN and diagnosed as microbiologically confirmed bloodstream infections (BSIs) between 2006 and 2016 were reviewed retrospectively. A total of 950 episodes in 552 patients with BSIs were analyzed. Of whom, 55.9% were male, the median age was 43 years, and 35.6% had acute myeloid leukemia. In total, 1016 microorganisms were isolated from blood cultures. Gram-negatives accounted for 42.4% (n = 403) of the episodes. Among Gram-negatives, Enterobacteriaceae accounted for 346 (86%) (E. coli, n = 197; 34% extended-spectrum β-lactamases (ESBL) producers, and Klebsiella spp., n = 120; 48.3% ESBL producers). Also, 24 (20.0%) of Klebsiella spp. had carbapenemase activity. There were 6 (5.0%) colistin-resistant Klebsiella spp. Thirteen (26.5%) of Pseudomonas spp. and 17 (60.7%) of Acinetobacter spp. had carbapenemase activity. There were 2 (5.6%) colistin-resistant Acinetobacter spp. The 30-day mortality rates were 12.0%, 21.5%, 34.6%, and 29.0% in BSIs due to Gram-positive, Gram-negative bacterial, fungal, and polymicrobial etiology respectively (p = 0.001). BSIs with ESBL-producing (p = 0.001) isolates, carbapenem (p < 0.001), and colistin-resistant isolates (p < 0.001) were associated with increased mortality risk. The tremendous rise in resistance rates among Gram-negatives is dreadfully related to increasing mortality and leads to sharp shifts toward extreme restrictions of unnecessary antibiotic uses. Antimicrobial stewardship in patients with FN requires vigilance and tailoring of treatment upon local surveillance data.
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27
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Clinical Predictive Model of Multidrug Resistance in Neutropenic Cancer Patients with Bloodstream Infection Due to Pseudomonas aeruginosa. Antimicrob Agents Chemother 2020; 64:AAC.02494-19. [PMID: 32015035 DOI: 10.1128/aac.02494-19] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/25/2020] [Indexed: 01/07/2023] Open
Abstract
We aimed to assess the rate and predictive factors of bloodstream infection (BSI) due to multidrug-resistant (MDR) Pseudomonas aeruginosa in neutropenic cancer patients. We performed a multicenter, retrospective cohort study including oncohematological neutropenic patients with BSI due to P. aeruginosa conducted across 34 centers in 12 countries from January 2006 to May 2018. A mixed logistic regression model was used to estimate a model to predict the multidrug resistance of the causative pathogens. Of a total of 1,217 episodes of BSI due to P. aeruginosa, 309 episodes (25.4%) were caused by MDR strains. The rate of multidrug resistance increased significantly over the study period (P = 0.033). Predictors of MDR P. aeruginosa BSI were prior therapy with piperacillin-tazobactam (odds ratio [OR], 3.48; 95% confidence interval [CI], 2.29 to 5.30), prior antipseudomonal carbapenem use (OR, 2.53; 95% CI, 1.65 to 3.87), fluoroquinolone prophylaxis (OR, 2.99; 95% CI, 1.92 to 4.64), underlying hematological disease (OR, 2.09; 95% CI, 1.26 to 3.44), and the presence of a urinary catheter (OR, 2.54; 95% CI, 1.65 to 3.91), whereas older age (OR, 0.98; 95% CI, 0.97 to 0.99) was found to be protective. Our prediction model achieves good discrimination and calibration, thereby identifying neutropenic patients at higher risk of BSI due to MDR P. aeruginosa The application of this model using a web-based calculator may be a simple strategy to identify high-risk patients who may benefit from the early administration of broad-spectrum antibiotic coverage against MDR strains according to the local susceptibility patterns, thus avoiding the use of broad-spectrum antibiotics in patients at a low risk of resistance development.
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28
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Criscuolo M, Trecarichi EM. Ceftazidime/Avibactam and Ceftolozane/Tazobactam for Multidrug-Resistant Gram Negatives in Patients with Hematological Malignancies: Current Experiences. Antibiotics (Basel) 2020; 9:antibiotics9020058. [PMID: 32028615 PMCID: PMC7168285 DOI: 10.3390/antibiotics9020058] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/16/2022] Open
Abstract
Patients suffering from hematological malignancies are at high risk for severe infections, including in particular bloodstream infections, which represent one of the most frequent life-threatening complications for these patients, with reported mortality rates reaching 40%. Furthermore, a worrisome increase in antimicrobial resistance of Gram-negative bacteria (e.g., cephalosporin- and/or carbapenem-resistant Enterobacteriaceae and multidrug-resistant (MDR) Pseudomonas aeruginosa) involved in severe infectious complications among patients with hematological malignancies has been reported during the last years. The two novel combination of cephalosporins and β-lactamase inhibitors, ceftolozane/tazobactam and ceftazidime/avibactam, were recently approved for treatment of complicated intra-abdominal and urinary tract infections and nosocomial pneumonia and display activity against several MDR Gram-negative strains. Although not specifically approved for neutropenic and/or cancer patients, these drugs are used in this setting due to increasing rates of infections caused by MDR Gram-negative bacteria. The aim of this review is to describe the actual evidence from scientific literature about the "real-life" use of these two novel drugs in patients with hematological malignancies and infections caused by MDR Gram-negative bacteria.
