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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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2
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MacKenzie P, Färber J, Post M, Esser T, Bechmann L, Kropf S, Croner R, Geginat G. Previous antibiotic therapy as independent risk factor for the presence of vancomycin-resistant enterococci in surgical inpatients. Results from a matched case-control study. BMC Infect Dis 2023; 23:274. [PMID: 37131139 PMCID: PMC10155433 DOI: 10.1186/s12879-023-08238-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Investigation of risk factors for the presence of vancomycin-resistant enterococci (VRE) in inpatients on surgical wards and associated intensive care units of a German tertiary care hospital. METHODS A single-centre retrospective matched case-control study was performed with surgical inpatients admitted between July 2013 and December 2016. Patients with in-hospital detection of VRE later than 48 h after admission were included and comprised 116 VRE-positive cases and 116 VRE-negative matched controls. VRE isolates of cases were typed by multi-locus sequence typing. RESULTS ST117 was identified as the dominant VRE sequence type. Next to length of stay in hospital or on an intensive care unit and previous dialysis the case-control study revealed previous antibiotic therapy as a risk factor for the in-hospital detection of VRE. The antibiotics piperacillin/tazobactam, meropenem, and vancomycin were associated with the highest risks. After taking into account length of stay in hospital as possible confounder other potential contact-related risk factors such as previous sonography, radiology, central venous catheter, and endoscopy were not significant. CONCLUSIONS Previous dialysis and previous antibiotic therapy were identified as independent risk factors for the presence of VRE in surgical inpatients.
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Affiliation(s)
- Philip MacKenzie
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jacqueline Färber
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Marius Post
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Torben Esser
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Lukas Bechmann
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Siegfried Kropf
- Institute for Biometry and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Roland Croner
- Department of General, Visceral, Vascular and Transplant Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Gernot Geginat
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
- Institut für medizinische Mikrobiologie und Krankenhaushygiene, Otto-von-Guericke University, Leipziger Straße 44, 39120, Magdeburg, Germany.
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3
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Epidemiological and genetic characteristics of vancomycin-resistant Enterococcus faecium isolates in a University Children's Hospital in Germany: 2019 to 2020. Antimicrob Resist Infect Control 2022; 11:48. [PMID: 35279207 PMCID: PMC8917738 DOI: 10.1186/s13756-022-01081-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/12/2022] [Indexed: 12/28/2022] Open
Abstract
Background Vancomycin-resistant Enterococcus faecium (VREfm) strains are one of the most important pathogens causing nosocomial infections in Germany. Due to limited treatment options and an increased risk for acquisition in immunocompromised children, surveillance to monitor occurrence of VREfm in paediatric clinical facilities is of critical importance. Following an unusual accumulation of VREfm positive patients between April 2019 and August 2020 at Dr. von Hauner Children’s Hospital in Munich, Germany, our study aimed to identify dynamics and routes of transmission, and analyse the affected population in view of previously described host risk factors for VREfm colonisation or infection.
Methods The hospital database was used to collect epidemiological and clinical data of VREfm cases. Descriptive statistical analyses were conducted to outline patient characteristics and depict possible differences between VREfm-colonised and -infected children. An outbreak investigation determining genetic relatedness among VREfm isolates was performed by core genome multilocus sequence typing (cgMLST). To examine potential transmission pathways, results of genome analysis were compared with epidemiological and clinical data of VREfm positive patients. Results VREfm acquisition was documented in a total of 33 children (< 18 years). Seven VREfm-colonised patients (21.2%), especially those with a haemato-oncological disease (4/7; p = 0.011), showed signs of clinical infection. cgMLST analysis revealed seven distinct clusters, demonstrating a possible connection within each clonal lineage. Additional eight singletons were identified. Comparison with epidemiological and clinical data provided strong evidence for a link between several VREfm positive patients within the hospital. Conclusions A nosocomial spread—at least in part—was the most likely reason for the unusual accumulation of VREfm cases. The study highlights that there is a constant need to increase efforts in hygiene measures, infection control and antibiotic stewardship to combat VREfm transmission events within German paediatric hospitals. Continuous monitoring of adherence to respective policies might reduce the occurrence of clustered cases and prevent future outbreaks.
