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Choi MH, Kim D, Kim J, Song YG, Jeong SH. Shift in risk factors for mortality by period of the bloodstream infection timeline. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:97-106. [PMID: 38092626 DOI: 10.1016/j.jmii.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/30/2023] [Accepted: 11/30/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND This study was designed to determine changes in risk factors on the prognosis of patients during each period of the bloodstream infection (BSI) timeline. METHODS Through an integrated study of multivariable regressions with machine learning techniques, the risk factors for mortality during each period of BSI were analyzed. RESULTS A total of 302,303 inpatients who underwent blood cultures during 2011-2021 were enrolled. More than 8 % of BSI cases progressed to subsequent BSI, and risk factors were identified as gut colonization with vancomycin-resistant enterococci (aOR 1.82; 95 % CI 1.47-2.24), intensive care unit admission (aOR 3.37; 95 % CI 3.35-4.28), and current cancer chemotherapy (aOR 1.54; 95 % CI 1.36-1.74). The mean SOFA score of the deceased patients during the first 7 days was 10.6 (SD 4.3), which was significantly higher than those on days 8-30 (7.0 ± 4.2) and after Day 30 (4.0 ± 3.5). BSIs caused by Acinetobacter baumannii and Candida albicans were more likely to result in deaths of patients for all time periods (all, P < 0.001). BSIs caused by Enterococcus faecalis and Enterococcus faecium were associated with a poor outcome in the period after Day 30 (both, P < 0.001). Nonsusceptible phenotypes to β-lactam/β-lactamase inhibitors of Escherichia coli and Klebsiella pneumoniae influenced the prognoses of patients with BSI in terms of high mortality rates during both days 8-30 and after Day 30. CONCLUSION Influence of microbiological factors on mortality, including BSI-causative microorganisms and their major antimicrobial resistance, was emphasized in both periods of days 8-30 and after Day 30.
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Affiliation(s)
- Min Hyuk Choi
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea
| | - Dokyun Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea
| | - Jihyun Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea.
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2
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Sim BZ, Slavin MA, Douglas AP. Risky business: The impact of antimicrobial prescribing on multidrug-resistant Gram-negative BSIs in acute myeloid leukemia patients. Transpl Infect Dis 2023; 25:e14102. [PMID: 37436795 DOI: 10.1111/tid.14102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Beatrice Z Sim
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
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Tori K, Tansarli GS, Parente DM, Kalligeros M, Ziakas PD, Mylonakis E. The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model. Medicine (Baltimore) 2020; 99:e20022. [PMID: 32443305 PMCID: PMC7254453 DOI: 10.1097/md.0000000000020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments. METHODS A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness. RESULTS The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options. DISCUSSION Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.
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Affiliation(s)
- Katerina Tori
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
| | | | - Diane M. Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
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Risk Factors of Carbapenem-resistant Acinetobacter baumannii Infection among Hospitalized Patients. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jecm.2014.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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5
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Baek JH, Kim CO, Jeong SJ, Ku NS, Han SH, Choi JY, Yong D, Song YG, Lee K, Kim JM. Clinical factors associated with acquisition of resistance to levofloxacin in Stenotrophomonas maltophilia. Yonsei Med J 2014; 55:987-93. [PMID: 24954328 PMCID: PMC4075404 DOI: 10.3349/ymj.2014.55.4.987] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Fluoroquinolones, rapidly gaining prominence in treatment of Stenotrophomonas maltophilia (SMP), are noted for their potency and tolerability. However, SMP may rapidly acquire resistance to fluoroquinolones. We evaluated associations of clinical factors with acquisition of levofloxacin resistance (LFr) in SMP. MATERIALS AND METHODS Our retrospective cohort study was based on patient data collected between January 2008 and June 2010. Through screening of 1275 patients, we identified 122 patients with data for SMP antibiotic susceptibility testing in ≥3 serial SMP isolates. RESULTS We assigned the 122 patients to either the SS group (n=54) in which levofloxacin susceptibility was maintained or the SR group (n=31) in which susceptible SMP acquired resistance. In multivariate regression analysis, exposure to levofloxacin for more than 3 weeks [odds ratio (OR) 15.39, 95% confidential interval (CI) 3.08-76.93, p=0.001] and co-infection or co-colonization with Klebsiella pneumoniae resistant to levofloxacin (OR 4.85, 95% CI 1.16-20.24, p=0.030) were independently associated with LFr acquisition in SMP. CONCLUSION Acquisition of LFr during serial sampling of SMP was related to the levofloxacin exposure.