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Affiliation(s)
- Marianna Criscuolo
- Dipartimento Scienze Radiologiche Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
| | - Enrico Maria Trecarichi
- Department of Medical and Surgical Sciences, Unit of Infectious and Tropical Diseases, “Magna Graecia” University, 88100 Catanzaro, Italy
- Correspondence: ; Tel.: +39-0961-369-7106
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Jia X, Ma W, He J, Tian X, Liu H, Zou H, Cheng S. Heteroresistance to cefepime in Pseudomonas aeruginosa bacteraemia. Int J Antimicrob Agents 2020; 55:105832. [PMID: 31669739 DOI: 10.1016/j.ijantimicag.2019.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/11/2019] [Accepted: 10/20/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Heteroresistance to antibiotic agents can lead to diagnostic and therapeutic failures; however, to date, cefepime heteroresistance (FEP-HR) in Pseudomonas aeruginosa (P. aeruginosa) bacteraemia has not been characterised. The primary goal of this study was to investigate the molecular epidemiology, mechanisms and risk factors for cefepime-heteroresistant P. aeruginosa bacteraemia over approximately 6 years in Southwest China. RESULTS A high prevalence (57.3%) of heteroresistance to cefepime was observed during the study period, and these FEP-HR isolates were not clonally related. Mechanistic studies revealed that AmpC hyperproduction contributed to the development of this phenomenon. In addition, patients with advanced age, haematological malignancies, central venous catheters, and previous cephalosporin therapy were identified as independent risk factors for acquiring FEP-HR P. aeruginosa bacteraemia. Furthermore, patients infected with FEP-HR were generally at a greater risk for an adverse prognosis compared with those with non-FEP-HR. More importantly, characterisation of three successive P. aeruginosa isolates recovered from the same patient revealed that heteroresistance can act as an intermediate stage during the evolution from susceptibility to full resistance in patients undergoing antibiotic therapy for prolonged periods. CONCLUSION These findings emphasised the necessity of antimicrobial stewardship programs in clinical settings, as well as the need for some rapid screening methods for detecting this phenomenon.
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Affiliation(s)
- Xiaojiong Jia
- Key Laboratory of Molecular Biology of Infectious Diseases Designated by the Chinese Ministry of Education, Institute for Viral Hepatitis, Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Weijia Ma
- Department of Laboratory Medicine, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Jianchun He
- Department of Laboratory Medicine, Chongqing Dazu District People's Hospital, Chongqing, China
| | - Xiaolang Tian
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Hang Liu
- Department of Laboratory Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Zou
- Department of Laboratory Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Orthopaedics, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. @cqmu.edu.cn
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Shock and Early Death in Hematologic Patients with Febrile Neutropenia. Antimicrob Agents Chemother 2019; 63:AAC.01250-19. [PMID: 31405857 DOI: 10.1128/aac.01250-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 02/08/2023] Open
Abstract
Empirical antibiotic therapy with a beta-lactam is the standard of care in febrile neutropenia (FN) and is given to prevent early death. The addition of vancomycin is recommended in certain circumstances, but the quality of evidence is low, reflecting the lack of clinical data. In order to characterize the epidemiology of early death and shock in FN, we reviewed all episodes of FN from 2003 to 2017 at University Hospital, Federal University of Rio de Janeiro, and looked at factors associated with shock at first fever and early death (within 3 days from first fever) by univariate and multivariate analyses. Among 1,305 episodes of FN, shock occurred in 42 episodes (3.2%) and early death in 15 (1.1%). Predictors of shock were bacteremia due to Escherichia coli (odds ratio [OR], 8.47; 95% confidence interval [95% CI], 4.08 to 17.55; P < 0.001), Enterobacter sp. (OR, 7.53; 95% CI, 1.60 to 35.33; P = 0.01), and Acinetobacter sp. (OR, 6.95; 95% CI, 1.49 to 32.36; P = 0.01). Factors associated with early death were non-Hodgkin's lymphoma (OR, 3.57; 95% CI, 1.18 to 10.73; P = 0.02), pneumonia (OR, 21.36; 95% CI, 5.72 to 79.72; P < 0.001), shock (OR, 11.64: 95% CI, 2.77 to 48.86; P = 0.01), and bacteremia due to Klebsiella pneumoniae (OR, 5.91; 95% CI, 1.11 to 31.47; P = 0.03). Adequate empirical antibiotic therapy was protective (OR, 0.23; 95% CI, 0.07 to 0.81; P = 0.02). Shock or early death was not associated with Gram-positive bacteremia; catheter-related, skin, or soft tissue infection; or inadequate Gram-positive coverage. These data challenge guideline recommendations for the empirical use of vancomycin at first fever in neutropenic patients.