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Chiang D, Dingle TC, Belga S, Kabbani D, Bhanji RA, Walter J, Abraldes JG, Cervera C. Association between Gut Colonization of Vancomycin-resistant Enterococci and Liver Transplant Outcomes. Transpl Infect Dis 2022; 24:e13821. [PMID: 35247208 DOI: 10.1111/tid.13821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/11/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) colonization is common in liver transplant recipients and has been associated with worse post-transplant outcomes. METHODS We conducted a retrospective cohort study at the University of Alberta Hospital including patients who underwent a liver transplant between September 2014 and December 2017. RESULTS Of 343 patients, 68 (19.8%) had pre-transplant VRE colonization and 27 (27/275, 9.8%) acquired VRE post-transplant, 67% were males and the median age was 56.5 years. VRE colonized patients at baseline had higher MELD scores and required longer post-transplant hospitalization. VRE colonization was associated with increased risk of early acute kidney injury (AKI) (64% vs 52%, p = 0. 044), clinically significant bacterial/fungal infection (29% vs 17%, p = 0. 012) and invasive VRE infection (5% vs 1%, p = 0. 017). Mortality at 2-years was 13% in VRE-colonized versus 7% in non-colonized (p = 0.085). On multivariate analysis, VRE colonization increased the risk of post-transplant AKI (HR 1.504, 95% CI: 1.077-2.100, p = 0.017) and clinically significant bacterial or fungal infection at 6 months (HR 2.038, 95%CI: 1.222-3.399, p = 0.006), and was associated with non-significant trend towards increased risk of mortality at 2-years post-transplant (HR 1.974 95% CI 0.890-4.378; p = 0.094). CONCLUSIONS VRE colonization in liver transplant patients is associated with increased risk of early AKI, clinically significant infections, and a trend towards increased mortality at 2-years. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Diana Chiang
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tanis C Dingle
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada.,Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Sara Belga
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rahima A Bhanji
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jens Walter
- Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Alberta, Canada.,Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine and APC Microbiome Ireland, University College Cork, Cork, Ireland.,School of Microbiology, University College Cork, Cork, Ireland
| | - Juan G Abraldes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Glasner C, Berends MS, Becker K, Esser J, Gieffers J, Jurke A, Kampinga G, Kampmeier S, Klont R, Köck R, von Müller L, Al Naemi N, Ott A, Ruijs G, Saris K, Tami A, Voss A, Waar K, van Zeijl J, Friedrich AW. A prospective multicentre screening study on multidrug-resistant organisms in intensive care units in the Dutch-German cross-border region, 2017 to 2018: the importance of healthcare structures. EURO SURVEILLANCE : BULLETIN EUROPEEN SUR LES MALADIES TRANSMISSIBLES = EUROPEAN COMMUNICABLE DISEASE BULLETIN 2022; 27. [PMID: 35115078 PMCID: PMC8815100 DOI: 10.2807/1560-7917.es.2022.27.5.2001660] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Antimicrobial resistance poses a risk for healthcare, both in the community and hospitals. The spread of multidrug-resistant organisms (MDROs) occurs mostly on a local and regional level, following movement of patients, but also occurs across national borders. Aim The aim of this observational study was to determine the prevalence of MDROs in a European cross-border region to understand differences and improve infection prevention based on real-time routine data and workflows. Methods Between September 2017 and June 2018, 23 hospitals in the Dutch (NL)–German (DE) cross-border region (BR) participated in the study. During 8 consecutive weeks, patients were screened upon admission to intensive care units (ICUs) for nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA) and rectal carriage of vancomycin-resistant Enterococcus faecium/E. faecalis (VRE), third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE) and carbapenem-resistant Enterobacteriaceae (CRE). All samples were processed in the associated laboratories. Results A total of 3,365 patients were screened (median age: 68 years (IQR: 57–77); male/female ratio: 59.7/40.3; NL-BR: n = 1,202; DE-BR: n = 2,163). Median screening compliance was 60.4% (NL-BR: 56.9%; DE-BR: 62.9%). MDRO prevalence was higher in DE-BR than in NL-BR, namely 1.7% vs 0.6% for MRSA (p = 0.006), 2.7% vs 0.1% for VRE (p < 0.001) and 6.6% vs 3.6% for 3GCRE (p < 0.001), whereas CRE prevalence was comparable (0.2% in DE-BR vs 0.0% in NL-BR ICUs). Conclusions This first prospective multicentre screening study in a European cross-border region shows high heterogenicity in MDRO carriage prevalence in NL-BR and DE-BR ICUs. This indicates that the prevalence is probably influenced by the different healthcare structures.
