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Okurowska K, Monk PN, Karunakaran E. Increased tolerance to commonly used antibiotics in a Pseudomonas aeruginosa ex vivo porcine keratitis model. MICROBIOLOGY (READING, ENGLAND) 2024; 170:001459. [PMID: 38739119 PMCID: PMC11165664 DOI: 10.1099/mic.0.001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
Introduction. Bacterial keratitis, particularly caused by Pseudomonas aeruginosa, is challenging to treat because of multi-drug tolerance, often associated with the formation of biofilms. Antibiotics in development are typically evaluated against planktonic bacteria in a culture medium, which may not accurately represent the complexity of infections in vivo.Hypothesis/Gap Statement. Developing a reliable, economic ex vivo keratitis model that replicates some complexity of tissue infections could facilitate a deeper understanding of antibiotic efficacy, thus aiding in the optimization of treatment strategies for bacterial keratitis.Methodology. Here we investigated the efficacy of three commonly used antibiotics (gentamicin, ciprofloxacin and meropenem) against Pseudomonas aeruginosa cytotoxic strain PA14 and invasive strain PA01 using an ex vivo porcine keratitis model.Results. Both strains of P. aeruginosa were susceptible to the MIC of the three tested antibiotics. However, significantly higher concentrations were necessary to inhibit bacterial growth in the minimum biofilm eradication concentration (MBEC) assay, with both strains tolerating concentrations greater than 512 mg l-1 of meropenem. When MIC and higher concentrations than MBEC (1024 mg l-1) of antibiotics were applied, ciprofloxacin exhibited the highest potency against both P. aeruginosa strains, followed by meropenem, while gentamicin showed the least potency. Despite this, none of the antibiotic concentrations used effectively cleared the infection, even after 18 h of continuous exposure.Conclusions. Further exploration of antibiotic concentrations and aligning dosing with clinical studies to validate the model is needed. Nonetheless, our ex vivo porcine keratitis model could be a valuable tool for assessing antibiotic efficacy.
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Affiliation(s)
- Katarzyna Okurowska
- Department of Chemical and Biological Engineering, University of Sheffield, Sheffield S10 2TN, UK
- National Institute for Health and Care Research, University of Leeds, Leeds LS2 9JT, UK
| | - Peter N. Monk
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK
| | - Esther Karunakaran
- Department of Chemical and Biological Engineering, University of Sheffield, Sheffield S10 2TN, UK
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Karabasevic N, Roberts JA, Stronach L, Naicker S, Wallis SC, Sjövall F, Sime F. Use of the Hollow-Fiber Infection Model to Measure the Effect of Combination Therapy of Septic Shock Exposures of Meropenem and Ciprofloxacin against Intermediate and Resistant Pseudomonas aeruginosa Clinical Isolates. Antimicrob Agents Chemother 2022; 66:e0214021. [PMID: 35389238 PMCID: PMC9112939 DOI: 10.1128/aac.02140-21] [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: 11/18/2021] [Accepted: 02/25/2022] [Indexed: 11/20/2022] Open
Abstract
Meropenem-ciprofloxacin combination therapy was compared to the respective monotherapy in a Hollow-Fiber Infection Model against two Pseudomonas aeruginosa isolates. Following initial kill of ∼ 5-logs by each monotherapy, rapid regrowth occurred within 24 h, reaching 108 - 1010 CFU/mL at 120 h. In contrast, combination therapy achieved > 5-log kill within 6 h and suppressed bacterial regrowth throughout. The results suggest that meropenem-ciprofloxacin combination may provide significantly enhanced bacterial killing and resistance suppression against P. aeruginosa.