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Affiliation(s)
- Ji Hyeon Baek
- Department of Infectious Disease, Inha University Hospital, Incheon, Korea
| | - Chang Oh Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Soo Ku
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dongeun Yong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Marín M, Gudiol C, Garcia-Vidal C, Ardanuy C, Carratalà J. Bloodstream infections in patients with solid tumors: epidemiology, antibiotic therapy, and outcomes in 528 episodes in a single cancer center. Medicine (Baltimore) 2014; 93:143-149. [PMID: 24797169 PMCID: PMC4632909 DOI: 10.1097/md.0000000000000026] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Current information regarding bloodstream infection (BSI) in patients with solid tumors is scarce. We assessed the epidemiology, antibiotic therapy, and outcomes of BSI in these patients. We also compared patients who died with those who survived to identify risk factors associated with mortality. From January 2006 to July 2012 all episodes of BSI in patients with solid tumors at a cancer center were prospectively recorded and analyzed. A total of 528 episodes of BSI were documented in 489 patients. The most frequent neoplasms were hepatobiliary tumors (19%), followed by lung cancer (18%) and lower gastrointestinal malignancies (16%). Many patients had received corticosteroid therapy (41%), and 15% had neutropenia (<500 neutrophils/μL) at the time of BSI. The most common source of BSI was cholangitis (21%), followed by other abdominal (19.5%) and urinary tract infections (17%). Gram-negative BSI occurred in 55% of cases, mainly due to Escherichia coli (55%), Pseudomonas aeruginosa (18%), and Klebsiella pneumoniae (16%). Among gram-positive BSI (35%), viridans group streptococci were the most frequent causative organisms (22%), followed by Staphylococcus aureus (21%) and Enterococcus species (18%). We identified 61 multidrug-resistant (MDR) organisms (13%), mainly extended-spectrum β-lactamase-producing Enterobacteriaceae (n = 20) and AmpC-producing Enterobacteriaceae (n = 13). The majority of patients with BSI caused by MDR organisms had received antibiotics (70%), and they had been previously hospitalized (61.4%) more frequently than patients with BSI caused by susceptible strains. Inadequate empirical antibiotic therapy was given to 23% of patients, with a higher proportion in those with BSI due to a MDR strain (69%). Early (<48 h) and overall (30 d) case-fatality rates were 7% and 32%, respectively. The overall case-fatality rate was higher among cases caused by MDR organisms (39.3%). The only independent risk factors for the early case-fatality rate were the endogenous source of BSI (odds ratio [OR], 3.57; 95% confidence interval [CI], 1.06-12.02), shock at presentation (OR, 3.63; 95% CI, 1.63-8.09), and corticosteroid therapy (OR, 3.245; 95% CI, 1.43-7.32). The independent risk factors for overall case-fatality rate were the presence of a chronic advanced cancer (OR, 35.39; 95% CI, 2.48-504.91), shock at presentation (OR, 25.84; 95% CI, 3.73-179.0), and corticosteroid therapy (OR, 6.98; 95% CI, 1.61-30.21).BSI in patients with solid tumors occurred mainly among those with hepatobiliary cancer, and cholangitis was the most frequent source; gram-negative bacilli were the most frequent causative agents. MDR organisms were relatively common, particularly in patients who had previously received antibiotics and had been hospitalized; these patients were frequently treated with inadequate empirical antibiotic therapy and had a poorer outcome. The case-fatality rate of patients with solid tumors and BSI was high and was associated with chronic advanced cancer, corticosteroid therapy, and shock at presentation.