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Changing epidemiology of bloodstream infection in a 25-years hematopoietic stem cell transplant program: current challenges and pitfalls on empiric antibiotic treatment impacting outcomes. Bone Marrow Transplant 2019; 55:603-612. [PMID: 31570779 DOI: 10.1038/s41409-019-0701-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/31/2019] [Accepted: 06/05/2019] [Indexed: 01/28/2023]
Abstract
We aimed to describe epidemiology changes in bloodstream infections (BSI) episodes in hematopoietic stem cell transplant (HSCT) recipients throughout a 25-year period (1993-2017), comparing five-year time spans, and we evaluate their impact on inappropriate empirical antibiotic treatment (IEAT) and mortality. During the study period, 1164 BSI episodes were documented in patients undergoing HSCT (71.6% allogenic and 29% autologous). A significant decrease in gram-positive cocci (GPC) and increase in gram-negative bacilli (GNB) were observed (p < 0.001). Among GP, coagulase-negative staphylococci (CoNS) significantly decreased whereas rising E. faecium BSI was documented. Among GNB, E. coli, Pseudomonas aeruginosa and K. pneumoniae rates increased. Multidrug-resistant (MDR) GNB, especially ESBL-E. coli and MDR-P. aeruginosa, emerged in 2008 and has gradually increased. IEAT against MDR-P. aeruginosa, but not in other MDR-GNB, augmented throughout the study period. Overall, 30-day and related mortality rates were 12.7% and 7.7% respectively, both increasing over time (p < 0.001 and p = 0.025). In GNB, 30-day and related mortality were 18.5% and 12.8%, respectively, increasing over time (p < 0.001 and p = 0.004). To conclude, important BSI epidemiological changes were described in a 25-year period. Concerning increase in IEAT for P. aeruginosa infections and rising 30-day mortality rate were documented.
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Viasus D, Puerta-Alcalde P, Cardozo C, Suárez-Lledó M, Rodríguez-Núñez O, Morata L, Fehér C, Marco F, Chumbita M, Moreno-García E, Fernández-Avilés F, Gutiérrez-Garcia G, Martínez JA, Mensa J, Rovira M, Esteve J, Soriano A, Garcia-Vidal C. Predictors of multidrug-resistant Pseudomonas aeruginosa in neutropenic patients with bloodstream infection. Clin Microbiol Infect 2019; 26:345-350. [PMID: 31295551 DOI: 10.1016/j.cmi.2019.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/07/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To assess risk factors for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infection in neutropenic patients. METHODS Single-centre retrospective analysis of consecutive bloodstream infection (BSI) episodes (2004-2017, Barcelona). Two multivariate regression models were used at BSI diagnosis and P. aeruginosa detection. Significant predictors were used to establish rules for stratifying patients according to MDR-PA BSI risk. RESULTS Of 661 Gram-negative BSI episodes, 190 (28.7%) were caused by P. aeruginosa (70 MDR-PA). Independent factors associated with MDR-PA among Gram-negative organisms were haematological malignancy (OR 3.30; 95% CI 1.15-9.50), pulmonary source of infection (OR 7.85; 95% CI 3.32-18.56), nosocomial-acquired BSI (OR 3.52; 95% CI 1.74-7.09), previous antipseudomonal cephalosporin (OR 13.66; 95% CI 6.64-28.10) and piperacillin/tazobactam (OR 2.42; 95% CI 1.04-5.63), and BSI occurring during ceftriaxone (OR 4.27; 95% CI 1.15-15.83). Once P. aeruginosa was identified as the BSI aetiological pathogen, nosocomial acquisition (OR 7.13; 95% CI 2.87-17.67), haematological malignancy (OR 3.44; 95% CI 1.07-10.98), previous antipseudomonal cephalosporin (OR 3.82; 95% CI 1.42-10.22) and quinolones (OR 3.97; 95% CI 1.37-11.48), corticosteroids (OR 2.92; 95% CI 1.15-7.40), and BSI occurring during quinolone (OR 4.88; 95% CI 1.58-15.05) and β-lactam other than ertapenem (OR 4.51; 95% CI 1.45-14.04) were independently associated with MDR-PA. Per regression coefficients, 1 point was assigned to each parameter, except for nosocomial-acquired BSI (3 points). In the second analysis, a score >3 points identified 60 (86.3%) out of 70 individuals with MDR-PA BSI and discarded 100 (84.2%) out of 120 with non-MDR-PA BSI. CONCLUSIONS A simple score based on demographic and clinical factors allows stratification of individuals with bacteraemia according to their risk of MDR-PA BSI, and may help facilitate the use of rapid MDR-detection tools and improve early antibiotic appropriateness.
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Affiliation(s)
- D Viasus
- Health Sciences Division, Universidad del Norte, and Hospital Universidad del Norte, Barranquilla, Colombia
| | - P Puerta-Alcalde
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - C Cardozo
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - M Suárez-Lledó
- Haematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - O Rodríguez-Núñez
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - L Morata
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - C Fehér
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - F Marco
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Microbiology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
| | - M Chumbita
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - E Moreno-García
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | | | - G Gutiérrez-Garcia
- Haematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - J A Martínez
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - J Mensa
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - M Rovira
- Haematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - J Esteve
- Haematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - A Soriano
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - C Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain.