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Affiliation(s)
| | - Jason A. Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Luke Stronach
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Saiyuri Naicker
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Steven C. Wallis
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Fredrik Sjövall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Mitochondrial Medicine, Lund University, Lund, Sweden
| | - Fekade Sime
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
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Lynch JP, Zhanel GG. Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy. Semin Respir Crit Care Med 2022; 43:191-218. [PMID: 35062038 DOI: 10.1055/s-0041-1740109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Hakki M, Humphries RM, Hemarajata P, Tallman GB, Shields RK, Mettus RT, Doi Y, Lewis JS. Fluoroquinolone Prophylaxis Selects for Meropenem-nonsusceptible Pseudomonas aeruginosa in Patients With Hematologic Malignancies and Hematopoietic Cell Transplant Recipients. Clin Infect Dis 2020; 68:2045-2052. [PMID: 30256922 DOI: 10.1093/cid/ciy825] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/21/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In Pseudomonas aeruginosa, fluoroquinolone exposure promotes resistance to carbapenems through upregulation of efflux pumps and transcriptional downregulation of the porin OprD. Evidence of this effect among hematologic malignancy (HM) patients or hematopoietic cell transplant (HCT) recipients receiving fluoroquinolone prophylaxis for neutropenia is lacking. METHODS We retrospectively evaluated episodes of P. aeruginosa bloodstream infections in HM patients or HCT recipients over a 7-year period at our institution. We determined the association of fluoroquinolone prophylaxis at the time of infection with meropenem susceptibility of P. aeruginosa breakthrough isolates and risk factors for meropenem nonsusceptibility. Whole-genome sequencing (WGS) and phenotypic assessments of meropenem efflux pump activity were performed on select isolates to determine the mechanisms of meropenem resistance. RESULTS We analyzed 55 episodes of P. aeruginosa bacteremia among 51 patients. Breakthrough bacteremia while on fluoroquinolone prophylaxis was associated with nonsusceptibility to meropenem, but not to antipseudomonal β-lactams or aminoglycosides. The receipt of fluoroquinolone prophylaxis was independently predictive of bacteremia with a meropenem-nonsusceptible isolate. All meropenem-nonsusceptible isolates analyzed by WGS contained oprD inactivating mutations, and all meropenem-nonsusceptible isolates tested demonstrated reductions in the meropenem minimum inhibitory concentration in the presence of an efflux pump inhibitor. A phylogenetic analysis based on WGS revealed several clusters of closely related isolates from different patients. CONCLUSIONS Fluoroquinolone prophylaxis in HM patients and HCT recipients is associated with breakthrough bacteremia with meropenem-nonsusceptible P. aeruginosa strains, likely due to both mutations increasing efflux pump activity and the epidemiology of P. aeruginosa bloodstream infections in our patient population.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Oregon Health and Science University, Portland
| | | | | | - Gregory B Tallman
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland
| | - Ryan K Shields
- Division of Infectious Diseases, Center for Innovative Antimicrobial Therapy, University of Pittsburgh School of Medicine, Pennsylvania
| | - Roberta T Mettus
- Division of Infectious Diseases, Center for Innovative Antimicrobial Therapy, University of Pittsburgh School of Medicine, Pennsylvania
| | - Yohei Doi
- Division of Infectious Diseases, Center for Innovative Antimicrobial Therapy, University of Pittsburgh School of Medicine, Pennsylvania.,Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - James S Lewis
- Department of Pharmacy Services, Oregon Health and Science University, Portland