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Affiliation(s)
- Mar Marín
- From the Oncology Department (MM), Institut Català d'Oncologia, L'Hospitalet, University of Barcelona, Barcelona; Infectious Disease Service (CG, CGV, JC) and Microbiology Department (CA), Institut d'Investigacío Biomèdica de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, University of Barcelona, Barcelona; REIPI (Spanish Network for Research in Infectious Disease) (CG, CGV, JC) and CIBERes (Centro de Investigacíon Biomèdica en Red en Enfermedades Respiratorias) (CA), Instituto de Salud Carlos III, Madrid; Spain
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Hess AS, Kleinberg M, Sorkin JD, Netzer G, Johnson JK, Shardell M, Thom KA, Harris AD, Roghmann MC. Prior colonization is associated with increased risk of antibiotic-resistant Gram-negative bacteremia in cancer patients. Diagn Microbiol Infect Dis 2014; 79:73-6. [PMID: 24582582 DOI: 10.1016/j.diagmicrobio.2014.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 01/13/2014] [Accepted: 01/21/2014] [Indexed: 11/27/2022]
Abstract
We hypothesized that prior colonization with antibiotic-resistant Gram-negative bacteria is associated with increased risk of subsequent antibiotic-resistant Gram-negative bacteremia among cancer patients. We performed a matched case-control study. Cases were cancer patients with a blood culture positive for antibiotic-resistant Gram-negative bacteria. Controls were cancer patients with a blood culture not positive for antibiotic-resistant Gram-negative bacteria. Prior colonization was defined as any antibiotic-resistant Gram-negative bacteria in surveillance or non-sterile-site cultures obtained 2-365 days before the bacteremia. Thirty-two (37%) of 86 cases and 27 (8%) of 323 matched controls were previously colonized by any antibiotic-resistant Gram-negative bacteria. Prior colonization was strongly associated with antibiotic-resistant Gram-negative bacteremia (odds ratio [OR] 7.2, 95% confidence interval [CI] 3.5-14.7) after controlling for recent treatment with piperacillin-tazobactam (OR 2.5, 95% CI 1.3-4.8). In these patients with suspected bacteremia, prior cultures may predict increased risk of antibiotic-resistant Gram-negative bacteremia.
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Affiliation(s)
- Aaron S Hess
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA.
| | - Michael Kleinberg
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
| | - John D Sorkin
- Baltimore VA Medical Center Geriatric Research, Education, and Clinical Center, University of Maryland School of Medicine, Baltimore, MD, USA; Division of Gerontology and Geriatric Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Giora Netzer
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland, Baltimore, MD, USA
| | | | - Michelle Shardell
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - Kerri A Thom
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA
| | - Mary-Claire Roghmann
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, USA; Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA.
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Ceftaroline. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0b013e3182948d1c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Epidemiology, antibiotic therapy and outcomes of bacteremia caused by drug-resistant ESKAPE pathogens in cancer patients. Support Care Cancer 2013; 22:603-10. [DOI: 10.1007/s00520-013-2012-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
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10
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Wiernik PH, Goldman JM, Dutcher JP, Kyle RA. Evaluation and Management of Bacterial and Fungal Infections Occurring in Patients with a Hematological Malignancy: A 2011 Update. NEOPLASTIC DISEASES OF THE BLOOD 2013. [PMCID: PMC7120157 DOI: 10.1007/978-1-4614-3764-2_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with a hematological malignancy are a heterogeneous patient population who are afflicted with diseases that range from rapidly fatal acute leukemia to indolent lymphoma or chronic leukemia. Treatment options for these patients range from observation to hematopoietic stem cell transplantation (HSCT), but all patients are more susceptible to infection. The problem of infection is dynamic with continued shifts in pathogenic organisms and microbial susceptibilities, new treatment regimens that further diminish immune function, and patients receiving treatment who are now older and frailer. The classic patterns of immunodeficiency for patients with a hematological malignancy include: periods of profound neutropenia, increased iatrogenic risks (i.e., central vascular catheters), and cellular immune suppression that affects HSCT recipients, patients with lymphoid malignancies, and those receiving treatment with corticosteroids or agents like alemtuzumab [1–4]. Recent advances in antimicrobial drug development, new technology, clinical trial results, and further clinical experience have enhanced the database on which to make infection prophylaxis and treatment decisions. However, the practicing clinician must remember that the majority of basic infection management principles for patients who are neutropenic remain unchanged.