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Albasanz-Puig A, Gudiol C, Parody R, Tebe C, Akova M, Araos R, Bote A, Brunel AS, Calik S, Drgona L, García E, Hemmati P, Herrera F, Ibrahim KY, Isler B, Kanj S, Kern W, Maestro de la Calle G, Manzur A, Marin JI, Márquez-Gómez I, Martín-Dávila P, Mikulska M, Montejo JM, Montero M, Morales HMP, Morales I, Novo A, Oltolini C, Peghin M, del Pozo JL, Puerta-Alcalde P, Ruiz-Camps I, Sipahi OR, Tilley R, Yáñez L, Gomes MZR, Carratalà J. Impact of antibiotic resistance on outcomes of neutropenic cancer patients with Pseudomonas aeruginosa bacteraemia (IRONIC study): study protocol of a retrospective multicentre international study. BMJ Open 2019; 9:e025744. [PMID: 31129580 PMCID: PMC6538198 DOI: 10.1136/bmjopen-2018-025744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Pseudomonas aeruginosa (PA) has historically been one of the major causes of severe sepsis and death among neutropenic cancer patients. There has been a recent increase of multidrug-resistant PA (MDRPA) isolates that may determine a worse prognosis, particularly in immunosuppressed patients. The aim of this study is to establish the impact of antibiotic resistance on the outcome of neutropenic onco-haematological patients with PA bacteraemia, and to identify the risk factors for MDRPA bacteraemia and mortality. METHODS AND ANALYSIS This is a retrospective, observational, multicentre, international study. All episodes of PA bacteraemia occurring in neutropenic onco-haematological patients followed up at the participating centres from 1 January 2006 to 31 May 2018 will be retrospectively reviewed. The primary end point will be overall case-fatality rate within 30 days of onset of PA bacteraemia. The secondary end points will be to describe the following: the incidence and risk factors for multidrug-resistant and extremely drug-resistant PA bacteraemia (by comparing the episodes due to susceptible PA with those produced by MDRPA), the efficacy of ceftolozane/tazobactam, the rates of persistent bacteraemia and bacteraemia relapse and the risk factors for very early (48 hours), early (7 days) and overall (30 days) case-fatality rates. ETHICS AND DISSEMINATION The Clinical Research Ethics Committee of Bellvitge University Hospital approved the protocol of the study at the primary site. To protect personal privacy, identifying information of each patient in the electronic database will be encrypted. The processing of the patients' personal data collected in the study will comply with the Spanish Data Protection Act of 1998 and with the European Directive on the privacy of data. All data collected, stored and processed will be anonymised. Results will be reported at conferences and in peer-reviewed publications.
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Affiliation(s)
- Adaia Albasanz-Puig
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Rocío Parody
- Haematology Department, Institut Català d' Oncologia (ICO)-Hospital Duran i Reynals, IDIBELL, Barcelona, Spain
| | - Cristian Tebe
- Statistics Advisory Service, Institute of Biomedical Research of Bellvitge, Rovira i Virgili University, Barcelona, Spain
| | - Murat Akova
- Infectious Diseases Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Rafael Araos
- Infectious Diseases Department, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Anna Bote
- Infectious Diseases Department, Parc Taulí University Hospital, Sabadell, Barcelona, Spain
| | - Anne-Sophie Brunel
- Infectious Diseases Department, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Sebnem Calik
- Department of Infectious Diseases and Clinical Microbiology, University of Health Science Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Lubos Drgona
- Oncohematology Department, Comenius University and National Cancer Institute, Bratislava, Slovakia
| | - Estefanía García
- Haematology Department, Reina Sofía University Hospital-IMIBIC-UCO, Córdoba, Spain
| | - Philipp Hemmati
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Academic Teaching Hospital of Charité University Medical School, Berlin, Germany
| | - Fabián Herrera
- Infectious Diseases Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Karim Yaqub Ibrahim
- Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Burcu Isler
- Department of Infectious Diseases and Clinical Microbiology, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Souha Kanj
- Infectious Diseases Division, American University of Beirut Medical Center, Beirut, Lebanon
| | - Winfried Kern
- Division of Infectious Diseases, Department of Medicine II, University of Freiburg, Medical Center and Faculty of Medicine, Freiburg, Germany
| | - Guillermo Maestro de la Calle
- Infectious Diseases Unit, Instituto de Investigación Hospital "12 de Octubre" (i+12), " 12 de Octubre" University Hospital, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Adriana Manzur
- Infectious Diseases, Hospital Rawson, San Juan, Argentina
| | - Jorge Iván Marin
- Infectious Diseases and Clinical Microbiology Department, Clínica Maraya, Pereira, Colombia
- Critical Care and Clinical Microbiology Department, Universidad de Manizales, Manizales, Colombia
| | - Ignacio Márquez-Gómez
- Infectious Diseases Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, Genova, Italy
| | - José Miguel Montejo
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Cruces University Hospital, Bilbao, Spain
| | - Milagros Montero
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Isabel Morales
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Emergency Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Andrés Novo
- Haematology Department, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Chiara Oltolini
- Unit of Infectious and Tropical Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maddalena Peghin
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Jose Luis del Pozo
- Infectious Diseases and Microbiology Unit, Navarra University Clinic, Pamplona, Spain
| | - Pedro Puerta-Alcalde