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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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Park SY, Kang CI, Wi YM, Chung DR, Peck KR, Lee NY, Song JH. Risk factors and molecular epidemiology of community-onset, multidrug resistance extended-spectrum β-lactamase-producing Escherichia coli infections. Korean J Intern Med 2017; 32:146-157. [PMID: 27093979 PMCID: PMC5214718 DOI: 10.3904/kjim.2015.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 01/15/2016] [Accepted: 01/22/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Although multidrug resistance (MDR) among extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) poses significant therapeutic challenges, little is known regarding the risk factors and epidemiology of community-onset MDR-ESBL-EC infections. We performed this study to investigate risk factors and the molecular epidemiology of community-onset MDR-ESBL-EC infections. METHODS We conducted a case-control-control study of community-onset infections. MDR-ESBL-EC was defined as ESBL-EC that demonstrated in vitro resistance to trimethoprim-sulfamethoxazole, fluoroquinolones (FQs), and gentamicin. Patients with MDR-ESBL-EC infections were designated as case patients. A control group I (CG I) patient was defined as a person whose clinical sample yielded ESBL-EC that did not meet the criteria for MDR. A control group II (CG II) patient was defined as a patient with a non-ESBL-EC infection. RESULTS Of 108 patients with ESBL-EC infections, 30 cases (27.8%) were due to MDR-ESBL-EC. Compared with CG I, prior use of FQs (odds ratio [OR], 3.16; 95% confidence interval [CI], 1.11 to 8.98) and immunosuppressant use (OR, 10.47; 95% CI, 1.07 to 102.57) were significantly associated with MDR-ESBL-EC. Compared with CG II, prior use of FQs (OR, 15.53; 95% CI, 2.86 to 84.27) and healthcare-associated infection (OR, 5.98; 95% CI, 2.26 to 15.86) were significantly associated with MDR-ESBL-EC. CTX-M-15 was the most common in MDR-ESBL-EC infections (59.1% [13/22]), while CTX-M-14 was the most common in non-MDR-ESBL-EC infections (41.6% [32/77]). CTX-M-15 was significantly associated with MDR-ESBL-EC (59.1% vs. 32.5%, p = 0.028). Pulsed-field gel electrophoresis showed clonal diversity of MDR-ESBL-EC isolates. CONCLUSIONS The emergence of strains of MDR-ESBL-EC in the community poses an important new public health threat. More information on the emergence and transmission of these strains will be necessary in order to prevent their spread.
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Affiliation(s)
- So Yeon Park
- Division of Infectious Diseases, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Correspondence to Cheol-In Kang, M.D. Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnamgu, Seoul 06351, Korea Tel: +82-2-3410-0324 Fax: +82-2-3410-0064 E-mail:
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam-Yong Lee
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Penicillin-Binding Protein 3 Is Essential for Growth of Pseudomonas aeruginosa. Antimicrob Agents Chemother 2016; 61:AAC.01651-16. [PMID: 27821444 DOI: 10.1128/aac.01651-16] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/23/2016] [Indexed: 12/19/2022] Open
Abstract
Penicillin-binding proteins (PBPs) function as transpeptidases, carboxypeptidases, or endopeptidases during peptidoglycan synthesis in bacteria. As the well-known drug targets for β-lactam antibiotics, the physiological functions of PBPs and whether they are essential for growth are of significant interest. The pathogen Pseudomonas aeruginosa poses a particular risk to immunocompromised and cystic fibrosis patients, and infections caused by this pathogen are difficult to treat due to antibiotic resistance. To identify potential drug targets among the PBPs in P. aeruginosa, we performed gene knockouts of all the high-molecular-mass (HMM) PBPs and determined the impacts on cell growth and morphology, susceptibility to β-lactams, peptidoglycan structure, virulence, and pathogenicity. Disruptions of the transpeptidase domains of most HMM PBPs, including double disruptions, had only minimal effects on cell growth. The exception was PBP3, where cell growth occurred only when the protein was conditionally expressed on an integrated plasmid. Conditional deletion of PBP3 also caused a defect in cell division and increased susceptibility to β-lactams. Knockout of PBP1a led to impaired motility, and this observation, together with its localization at the cell poles, suggests its involvement in flagellar function. Overall, these findings reveal that PBP3 represents the most promising target for drug discovery against P. aeruginosa, whereas other HMM PBPs have less potential.