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Affiliation(s)
- Corinna Glasner
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Matthijs S Berends
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Certe Medical Diagnostics and Advice Foundation, Groningen, the Netherlands
| | - Karsten Becker
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.,Friedrich Loeffler-Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Jutta Esser
- Practice of Laboratory Medicine and University Osnabrück, Department of Dermatology, Environmental Medicine and Health Theory, Osnabrück, Germany
| | - Jens Gieffers
- Institute for Microbiology, Hygiene and Laboratory Medicine, Klinikum Lippe, Detmold, Germany
| | - Annette Jurke
- North Rhine-Westphalian Centre for Health, Section Infectious Disease Epidemiology, Bochum, Germany
| | - Greetje Kampinga
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Rob Klont
- Laboratory Microbiology Twente Achterhoek, Hengelo, the Netherlands
| | - Robin Köck
- Institute of Hygiene, DRK Kliniken Berlin, Berlin, Germany.,Institute of Hygiene, University Hospital Münster, Münster, Germany
| | - Lutz von Müller
- Institute for Laboratory Medicine, Microbiology and Hygiene, Christophorus-Kliniken GmbH, Coesfeld, Germany
| | - Nashwan Al Naemi
- Laboratory Microbiology Twente Achterhoek, Hengelo, the Netherlands
| | - Alewijn Ott
- Certe Medical Diagnostics and Advice Foundation, Groningen, the Netherlands
| | - Gijs Ruijs
- Laboratory for Medical Microbiology and Infectious Diseases, Isala, Zwolle, the Netherlands
| | - Katja Saris
- Department of Medical Microbiology, Radboud University Medical Centre and Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Adriana Tami
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Centre and Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Karola Waar
- Izore, Centre for Infectious Diseases Friesland, Leeuwarden, the Netherlands.,Certe Medical Diagnostics and Advice Foundation, Groningen, the Netherlands
| | - Jan van Zeijl
- Izore, Centre for Infectious Diseases Friesland, Leeuwarden, the Netherlands.,Certe Medical Diagnostics and Advice Foundation, Groningen, the Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,European Prevention Networks in Infection Control, University Hospital Münster, Münster, Germany
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Szychowiak P, Villageois-Tran K, Patrier J, Timsit JF, Ruppé É. The role of the microbiota in the management of intensive care patients. Ann Intensive Care 2022; 12:3. [PMID: 34985651 PMCID: PMC8728486 DOI: 10.1186/s13613-021-00976-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.
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Affiliation(s)
- Piotr Szychowiak
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, 37000, Tours, France
| | - Khanh Villageois-Tran
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Laboratoire de Bactériologie, AP-HP, Hôpital Beaujon, 92110, Paris, France
| | - Juliette Patrier
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Jean-François Timsit
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Étienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.
- Laboratoire de Bactériologie, AP-HP, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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Wyres KL, Hawkey J, Mirčeta M, Judd LM, Wick RR, Gorrie CL, Pratt NF, Garlick JS, Watson KM, Pilcher DV, McGloughlin SA, Abbott IJ, Macesic N, Spelman DW, Jenney AWJ, Holt KE. Genomic surveillance of antimicrobial resistant bacterial colonisation and infection in intensive care patients. BMC Infect Dis 2021; 21:683. [PMID: 34261450 PMCID: PMC8278603 DOI: 10.1186/s12879-021-06386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Third-generation cephalosporin-resistant Gram-negatives (3GCR-GN) and vancomycin-resistant enterococci (VRE) are common causes of multi-drug resistant healthcare-associated infections, for which gut colonisation is considered a prerequisite. However, there remains a key knowledge gap about colonisation and infection dynamics in high-risk settings such as the intensive care unit (ICU), thus hampering infection prevention efforts. METHODS We performed a three-month prospective genomic survey of infecting and gut-colonising 3GCR-GN and VRE among patients admitted to an Australian ICU. Bacteria were isolated from rectal swabs (n = 287 and n = 103 patients ≤2 and > 2 days from admission, respectively) and diagnostic clinical specimens between Dec 2013 and March 2014. Isolates were subjected to Illumina whole-genome sequencing (n = 127 3GCR-GN, n = 41 VRE). Multi-locus sequence types (STs) and antimicrobial resistance determinants were identified from de novo assemblies. Twenty-three isolates were selected for sequencing on the Oxford Nanopore MinION device to generate completed reference genomes (one for each ST isolated from ≥2 patients). Single nucleotide variants (SNVs) were identified by read mapping and variant calling against these references. RESULTS Among 287 patients screened on admission, 17.4 and 8.4% were colonised by 3GCR-GN and VRE, respectively. Escherichia coli was the most common species (n = 36 episodes, 58.1%) and the most common cause of 3GCR-GN infection. Only two VRE infections were identified. The rate of infection among patients colonised with E. coli was low, but higher than those who were not colonised on admission (n = 2/33, 6% vs n = 4/254, 2%, respectively, p = 0.3). While few patients were colonised with 3GCR- Klebsiella pneumoniae or Pseudomonas aeruginosa on admission (n = 4), all such patients developed infections with the colonising strain. Genomic analyses revealed 10 putative nosocomial transmission clusters (≤20 SNVs for 3GCR-GN, ≤3 SNVs for VRE): four VRE, six 3GCR-GN, with epidemiologically linked clusters accounting for 21 and 6% of episodes, respectively (OR 4.3, p = 0.02). CONCLUSIONS 3GCR-E. coli and VRE were the most common gut colonisers. E. coli was the most common cause of 3GCR-GN infection, but other 3GCR-GN species showed greater risk for infection in colonised patients. Larger studies are warranted to elucidate the relative risks of different colonisers and guide the use of screening in ICU infection control.