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Affiliation(s)
- Peter H. Wiernik
- Beth Israel Hospital, Cancer Center, St. Lukes-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - John M. Goldman
- , Department of Hematology, Imperial College of London, Du Cane Road 150, London, W12 0NN United Kingdom
| | - Janice P. Dutcher
- Continuum Cancer Centers, Department of Medicine, St. Luke's-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - Robert A. Kyle
- , Division of Hematology, Mayo Clinic, First Street SW. 200, Rochester, 55905 Minnesota USA
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Zhong L, Men TY, Li H, Peng ZH, Gu Y, Ding X, Xing TH, Fan JW. Multidrug-resistant gram-negative bacterial infections after liver transplantation - spectrum and risk factors. J Infect 2011; 64:299-310. [PMID: 22198738 DOI: 10.1016/j.jinf.2011.12.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/09/2011] [Accepted: 12/10/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Gram-negative bacilli infections, especially multidrug-resistant gram-negative bacilli infections, are the leading cause of high mortality after liver transplantation. This study sought to investigate the type of infection, infection rate, pathogenic spectrum, antibiotic-resistance profile, risk factors, and epidemiology of multidrug-resistant gram-negative bacterial infection. METHODS A retrospective cohort study was conducted and data of 217 liver transplant patients receiving cadaveric livers between January 2007 and April 2010 were analyzed. Antibiotic susceptibility was determined by minimum inhibitory concentration test. Extended-spectrum and metallo-β-lactamase assays were used to analyze β-lactamase-produced isolates, and repetitive-sequence polymerase chain reaction was used to differentiate bacterium subspecies. RESULTS Sixty-seven isolates of multidrug-resistant gram-negative bacteria were isolated from 66 infected liver transplant patients. Stenotrophomonas maltophilia (100%, 8/8), Klebsiella pneumoniae (61.5%, 8/13), Enterobacter cloacae (75%, 3/4) and Escherichia coli (81.3%, 13/16) were the most common extended-spectrum β-lactamase-producing bacilli. Metallo-β-lactamase expressing isolates were identified as S. maltophilia (100%, 8/8), Pseudomonas aeruginosa (83.3%, 5/6), Acinetobacter baumannii (95%, 19/20). Significant independent risk factors for multidrug-resistant gram-negative infection were extended use of pre-transplant broad-spectrum antibiotics (OR 9.027, P=0.001) and prolonged (≧72h) endotracheal intubation (OR 3.537, P=0.033). CONCLUSIONS To reduce the risk of acquiring MDR gram-negative bacillus infections after liver transplant, control measures are required to limit the use of prophylactic antibiotic in preventing infection during liver transplant and to shorten endotracheal intubation time.
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Affiliation(s)
- Lin Zhong
- Department of General Surgery, Shanghai First Peoples Hospital, Medical School of Shanghai Jiaotong University, 85 Wu Jing Road, 200080 Shanghai, People's Republic of China.
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12
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56-93. [PMID: 21258094 DOI: 10.1093/cid/cir073] [Citation(s) in RCA: 1812] [Impact Index Per Article: 139.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care-associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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13
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Executive Summary: Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:427-31. [DOI: 10.1093/cid/ciq147] [Citation(s) in RCA: 508] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia.
Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving.
What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens.
Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care–associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G. Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Eric J. Bow
- Departments of Medical Microbiology and Internal Medicine, the University of Manitoba, and Infection Control Services, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Kent A. Sepkowitz
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York
| | - Michael J. Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research, Seattle, Washington
| | - James I. Ito
- Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California
| | - Craig A. Mullen
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Issam I. Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kenneth V. Rolston
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jo-Anne H. Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - John R. Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
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Gudiol C, Tubau F, Calatayud L, Garcia-Vidal C, Cisnal M, Sanchez-Ortega I, Duarte R, Calvo M, Carratala J. Bacteraemia due to multidrug-resistant Gram-negative bacilli in cancer patients: risk factors, antibiotic therapy and outcomes. J Antimicrob Chemother 2010; 66:657-63. [DOI: 10.1093/jac/dkq494] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Chen WT, Liu TM, Wu SH, Tan TD, Tseng HC, Shih CC. Improving diagnosis of central venous catheter-related bloodstream infection by using differential time to positivity as a hospital-wide approach at a cancer hospital. J Infect 2009; 59:317-23. [DOI: 10.1016/j.jinf.2009.09.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Revised: 08/12/2009] [Accepted: 09/06/2009] [Indexed: 11/27/2022]
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Worth LJ, Slavin MA. Bloodstream infections in haematology: risks and new challenges for prevention. Blood Rev 2008; 23:113-22. [PMID: 19046796 DOI: 10.1016/j.blre.2008.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Bloodstream infections are an important cause of morbidity and mortality in the haematology population, and may contribute to delayed administration of chemotherapy, increased length of hospitalisation, and increased healthcare expenditure. For gram-positive, gram-negative, anaerobic and fungal infections, specific risk factors are recognised. Unique host and environmental factors contributing to pathogenesis are acknowledged in this population. Trends in spectrum and antimicrobial susceptibility of pathogens are examined, and potential contributing factors are discussed. These include the widespread use of empiric antimicrobial therapy, increasingly intensive chemotherapeutic regimens, frequent use of central venous catheters, and local infection control practices. In addition, the risks and benefits of prophylaxis, and spectrum of endemic flora are identified as relevant factors within individual centres. Finally, challenges are presented regarding prevention, early detection, surveillance and prophylaxis. To reduce the rate and impact of bloodstream infections multifaceted and customised strategies are required within individual haematology units.