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Arizpe A, Reveles KR, Aitken SL. Regional variation in antibiotic prescribing among medicare part D enrollees, 2013. BMC Infect Dis 2016; 16:744. [PMID: 27938336 PMCID: PMC5148872 DOI: 10.1186/s12879-016-2091-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/03/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Antibiotics are among the most widely prescribed medications. The geographic variation in antibiotic prescribing patterns and associated costs among Medicare Part D recipients have not been described. The purpose of this study was to assess the regional variation in antibiotic prescriptions and costs among Medicare Part D enrollees in 2013. METHODS Retrospective cohort review of all Medicare Part D enrollees in 2013, using the Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use File. All original or refill prescription claims for antibiotics as listed in the Part D Prescriber Public Use File were included. Our primary outcomes were total antibiotic claims and antibiotic cost per Medicare Part D Enrollee. Data were analyzed descriptively by state and by geographic region as defined by the United States Census Bureau. Antibiotic claims were described overall and by antibiotic class. RESULTS Over 54 million outpatient antibiotic claims were filed for Part D enrollees in 2013, representing more than $1.5 billion in total antibiotic expenditures. Antibiotic use was highest in the South (1,623 claims/1,000 enrollees), followed by the Midwest (1,401 claims/1,000 enrollees), Northeast (1,366 claims/1,000 enrollees), and West (1,292 claims/1,000 enrollees). Average antibiotic costs per enrollee in each region were as follows: South $46.58, Northeast $43.70, Midwest $40.54, and West $36.42. Fluoroquinolones were the most commonly prescribed class overall (12.2 million claims). CONCLUSIONS Antibiotic use among elderly Medicare enrollees in the United States was highest in the South region. Fluoroquinolones were the most common antibiotics used in all regions. These patterns could be utilized in the development of targeted antimicrobial stewardship efforts.
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Affiliation(s)
- Andre Arizpe
- College of Pharmacy, The University of Texas at Austin, Austin, TX USA
- Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Kelly R. Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX USA
- Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX USA
| | - Samuel L. Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0090, Houston, TX 77030 USA
- Center for Antimicrobial Resistance and Microbial Genomics, UTHealth McGovern Medical School, Houston, TX USA
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Evaluation of Risk Factors for Antibiotic Resistance in Patients with Nosocomial Infections Caused by Pseudomonas aeruginosa. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:1321487. [PMID: 27656220 PMCID: PMC5021456 DOI: 10.1155/2016/1321487] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/03/2016] [Accepted: 07/25/2016] [Indexed: 12/05/2022]
Abstract
Background. Pseudomonas aeruginosa (P. aeruginosa) is resistant to various antibiotics and can cause serious nosocomial infections with high morbidity and mortality. In this clinical study, we investigated the risk factors in patients who were diagnosed with P. aeruginosa-related nosocomial infection. Methods. A retrospective case control study including patients with P. aeruginosa-related nosocomial infection. Patients who were resistant to any of the six antibiotics (imipenem, meropenem, piperacillin-tazobactam, ciprofloxacin, amikacin, and ceftazidime) constituted the study group. Results. One hundred and twenty isolates were isolated. Various risk factors were detected for each antibiotic in the univariate analysis. In the multivariate analysis, previous cefazolin use was found as an independent risk factor for the development of imipenem resistance (OR = 3.33; CI 95% [1.11–10.0]; p = 0.03), whereas previous cerebrovascular attack (OR = 3.57; CI 95% [1.31–9.76]; p = 0.01) and previous meropenem use (OR = 4.13; CI 95% [1.21–14.07]; p = 0.02) were independent factors for the development of meropenem resistance. For the development of resistance to ciprofloxacin, hospitalization in the neurology intensive care unit (OR = 4.24; CI 95% [1.5–11.98]; p = 0.006) and mechanical ventilator application (OR = 11.7; CI 95% [2.24–61.45]; p = 0.004) were independent risk factors. Conclusion. The meticulous application of contact measures can decrease the rate of nosocomial infections.