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Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Jane Hawkey
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mirianne Mirčeta
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ryan R Wick
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claire L Gorrie
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel F Pratt
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jill S Garlick
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kerrie M Watson
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David V Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Steve A McGloughlin
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Iain J Abbott
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nenad Macesic
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Denis W Spelman
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam W J Jenney
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- London School of Hygiene and Tropical Medicine, London, UK
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Shirvani F, Behzad A, Abdollahi N, Mohkam M, Sharifian M, Esfandiar N, Fallah F. Frequency and co-colonization of vancomycin-resistant Enterococci and Candida in ICU-hospitalized children. New Microbes New Infect 2021; 41:100881. [PMID: 34026230 PMCID: PMC8121691 DOI: 10.1016/j.nmni.2021.100881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 02/03/2023] Open
Abstract
In the time span between January 2018 and September 2020, 205 patients were enrolled in a prospective cohort study at Mofid Children's Hospital. Demographic information and clinical data on all the participating children were collected and rectal swabs were performed for the sampling method. All samples were analysed so as to identify the presence of Enterococcus and Candida colonization by the use of conventional biochemical tests. Resistance to vancomycin in Enterococcus isolates was phenotypically identified using an E-test kit and MIC value, interpreted according to the CLSI criteria. The presence of vanA and vanB genes, which encode the resistance to vancomycin, was screened by PCR assay. Candida species were detected in 21.5% of rectal swab samples. Candida glabrata (56.8%) and Candida albicans (43.2%) were the only Candida species detected. Enterococcus species were detected in 29.3% of rectal swab samples. Out of 60 Enterococcus isolates, 33 (55%) were resistant to vancomycin. Moreover, vanA was detected in 84.8% and vanB was detected in 3% of the 33 vancomycin-resistant Enterococcus isolates. Enterococcus and Candida species were frequently detected in the <1 year and 1–3 years age groups, respectively. Central venous access catheter and brain tumour were the main reasons for hospital admissions, 32.2% and 20.1% of total admissions, respectively. Furthermore, it must be noted that the most frequent underlying medical conditions in participating patients were esophageal atresia and hydrocephalus. The results of the present study demonstrated the necessity of determining the susceptibility of Enterococcus isolates to vancomycin before prescribing antibiotics.
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Affiliation(s)
- F Shirvani
- Paediatric Infections Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - A Behzad
- Paediatric Intensive Care Department, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Abdollahi
- Paediatric Infections Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Mohkam
- Paediatric Nephrology Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Sharifian
- Paediatric Nephrology Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - N Esfandiar
- Paediatric Nephrology Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - F Fallah
- Paediatric Infections Research Centre, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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9
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Impact of a vancomycin-resistant Enterococcus (VRE) screening result on appropriateness of antibiotic therapy. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e41. [PMID: 36168474 PMCID: PMC9495624 DOI: 10.1017/ash.2021.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/20/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022]
Abstract
Objective: Vancomycin-resistant Enterococcus (VRE) infections have been associated with increased mortality and poor outcomes. VRE screening has been used to identify colonized patients to prevent transmission; however, little is known about the utility of screening results to guide antibiotic therapy. Design and setting: A retrospective review was performed at a tertiary-care center between June 1, 2015, and May 31, 2018. Patients: All patients who underwent VRE polymerase chain reaction assay (PCR) screening and had a bacterial culture from 7 days before to 90 days after the screening test were included. In total, 1,374 patients who had a VRE screening test met inclusion criteria. Methods: Sensitivity, specificity, and positive and negative predictive values of VRE screening for VRE infection were calculated. The appropriateness of the antibiotic therapy for each patient based on screening results was also assessed. Results: We detected no difference in the appropriateness of antibiotic therapy between patients with a positive screen and those with a negative screen (59.3% vs 61.0%; P = .8657). The VRE PCR demonstrated 54% sensitivity, 89% specificity, a positive predictive value (PPV) of 13% and a negative predictive value (NPV) of 98%. Conclusions: The high NPV and specificity indicate that patients with a negative VRE screening results may not require empiric antibiotic coverage for VRE. Although VRE screening may have utility to detect colonization in high-risk patients, a positive VRE screen is of limited value in determining the need for an antibiotic with VRE culture-directed coverage.