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Affiliation(s)
- Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia.
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Cheong HS, Kang CI, Wi YM, Kim ES, Lee JS, Ko KS, Chung DR, Lee NY, Song JH, Peck KR. Clinical significance and predictors of community-onset Pseudomonas aeruginosa bacteremia. Am J Med 2008; 121:709-14. [PMID: 18691485 DOI: 10.1016/j.amjmed.2008.03.034] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 03/14/2008] [Accepted: 03/15/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa bacteremia is a serious and possibly fatal condition. It is important to determine the likelihood of P. aeruginosa bacteremia when Gram-negative sepsis is suspected in community-onset infection. METHODS We performed a retrospective cohort study to identify the risk factors for P. aeruginosa infection in community-onset Gram-negative bacteremia. RESULTS A total of 106 patients with P. aeruginosa bacteremia and a total 508 patients with E. coli bacteremia were included in this study. Factors associated with P. aeruginosa bacteremia in the multivariate analysis included presentation with neutropenia, presentation with septic shock, indwelling central venous catheter, and health-care-associated infection (all P <.05). The 30-day mortality rate was 26.4% in patients with P. aeruginosa and 13.6% in those with E. coli bacteremia (P <.001). Multivariate analysis demonstrated that risk factors for mortality included a P. aeruginosa bacteremia, inappropriate initial antimicrobial therapy, a higher Charlson's weighted index of comorbidity, and a higher Pitt bacteremia score (all P <.05). In addition, urinary tract infection and benign pancreatobiliary disease were found to be protective factors for mortality based on multivariate analysis (all P <.05). CONCLUSIONS Our data suggest that initial empirical antimicrobial coverage of P. aeruginosa should be seriously considered in patients with neutropenia, presentation with septic shock, indwelling central venous catheter, or health-care-associated infection, when Gram-negative sepsis is suspected in community-onset infection.
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Affiliation(s)
- Hae Suk Cheong
- Division of Infectious Disease, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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18
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Vonberg RP, Wolter A, Chaberny IF, Kola A, Ziesing S, Suerbaum S, Gastmeier P. Epidemiology of multi-drug-resistant Gram-negative bacteria: Data from an university hospital over a 36-month period. Int J Hyg Environ Health 2008; 211:251-7. [DOI: 10.1016/j.ijheh.2007.08.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 08/01/2007] [Accepted: 08/15/2007] [Indexed: 11/29/2022]
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Falagas ME, Mourtzoukou EG, Giannopoulou KP, Alexiou VG, Rafailidis PI. Matching criteria in case-control studies in the field of antimicrobial resistance. Microb Drug Resist 2008; 14:171-82. [PMID: 18489243 DOI: 10.1089/mdr.2008.0820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We evaluated the available evidence from case-control studies in the field of antimicrobial resistance to identify the degree that matching was performed and the criteria used to do so. METHODS We performed a systematic search of the PubMed database (articles archived by 08/2006) to identify relevant studies. Studies that used the individual matching technique were further analyzed. RESULTS 115 case-control studies with a focus on antimicrobial resistance were identified: 28 regarding Acinetobacter baumannii, 25 regarding Pseudomonas aeruginosa, and 62 for other bacteria. Individual matching was performed in 32 (27.8%) out of the 115 studies. Age was the most frequently used matching criterion in 22 of 32 (69%) evaluated matched case-control studies, while sex was used in 11 (34%), presence of underlying illness in 8 (25%), site of infection in 5 (16%), and area of residence in 4 studies (12.5%). Other criteria were used in less than 10% of the studies. Analysis of data for matched pairs was performed in 18 of 32 (56.3%) studies that used a matched case-control design. DISCUSSION The available evidence from the analyzed data from case-control studies in the field of antimicrobial resistance shows that individual matching is employed only in a proportion of such studies and only for a few characteristics, when it was used. Also, analysis for matched pairs was not used by almost a half of the relevant studies.