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How to stratify patients at risk for resistant bugs in skin and soft tissue infections? Curr Opin Infect Dis 2016; 29:116-23. [DOI: 10.1097/qco.0000000000000244] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Cobos-Trigueros N, Solé M, Castro P, Torres JL, Hernández C, Rinaudo M, Fernández S, Soriano Á, Nicolás JM, Mensa J, Vila J, Martínez JA. Acquisition of Pseudomonas aeruginosa and its resistance phenotypes in critically ill medical patients: role of colonization pressure and antibiotic exposure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:218. [PMID: 25936721 PMCID: PMC4432505 DOI: 10.1186/s13054-015-0916-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/10/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The objective of this work was to investigate the risk factors for the acquisition of Pseudomonas aeruginosa and its resistance phenotypes in critically ill patients, taking into account colonization pressure. METHODS We conducted a prospective cohort study in an 8-bed medical intensive care unit during a 35-month period. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48 hours of admission and thrice weekly thereafter. During the study, a policy of consecutive mixing and cycling periods of three classes of antipseudomonal antibiotics was followed in the unit. RESULTS Of 850 patients admitted for ≥ 3 days, 751 (88.3%) received an antibiotic, 562 of which (66.1%) were antipseudomonal antibiotics. A total of 68 patients (8%) carried P. aeruginosa upon admission, and among the remaining 782, 104 (13%) acquired at least one strain of P. aeruginosa during their stay. Multivariate analysis selected shock (odds ratio (OR) = 2.1; 95% confidence interval (CI), 1.2 to 3.7), intubation (OR = 3.6; 95% CI, 1.7 to 7.5), enteral nutrition (OR = 3.6; 95% CI, 1.8 to 7.6), parenteral nutrition (OR = 3.9; 95% CI, 1.6 to 9.6), tracheostomy (OR = 4.4; 95% CI, 2.3 to 8.3) and colonization pressure >0.43 (OR = 4; 95% CI, 1.2 to 5) as independently associated with the acquisition of P. aeruginosa, whereas exposure to fluoroquinolones for >3 days (OR = 0.4; 95% CI, 0.2 to 0.8) was protective. In the whole series, prior exposure to carbapenems was independently associated with carbapenem resistance, and prior amikacin use predicted piperacillin-tazobactam, fluoroquinolone and multiple-drug resistance. CONCLUSIONS In critical care settings with a high rate of antibiotic use, colonization pressure and non-antibiotic exposures may be the crucial factors for P. aeruginosa acquisition, whereas fluoroquinolones may actually decrease its likelihood. For the acquisition of strains resistant to piperacillin-tazobactam, fluoroquinolones and multiple drugs, exposure to amikacin may be more relevant than previously recognized.
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Affiliation(s)
- Nazaret Cobos-Trigueros
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Mar Solé
- ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Jorge Luis Torres
- Department of Internal Medicine, University Hospital of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.
| | - Cristina Hernández
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Mariano Rinaudo
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Álex Soriano
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - José María Nicolás
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Jordi Vila
- ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic, University of Barcelona, Barcelona, Spain. .,Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain.
| | - José Antonio Martínez
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
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Averbuch D, Orasch C, Cordonnier C, Livermore DM, Mikulska M, Viscoli C, Gyssens IC, Kern WV, Klyasova G, Marchetti O, Engelhard D, Akova M. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia. Haematologica 2014; 98:1826-35. [PMID: 24323983 DOI: 10.3324/haematol.2013.091025] [Citation(s) in RCA: 381] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Owing to increasing resistance and the limited arsenal of new antibiotics, especially against Gram-negative pathogens, carefully designed antibiotic regimens are obligatory for febrile neutropenic patients, along with effective infection control. The Expert Group of the 4(th) European Conference on Infections in Leukemia has developed guidelines for initial empirical therapy in febrile neutropenic patients, based on: i) the local resistance epidemiology; and ii) the patient's risk factors for resistant bacteria and for a complicated clinical course. An 'escalation' approach, avoiding empirical carbapenems and combinations, should be employed in patients without particular risk factors. A 'de-escalation' approach, with initial broad-spectrum antibiotics or combinations, should be used only in those patients with: i) known prior colonization or infection with resistant pathogens; or ii) complicated presentation; or iii) in centers where resistant pathogens are prevalent at the onset of febrile neutropenia. In the latter case, infection control and antibiotic stewardship also need urgent review. Modification of the initial regimen at 72-96 h should be based on the patient's clinical course and the microbiological results. Discontinuation of antibiotics after 72 h or later should be considered in neutropenic patients with fever of unknown origin who are hemodynamically stable since presentation and afebrile for at least 48 h, irrespective of neutrophil count and expected duration of neutropenia. This strategy aims to minimize the collateral damage associated with antibiotic overuse, and the further selection of resistance.