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Department, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | - Isabel Ruiz-Camps
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - Robert Tilley
- Microbiology Department, University Hospitals Plymouth NHS Trust, UK
| | - Lucrecia Yáñez
- Haematology Department, Marques de Valdecilla University Hospital, Santander, Spain
| | - Marisa Zenaide Ribeiro Gomes
- Instituto Oswaldo Cruz, Fundaçao Oswaldo Cruz, Rio de Janeiro, Brazil
- Hospital Federal Servidores do Estado, Ministerio da Saúde, Rio de Janeiro, Brazil
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
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Li S, Jia X, Li C, Zou H, Liu H, Guo Y, Zhang L. Carbapenem-resistant and cephalosporin-susceptible Pseudomonas aeruginosa: a notable phenotype in patients with bacteremia. Infect Drug Resist 2018; 11:1225-1235. [PMID: 30154669 PMCID: PMC6108401 DOI: 10.2147/idr.s174876] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Pseudomonas aeruginosa is recognized as a major cause of severe and potentially life-threatening infection. However, P. aeruginosa isolates with the phenotype of being carbapenem resistant and cephalosporin susceptible (Carb-R/Ceph-S) have not been thoroughly characterized to date. The aim of this study was to assess the mechanisms, risk factors, and clinical impact of Carb-R/Ceph-S P. aeruginosa bacteremia on mortality. Patients and methods We conducted a retrospective case-case-control study of the risk factors and clinical outcomes of hospitalized patients with Carb-R/Ceph-S P. aeruginosa bacteremia from 2011 to 2017 in Chongqing, China. Case patients infected with Carb-R/Ceph-S P. aeruginosa, carbapenem-susceptible and cephalosporin-susceptible (Carb-S/Ceph-S) P. aeruginosa, and controls with no P. aeruginosa bacteremia were compared at a ratio of 1:1:2. Real-time reverse transcription polymerase chain reaction was performed to assess resistance mechanisms. A multivariate logistic regression model was performed to investigate several potential predictors for mortality. Results We collected 63 Carb-R/Ceph-S P. aeruginosa isolates during the study period. None of these isolates possessed carbapenemase or extended-spectrum β-lactamase-encoding genes. The overall 30-day mortality rate was 27.0%. Real-time reverse transcription polymerase chain reaction analysis showed that an overexpression of efflux systems and decreased expression of OprD were associated with Carb-R/Ceph-S P. aeruginosa. Multivariate analysis indicated that 30-day readmission, central venous catheters, and exposure to carbapenems were unique independent predictors for acquiring Carb-R/Ceph-S P. aeruginosa bacteremia. Additionally, hematologic malignancy was a peculiar predictor for Carb-S/Ceph-S P. aeruginosa bacteremia. Notably, total parenteral nutrition was the only common factor of both Carb-R/Ceph-S and Carb-S/Ceph-S groups compared to controls. In a multivariate analysis for the outcome, intensive care unit admission and septic shock were identified as the independent predictors for mortality. Conclusion Our findings can potentially improve the ability of physicians to identify the high-risk patients, and carbapenems were noted to potentially increase the risk of Carb-R/Ceph-S P. aeruginosa. Additionally, cephalosporin should be considered a valuable therapeutic option for such cases of bacteremia.
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Affiliation(s)
- Shuang Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Xiaojiong Jia
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Congya Li
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Hua Zou
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Hang Liu
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
| | - Yuanbiao Guo
- Medical Research Center, The Second Chengdu Hospital Affiliated to Chongqing Medical University, Chengdu, China,
| | - Liping Zhang
- Department of Laboratory Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
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Garcia-Vidal C, Cardozo-Espinola C, Puerta-Alcalde P, Marco F, Tellez A, Agüero D, Romero-Santana F, Díaz-Beyá M, Giné E, Morata L, Rodríguez-Núñez O, Martinez JA, Mensa J, Esteve J, Soriano A. Risk factors for mortality in patients with acute leukemia and bloodstream infections in the era of multiresistance. PLoS One 2018; 13:e0199531. [PMID: 29953464 PMCID: PMC6023133 DOI: 10.1371/journal.pone.0199531] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 06/08/2018] [Indexed: 12/23/2022] Open
Abstract
Objectives We assess the epidemiology and risk factors for mortality of bloodstream infection (BSI) in patients with acute leukemia (AL). Methods Prospectively collected data of a cohort study from July 2004 to February 2016. Multivariate analyses were performed. Results 589 episodes of BSI were documented in 357 AL patients, 55% caused by gram-positive bacteria (coagulase-negative staphylococci 35.7%, Enterococcus spp 10.8%) and 43.5% by gram-negative bacteria (E. coli 21%, PA 12%). We identified 110 (18.7%) multidrug-resistant (MDR) microorganisms, especially MDR-Pseudomonas aeruginosa (7%) and extended-spectrum beta-lactamase producing Enterobacteriaceae (7%). The 30-day mortality was 14.8%. Age (OR 3.1; 95% CI 1.7–5.7); chronic lung disease (4.8; 1.1–21.8); fatal prognosis according to McCabe index (13.9; 6.4–30.3); shock (3.8; 1.9–7.7); pulmonary infection (3.6; 1.3–9.9); and MDR-PA infections with inappropriate treatment (12.8; 4.1–40.5) were related to mortality. MDR-PA BSI was associated to prior antipseudomonal cephalosporin use (9.31; 4.38–19.79); current use of betalactams (2.01; 1.01–4.3); shock (2.63; 1.03–6.7) and pulmonary source of infection (9.6; 3.4–27.21). Conclusions MDR organisms were commonly isolated in BSI in AL. Inappropriate empiric antibiotic treatment for MDR-PA is the primary factor related to mortality that can be changed. New treatment strategies to improve the coverage of MDR-PA BSI should be considered in those patients with risk factors for this infection.