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20
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Raad I, Hachem R, Hanna H, Bahna P, Chatzinikolaou I, Fang X, Jiang Y, Chemaly RF, Rolston K. Sources and outcome of bloodstream infections in cancer patients: the role of central venous catheters. Eur J Clin Microbiol Infect Dis 2007; 26:549-56. [PMID: 17582536 DOI: 10.1007/s10096-007-0320-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Simultaneously drawn quantitative blood cultures are used to diagnose catheter-related bloodstream infections. We conducted this study to determine the frequency with which central venous catheters were the source of bloodstream infections detected through paired positive blood cultures drawn from cancer patients and the potential for quantitative blood cultures to help predict outcome in neutropenic and non-neutropenic patients. From September 1999 to November 2000, we identified 169 patients with bloodstream infections. Of all bloodstream infections, 56% were catheter-related bloodstream infections. Gram-positive bacteremia was found to be catheter-related in 55% and 69% of patients with hematologic malignancy and solid tumors, respectively, whereas gram-negative bacteremia was catheter-related in only 19% of patients with underlying hematologic malignancy and in 60% of patients with solid tumor (P = 0.01). By multivariate analysis, poor response was associated with critical illness and persistent neutropenia (P < 0.01). In neutropenic patients with catheter-related bloodstream infections, peripheral quantitative blood cultures of >or=100 CFU/mL was also associated with poor response (P = 0.05). Central venous catheters were the major source of bloodstream infection, particularly in patients with solid tumors. In addition to critical illness and persistent neutropenia, quantitative blood cultures might be useful in predicting outcomes for neutropenic patients with catheter-related bloodstream infections.
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Affiliation(s)
- I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, Unit 402, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77230-1402, USA.
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21
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Ansari SR, Hanna H, Hachem R, Jiang Y, Rolston K, Raad I. Risk factors for infections with multidrug-resistantStenotrophomonas maltophilia in patients with cancer. Cancer 2007; 109:2615-22. [PMID: 17487860 DOI: 10.1002/cncr.22705] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Stenotrophomonas maltophilia is responsible for an increasing number of infections, especially in hospitalized patients. Therapy options are limited and trimethoprim/sulfamethoxazole (TMP/SMX) is often the main treatment option for this infection. In the current study, the risk factors were determined for the emergence of multidrug-resistant (MDR) S. maltophilia. METHODS A case-control study was conducted to determine risk factors for the development of MDR S. maltophilia in cancer patients. The case group was composed of patients treated at the University of Texas M. D. Anderson Cancer Center for MDR S. maltophilia between 1996 and 2004 (n = 54). Two control groups were used: patients at comparable risk for S. maltophilia (C-controls) and patients with S. maltophilia infection that was susceptible to TMP-SMX and at least 2 other antibiotics (ciprofloxacin, ceftazidime, amikacin, and ticarcillin/clavulanate) (S-controls). RESULTS When compared with C-controls, prior use of carbapenems or quinolones and admission to an intensive care unit within 30 days of isolation of the pathogen were found to be independently associated with MDR S. maltophilia infection (P < .02), as was an increased overall mortality rate (P = .04). When compared with S-controls, risk factors were history of S. maltophilia infection during the prior year and prior use of TMP-SMX (P = .015). CONCLUSIONS Judicious use of TMP-SMX, carbapenems, and quinolones is necessary to control the risk for MDR S. maltophilia infection.