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Muraki Y, Kitamura M, Maeda Y, Kitahara T, Mori T, Ikeue H, Tsugita M, Tadano K, Takada K, Akamatsu T, Yamada T, Yamada T, Shiraishi T, Okuda M. Nationwide surveillance of antimicrobial consumption and resistance to Pseudomonas aeruginosa isolates at 203 Japanese hospitals in 2010. Infection 2013; 41:415-23. [DOI: 10.1007/s15010-013-0440-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 02/20/2013] [Indexed: 12/01/2022]
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Gbaguidi-Haore H, Dumartin C, L'Heriteau F, Pefau M, Hocquet D, Rogues AM, Bertrand X. Antibiotics involved in the occurrence of antibiotic-resistant bacteria: a nationwide multilevel study suggests differences within antibiotic classes. J Antimicrob Chemother 2012; 68:461-70. [DOI: 10.1093/jac/dks406] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Extensively drug-resistant Pseudomonas aeruginosa: risk of bloodstream infection in hospitalized patients. Eur J Clin Microbiol Infect Dis 2012; 31:2791-7. [DOI: 10.1007/s10096-012-1629-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 04/11/2012] [Indexed: 11/28/2022]
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16
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Akhabue E, Synnestvedt M, Weiner MG, Bilker WB, Lautenbach E. Cefepime-resistant Pseudomonas aeruginosa. Emerg Infect Dis 2011; 17:1037-43. [PMID: 21749765 DOI: 10.3201/eid/1706.100358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Resistance to extended-spectrum cephalosporins complicates treatment of Pseudomonas aeruginosa infections. To elucidate risk factors for cefepime-resistant P. aeruginosa and determine its association with patient death, we conducted a case-control study in Philadelphia, Pennsylvania. Among 2,529 patients hospitalized during 2001-2006, a total of 213 (8.4%) had cefepime-resistant P. aeruginosa infection. Independent risk factors were prior use of an extended-spectrum cephalosphorin (p<0.001), prior use of an extended-spectrum penicillin (p = 0.005), prior use of a quinolone (p<0.001), and transfer from an outside facility (p = 0.01). Among those hospitalized at least 30 days, mortality rates were higher for those with cefepime-resistant than with cefepime-susceptible P. aeruginosa infection (20.2% vs. 13.2%, p = 0.007). Cefepime-resistant P. aeruginosa was an independent risk factor for death only for patients for whom it could be isolated from blood (p = 0.001). Strategies to counter its emergence should focus on optimizing use of antipseudomonal drugs.