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Affiliation(s)
- Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- * E-mail: , (CGV); (PPA)
| | | | - Pedro Puerta-Alcalde
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- * E-mail: , (CGV); (PPA)
| | - Francesc Marco
- Microbiology Department, Centre Diagnòstic Biomèdic. Hospital Clínic, Barcelona, Spain
- ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Adrian Tellez
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Daiana Agüero
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Francisco Romero-Santana
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- Internal Medicine Department, Hospital Insular Universitario de Gran Canaria, Las Palmas de Gran Canaria, España
| | - Marina Díaz-Beyá
- Hematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Eva Giné
- Hematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Laura Morata
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | | | | | - Josep Mensa
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Jordi Esteve
- Hematology Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Alex Soriano
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
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Yao JF, Li N, Jiang J. Clinical Characteristics of Bloodstream Infections in Pediatric Acute Leukemia: A Single-center Experience with 231 Patients. Chin Med J (Engl) 2018; 130:2076-2081. [PMID: 28836551 PMCID: PMC5586176 DOI: 10.4103/0366-6999.213411] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Acute leukemia is the most common pediatric hematological malignancy. Bloodstream infections (BSIs) are severe complications in these patients during chemotherapy. This study aimed to explore the clinical presentation and etiology of BSI, as well as the common sites of infection, and to provide a basis for the rational regarding antibiotic use. Methods: We performed a retrospective chart review of all pediatric patients who had acute leukemia accompanied by a BSI in our hospital from December 2011 to September 2015. All patients were selected based on clinical presentation and had to have at least one positive blood culture for inclusion. The basic clinical characteristics, blood culture results, and antimicrobial susceptibilities were analyzed. Results: All 231 patients had a fever; of them, 12 patients continued to have a fever. Twenty-five patients had nonremitting (NR) leukemia, and 206 patients achieved complete remission (CR). Differences in the duration of fever between the NR and CR groups were significant (9.6 ± 7.9 vs. 5.1 ± 3.8 days, P = 0.016). One hundred and eighty patients had agranulocytosis. Differences in fever duration between the agranulocytosis and nonagranulocytosis groups were significant (6.2 ± 5.1 vs. 4.1 ± 2.6 days, P = 0.001). The other sites of infection in these 231 patients were the lung, mouth, digestive tract, and rectum. Blood culture comprised 2635 samples. There were 619 samples, which were positive. Of the 619 positive blood culture samples, 59.9% had Gram-negative bacteria, 39.3% had Gram-positive bacteria, and 0.8% had fungus. The primary pathogens were Pseudomonas aeruginosa, Enterobactercloacae, Escherichia coli, and Klebsiella pneumoniae. Of these 231 patients, 217 patients were cured. The effective treatment ratio was 94%. Conclusions: Gram-negative bacteria were the main pathogenic bacteria in patients with acute leukemia in our center. NR primary illness, agranulocytosis, and drug-resistant pathogenic bacteria were all risk factors for poor prognosis.
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Affiliation(s)
- Jia-Feng Yao
- Hematology Oncology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Nan Li
- Hematology Oncology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
| | - Jin Jiang
- Hematology Oncology Center, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China
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37
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Hakki M, Lewis JS. Ceftolozane-tazobactam therapy for multidrug-resistant Pseudomonas aeruginosa infections in patients with hematologic malignancies and hematopoietic-cell transplant recipients. Infection 2018; 46:431-434. [PMID: 29460229 DOI: 10.1007/s15010-018-1125-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Abstract
Multidrug-resistant (MDR) Pseudomonas aeruginosa infection causes significant mortality among patients with hematologic malignancies and hematopoietic-cell transplant recipients. Ceftolozane-tazobactam (C-T) is a novel therapeutic option for MDR-P. aeruginosa infections but clinical experience in these patients is limited. We report favorable clinical outcomes and lack of limiting toxicities using C-T monotherapy to treat invasive MDR-P. aeruginosa infections in these patient populations.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Department of Internal Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L457, Portland, OR, 97239, USA.
| | - James S Lewis
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
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38
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Dumford DM, Skalweit M. Antibiotic-Resistant Infections and Treatment Challenges in the Immunocompromised Host. Infect Dis Clin North Am 2017; 30:465-489. [PMID: 27208768 DOI: 10.1016/j.idc.2016.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This article reviews antibiotic resistance and treatment of bacterial infections in the growing number of patients who are immunocompromised: solid organ transplant recipients, the neutropenic host, and persons with human immunodeficiency virus and AIDS. Specific mechanisms of resistance in both gram-negative and gram-positive bacteria, as well as newer treatment options are addressed elsewhere, and are only briefly discussed in the context of the immunocompromised host.