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Affiliation(s)
- Shoaib R Ansari
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Oliveira AL, de Souza M, Carvalho-Dias VMH, Ruiz MA, Silla L, Tanaka PY, Simões BP, Trabasso P, Seber A, Lotfi CJ, Zanichelli MA, Araujo VR, Godoy C, Maiolino A, Urakawa P, Cunha CA, de Souza CA, Pasquini R, Nucci M. Epidemiology of bacteremia and factors associated with multi-drug-resistant gram-negative bacteremia in hematopoietic stem cell transplant recipients. Bone Marrow Transplant 2007; 39:775-81. [PMID: 17438585 DOI: 10.1038/sj.bmt.1705677] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The incidence of Gram-negative bacteremia has increased in hematopoietic stem cell transplant (HSCT) recipients. We prospectively collected data from 13 Brazilian HSCT centers to characterize the epidemiology of bacteremia occurring early post transplant, and to identify factors associated with infection due to multi-drug-resistant (MDR) Gram-negative isolates. MDR was defined as an isolate with resistance to at least two of the following: third- or fourth-generation cephalosporins, carbapenems or piperacillin-tazobactam. Among 411 HSCT, fever occurred in 333, and 91 developed bacteremia (118 isolates): 47% owing to Gram-positive, 37% owing to Gram-negative, and 16% caused by Gram-positive and Gram-negative bacteria. Pseudomonas aeruginosa (22%), Klebsiella pneumoniae (19%) and Escherichia coli (17%) accounted for the majority of Gram-negative isolates, and 37% were MDR. These isolates were recovered from 20 patients, representing 5% of all 411 HSCT and 22% of the episodes with bacteremia. By multivariate analysis, treatment with third-generation cephalosporins (odds ratio (OR) 10.65, 95% confidence interval (CI) 3.75-30.27) and being at one of the hospitals (OR 9.47, 95% CI 2.60-34.40) were associated with infection due to MDR Gram-negative isolates. These findings may have important clinical implications in the decision of giving prophylaxis and selecting the empiric antibiotic regimen.
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Affiliation(s)
- A L Oliveira
- Hospital Universitário, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Combes A, Luyt CE, Fagon JY, Wolff M, Trouillet JL, Chastre J. Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia. Intensive Care Med 2006; 32:1970-8. [PMID: 16957901 DOI: 10.1007/s00134-006-0355-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 07/26/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial. STUDY OBJECTIVE, DESIGN, AND PATIENTS: We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics. RESULTS Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03-1.12); female gender (OR: 4.00; 95% CI: 1.41-11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02-7.33); and SOFA score (OR: 1.17; 95% CI: 1.03-1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72-5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status. CONCLUSIONS For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.
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Affiliation(s)
- Alain Combes
- Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris Université Pierre et Marie Curie, Paris 6, Service de Réanimation Médicale, Institut de Cardiologie, Paris, France,
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Falagas ME, Kopterides P. Risk factors for the isolation of multi-drug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa: a systematic review of the literature. J Hosp Infect 2006; 64:7-15. [PMID: 16822583 DOI: 10.1016/j.jhin.2006.04.015] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Accepted: 04/18/2006] [Indexed: 02/06/2023]
Abstract
An understanding of the epidemiology of multi-drug-resistant (MDR) Acinetobacter baumannii and Pseudomonas aeruginosa infections is necessary in order to develop strategies to curtail their spread. For this purpose, the evidence linking the isolation of MDR A. baumannii and P. aeruginosa with specific risk factors was evaluated. PubMed was searched for the 20-year period from September 1985 to September 2005, and eligible studies were considered to be those that: (1) linked the isolation of A. baumannii and P. aeruginosa with specific risk factors; (2) described the characteristics of the affected patients in detail; and (3) provided data on the antibiotic resistance profile of the isolated micro-organisms. Fifty-five studies were found referring to A. baumannii (28 with case-control methodology and 27 outbreak investigations without case-control methodology), and 42 studies were found referring to P. aeruginosa (25 with case-control methodology and 17 outbreak investigations without case-control methodology). Although heterogeneous study designs and investigated risk factors limited this analysis, it was concluded that acquisition and spread of these micro-organisms appear to be related to a large number of variables. Among the most important were deficiencies in the implementation of infection control guidelines and the use of broad-spectrum antibiotics. Use of carbapenems and third-generation cephalosporins appear to be related to the development of an MDR phenotype by A. baumannii, while carbapenems and fluoroquinolones are implicated in MDR P. aeruginosa. The diversity of risk factors associated with the development of MDR A. baumannii and P. aeruginosa suggests that a separate outbreak investigation should be performed in each hospital setting. The development of innovative control strategies is needed in order to limit the spread of these pathogens.
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Affiliation(s)
- M E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece.
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