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Affiliation(s)
- Ehimare Akhabue
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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17
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Bliziotis IA, Petrosillo N, Michalopoulos A, Samonis G, Falagas ME. Impact of definitive therapy with beta-lactam monotherapy or combination with an aminoglycoside or a quinolone for Pseudomonas aeruginosa bacteremia. PLoS One 2011; 6:e26470. [PMID: 22046290 PMCID: PMC3202542 DOI: 10.1371/journal.pone.0026470] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 09/27/2011] [Indexed: 11/18/2022] Open
Abstract
Background Bacteremia by Pseudomonas aeruginosa represents one severe infection. It is not clear whether beta-lactam monotherapy leads to similar rates of treatment success compared to combinations of beta-lactams with aminoglycosides or quinolones. Methods Retrospective cohort study from 3 tertiary hospitals (2 in Greece and 1 in Italy). Pseudomonas aeruginosa isolates were susceptible to a beta-lactam and an aminoglycoside or a quinolone. Patients received appropriate therapy for at least 48 hours. Primary outcome of interest was treatment success in patients with definitive beta-lactam combination therapy compared to monotherapy. Secondary outcomes were treatment success keeping the same empirical and definitive regimen, mortality, and toxicity. Results Out of 92 bacteremias there were 54 evaluable episodes for the primary outcome (20 received monotherapy). Treatment success was higher with combination therapy (85%) compared to beta-lactam monotherapy (65%), however not statistically significantly [Odds ratio (OR) 3.1; 95% Confidence Interval (CI) 0.69–14.7, p = 0.1]. Very long (>2 months) hospitalisation before bacteremia was the only factor independently associated with treatment success (OR 0.73; 95% CI 0.01–0.95, p = 0.046), however this result entailed few episodes. All-cause mortality did not differ significantly between combination therapy [6/31 (19%)] and monotherapy [8/19 (42%)], p = 0.11. Only Charlson comorbidity index was associated with excess mortality (p = 0.03). Conclusion Our study, in accordance with previous ones, indicates that the choice between monotherapy and combination therapy may not affect treatment success significantly. However, our study does not have statistical power to identify small or moderate differences. A large randomized controlled trial evaluating this issue is justified.
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Affiliation(s)
| | - Nicola Petrosillo
- National Institute for Infectious Diseases “L. Spallanzani”, Rome, Italy
| | - Argyris Michalopoulos
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- Intensive Care Unit, “Henry Dunant” Hospital, Athens, Greece
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - Matthew E. Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- Department of Medicine, “Henry Dunant” Hospital, Athens, Greece
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
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Lu Q, Yang J, Liu Z, Gutierrez C, Aymard G, Rouby JJ. Nebulized Ceftazidime and Amikacin in Ventilator-associated Pneumonia Caused byPseudomonas aeruginosa. Am J Respir Crit Care Med 2011; 184:106-15. [DOI: 10.1164/rccm.201011-1894oc] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Joo EJ, Kang CI, Ha YE, Kang SJ, Park SY, Chung DR, Peck KR, Lee NY, Song JH. Risk Factors for Mortality in Patients with Pseudomonas aeruginosa Bacteremia: Clinical Impact of Antimicrobial Resistance on Outcome. Microb Drug Resist 2011; 17:305-12. [DOI: 10.1089/mdr.2010.0170] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Eun-Jeong Joo
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Eun Ha
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Ji Kang
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Yeon Park
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Chew FLM, Soong TK, Shin HC, Samsudin A, Visvaraja S. Topical piperacillin/tazobactam for recalcitrant pseudomonas aeruginosa keratitis. J Ocul Pharmacol Ther 2010; 26:219-22. [PMID: 20415627 DOI: 10.1089/jop.2009.0077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To report the treatment of therapy-resistant Pseudomonas aeruginosa keratitis with topical piperacillin/tazobactam. METHODS Retrospective report of 3 cases. RESULTS Three patients with P. aeruginosa keratitis were unresponsive to various antimicrobials. Resolution of all 3 cases of keratitis occurred upon commencement of topical piperacillin/tazobactam. CONCLUSION Therapy-resistant P. aeruginosa keratitis acquired from the community is becoming an increasing problem. Topical piperacillin/tazobactam is an option for the treatment of therapy-resistant P. aeruginosa keratitis.
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Affiliation(s)
- Fiona L M Chew
- Department of Ophthalmology, Faculty of Medicine, University of Malaya, Jalan Universiti, Kuala Lumpur, Wilayah Persekutuan 50603, Malaysia.
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