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Affiliation(s)
- Donald M Dumford
- Akron General Medical Center, 1 Akron General Way, Akron, OH 44302, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, Ohio 44272, USA.
| | - Marion Skalweit
- Louis Stokes Cleveland Department of Veterans Affairs, 10701 East Blvd 111(W), Cleveland, OH 44106, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, OH 44106, USA
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39
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Lucas N, Humble M, Sim D, Balm M, Carter J, Weinkove R. Temporal changes in neutropenic blood culture isolates and disease associations: a single centre series of 1139 episodes. Intern Med J 2017; 47:962-965. [PMID: 28782216 DOI: 10.1111/imj.13509] [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: 09/13/2016] [Revised: 01/26/2017] [Accepted: 02/26/2017] [Indexed: 11/29/2022]
Abstract
Neutropenic infections are life-threatening and require empiric antibiotic treatment. We examined 1139 blood culture isolates from our institution over a 36-year period from neutropenic patients to examine temporal trends and disease associations. Positive associations were found between viridans streptococci and acute myeloid leukaemia, coagulase negative staphylococci and acute lymphoblastic leukaemia and Pseudomonas aeruginosa and indolent B-cell malignancies.
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Affiliation(s)
- Nathanael Lucas
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand.,School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Michael Humble
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Dalice Sim
- Dean's Department, University of Otago, Wellington, New Zealand
| | - Michelle Balm
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand.,Wellington Southern Community Laboratories, Wellington Hospital, Wellington, New Zealand.,Infection Services, Capital and Coast District Health Board, Wellington, New Zealand
| | - John Carter
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand.,Wellington Blood and Cancer Centre, Capital and Coast District Health Board, Wellington, New Zealand
| | - Robert Weinkove
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand.,Malaghan Institute of Medical Research, Wellington, New Zealand.,Wellington Blood and Cancer Centre, Capital and Coast District Health Board, Wellington, New Zealand
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40
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Tofas P, Samarkos M, Piperaki ET, Kosmidis C, Triantafyllopoulou ID, Kotsopoulou M, Pantazatou A, Perlorentzou S, Poulli A, Vagia M, Daikos GL. Pseudomonas aeruginosa bacteraemia in patients with hematologic malignancies: risk factors, treatment and outcome. Diagn Microbiol Infect Dis 2017; 88:335-341. [DOI: 10.1016/j.diagmicrobio.2017.05.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/12/2017] [Accepted: 05/07/2017] [Indexed: 11/29/2022]
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41
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Kuo FC, Wang SM, Shen CF, Ma YJ, Ho TS, Chen JS, Cheng CN, Liu CC. Bloodstream infections in pediatric patients with acute leukemia: Emphasis on gram-negative bacteria infections. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 50:507-513. [DOI: 10.1016/j.jmii.2015.08.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/10/2015] [Accepted: 08/27/2015] [Indexed: 12/29/2022]
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42
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Kim HS, Park BK, Kim SK, Han SB, Lee JW, Lee DG, Chung NG, Cho B, Jeong DC, Kang JH. Clinical characteristics and outcomes of Pseudomonas aeruginosa bacteremia in febrile neutropenic children and adolescents with the impact of antibiotic resistance: a retrospective study. BMC Infect Dis 2017; 17:500. [PMID: 28716109 PMCID: PMC5513208 DOI: 10.1186/s12879-017-2597-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/06/2017] [Indexed: 11/27/2022] Open
Abstract
Background Although the proportion of Pseudomonas aeruginosa infections has reduced after the introduction of antibiotics with anti-pseudomonal effects, P. aeruginosa bacteremia still causes high mortality in immunocompromised patients. This study determined the clinical characteristics and outcomes of P. aeruginosa bacteremia and the antibiotic susceptibilities of strains isolated from febrile neutropenic patients. Methods Thirty-one febrile neutropenic children and adolescents with underlying hematologic/oncologic disorders diagnosed with P. aeruginosa bacteremia between 2011 and 2016 were enrolled in the study. Their medical records were retrospectively reviewed to evaluate the demographic and clinical characteristics. Antibiotic susceptibility rates of the isolated P. aeruginosa to eight antibiotic categories (anti-pseudomonal penicillin, anti-pseudomonal penicillin and β-lactamase inhibitor combination, anti-pseudomonal cephalosporin, monobactam, carbapenem, aminoglycoside, fluoroquinolone, and colistin) were also determined. Among the investigated factors, risk factors for mortality and infections by a multidrug-resistance (MDR) strain were determined. Results Thirty-six episodes of P. aeruginosa bacteremia were identified. The mean age of the enrolled patients was 9.5 ± 5.4 years, and 26 (72.2%) episodes occurred in boys. Acute myeloid leukemia (41.7%) and acute lymphoblastic leukemia (33.3%) were the most common underlying disorders. The 30-day mortality was 38.9%, and 36.1% of the episodes were caused by MDR strains. The deceased patients were more likely to experience breakthrough infection (P = 0.036) and bacteremia (P = 0.005) due to MDR strains when compared with the patients who survived. The survived patients more likely received appropriate empirical antibiotic therapy (P = 0.024) and anti-pseudomonal β-lactam and aminoglycoside combination therapy (P = 0.039) compared with the deceased patients. The antibiotic susceptibility rates of the isolated P. aeruginosa strains were as follows: piperacillin/tazobactam, 67.6%; meropenem, 72.2%; and amikacin, 100%. Conclusions Mortality due to P. aeruginosa bacteremia remained at 38.9% in this study, and more than one-third of the isolated strains were MDR. In this context, empirical antibiotic combination therapy to expand the antibiotic spectrum may be a strategy to reduce mortality due to P. aeruginosa bacteremia in febrile neutropenic patients.
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Affiliation(s)
- Hyo Sup Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Bo Kyoung Park
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Seong Koo Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Beom Han
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea. .,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jae Wook Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Gun Lee
- The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Nack-Gyun Chung
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bin Cho
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Catholic Blood and Marrow Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dae Chul Jeong
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Han Kang
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,The Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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43
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Increased risk of death with recurrent Pseudomonas aeruginosa bacteremia. Diagn Microbiol Infect Dis 2017; 88:152-157. [DOI: 10.1016/j.diagmicrobio.2017.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 11/22/2022]
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44
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Heidenreich D, Kreil S, Nolte F, Hofmann WK, Miethke T, Klein SA. Multidrug-resistant organisms in allogeneic hematopoietic cell transplantation. Eur J Haematol 2017; 98:485-492. [DOI: 10.1111/ejh.12859] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 12/22/2022]
Affiliation(s)
| | - Sebastian Kreil
- III. Medizinische Klinik; Universitätsmedizin Mannheim; Mannheim Germany
| | - Florian Nolte
- III. Medizinische Klinik; Universitätsmedizin Mannheim; Mannheim Germany
| | - Wolf K. Hofmann
- III. Medizinische Klinik; Universitätsmedizin Mannheim; Mannheim Germany
| | - Thomas Miethke
- Institut für Medizinische Mikrobiologie und Hygiene; Universitätsmedizin Mannheim; Mannheim Germany
| | - Stefan A. Klein
- III. Medizinische Klinik; Universitätsmedizin Mannheim; Mannheim Germany
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45
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Non-fermentative Gram-negative rods bacteremia in children with cancer: a 14-year single-center experience. Infection 2017; 45:327-334. [DOI: 10.1007/s15010-017-0988-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/31/2017] [Indexed: 12/21/2022]
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46
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Cattaneo C, Zappasodi P, Mancini V, Annaloro C, Pavesi F, Skert C, Ferrario A, Todisco E, Saccà V, Verga L, Passi A, Da Vià M, Ferrari S, Mometto G, Petullà M, Nosari A, Rossi G. Emerging resistant bacteria strains in bloodstream infections of acute leukaemia patients: results of a prospective study by the Rete Ematologica Lombarda (Rel). Ann Hematol 2016; 95:1955-1963. [DOI: 10.1007/s00277-016-2815-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/01/2016] [Indexed: 02/05/2023]
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47
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Klastersky J, Paesmans M, Aoun M, Georgala A, Loizidou A, Lalami Y, Dal Lago L. Clinical research in febrile neutropenia in cancer patients: Past achievements and perspectives for the future. World J Clin Infect Dis 2016; 6:37-60. [DOI: 10.5495/wjcid.v6.i3.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 12/02/2015] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
Febrile neutropenia (FN) is responsible for significant morbidity and mortality. It can also be the reason for delaying or changing potentially effective treatments and generates substantial costs. It has been recognized for more than 50 years that empirical administration of broad spectrum antibiotics to patients with FN was associated with much improved outcomes; that has become a paradigm of management. Increase in the incidence of microorganisms resistant to many antibiotics represents a challenge for the empirical antimicrobial treatment and is a reason why antibiotics should not be used for the prevention of neutropenia. Prevention of neutropenia is best performed with the use of granulocyte colony-stimulating factors (G-CSFs). Prophylactic administration of G-CSFs significantly reduces the risk of developing FN and consequently the complications linked to that condition; moreover, the administration of G-CSF is associated with few complications, most of which are not severe. The most common reason for not using G-CSF as a prophylaxis of FN is the relatively high cost. If FN occurs, in spite of prophylaxis, empirical therapy with broad spectrum antibiotics is mandatory. However it should be adjusted to the risk of complications as established by reliable predictive instruments such as the Multinational Association for Supportive Care in Cancer. Patients predicted at a low level of risk of serious complications, can generally be treated with orally administered antibiotics and as out-patients. Patients with a high risk of complications should be hospitalized and treated intravenously. A short period of time between the onset of FN and beginning of empirical therapy is crucial in those patients. Persisting fever in spite of antimicrobial therapy in neutropenic patients requires a special diagnostic attention, since invasive fungal infection is a possible cause for it and might require the use of empirical antifungal therapy.
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48
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Alshukairi A, Alserehi H, El-Saed A, Kelta M, Rehman JU, Khan FA, Alsalmi H, Alattas M, Aslam M. A de-escalation protocol for febrile neutropenia cases and its impact on carbapenem resistance: A retrospective, quasi-experimental single-center study. J Infect Public Health 2016; 9:443-51. [DOI: 10.1016/j.jiph.2015.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 11/15/2022] Open
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50
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Rapoport B, Klastersky J, Raftopoulos H, Freifeld A, Aoun M, Zinner SH, Rolston KVI. The emerging problem of bacterial resistance in cancer patients; proceedings of a workshop held by MASCC "Neutropenia, Infection and Myelosuppression" Study Group during the MASCC annual meeting held in Berlin on 27-29 June 2013. Support Care Cancer 2016; 24:2819-26. [PMID: 27098065 DOI: 10.1007/s00520-016-3183-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 03/21/2016] [Indexed: 11/25/2022]
Affiliation(s)
| | - Jean Klastersky
- Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Mickael Aoun
- Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles, Brussels, Belgium
| | - Stephen H Zinner
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
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