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Gaiser RA, Ayerra Mangado J, Mechkarska M, Kaman WE, van Baarlen P, Conlon JM, Wells JM. Selection of antimicrobial frog peptides and temporin-1DRa analogues for treatment of bacterial infections based on their cytotoxicity and differential activity against pathogens. Chem Biol Drug Des 2020; 96:1103-1113. [PMID: 31102497 PMCID: PMC7891380 DOI: 10.1111/cbdd.13569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/27/2019] [Accepted: 05/05/2019] [Indexed: 01/02/2023]
Abstract
Cationic, amphipathic, α-helical host-defense peptides (HDPs) that are naturally secreted by certain species of frogs (Anura) possess potent broad-spectrum antimicrobial activity and show therapeutic potential as alternatives to treat infections by multidrug-resistant pathogens. Fourteen amphibian skin peptides and twelve analogues of temporin-1DRa were studied for their antimicrobial activities against clinically relevant human or animal skin infection-associated pathogens. For comparison, antimicrobial potencies of frog skin peptides against a range of probiotic lactobacilli were determined. We used the VITEK 2 system to define a profile of antibiotic susceptibility for the bacterial panel. The minimal inhibitory concentration (MIC) values of the naturally occurring temporin-1DRa, CPF-AM1, alyteserin-1c, hymenochirin-2B, and hymenochirin-4B for pathogenic bacteria were threefold to ninefold lower than the values for the tested probiotic strains. Similarly, temporin-1DRa and its [Lys4 ], [Lys5 ], and [Aib8 ] analogues showed fivefold to 6.5-fold greater potency against the pathogens. In the case of PGLa-AM1, XT-7, temporin-1DRa and its [D-Lys8 ] and [Aib13 ] analogues, no apoptosis or necrosis was detected in human peripheral blood mononuclear cells at concentrations below or above the MIC. Given the differential activity against commensal bacteria and pathogens, some of these peptides are promising candidates for further development into therapeutics for topical treatment of skin infections.
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Affiliation(s)
- Rogier A Gaiser
- Host-Microbe Interactomics Group, Animal Sciences Department, Wageningen University, Wageningen, The Netherlands
| | - Jaione Ayerra Mangado
- Host-Microbe Interactomics Group, Animal Sciences Department, Wageningen University, Wageningen, The Netherlands
| | - Milena Mechkarska
- Department of Biochemistry, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Wendy E Kaman
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre Rotterdam (EMC), Rotterdam, The Netherlands
| | - Peter van Baarlen
- Host-Microbe Interactomics Group, Animal Sciences Department, Wageningen University, Wageningen, The Netherlands
| | - J Michael Conlon
- Department of Biochemistry, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Jerry M Wells
- Host-Microbe Interactomics Group, Animal Sciences Department, Wageningen University, Wageningen, The Netherlands
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Moron R, Galvez J, Colmenero M, Anderson P, Cabeza J, Rodriguez-Cabezas ME. The Importance of the Microbiome in Critically Ill Patients: Role of Nutrition. Nutrients 2019; 11:E3002. [PMID: 31817895 PMCID: PMC6950228 DOI: 10.3390/nu11123002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022] Open
Abstract
Critically ill patients have an alteration in the microbiome in which it becomes a disease-promoting pathobiome. It is characterized by lower bacterial diversity, loss of commensal phyla, like Firmicutes and Bacteroidetes, and a domination of pathogens belonging to the Proteobacteria phylum. Although these alterations are multicausal, many of the treatments administered to these patients, like antibiotics, play a significant role. Critically ill patients also have a hyperpermeable gut barrier and dysregulation of the inflammatory response that favor the development of the pathobiome, translocation of pathogens, and facilitate the emergence of sepsis. In order to restore the homeostasis of the microbiome, several nutritional strategies have been evaluated with the aim to improve the management of critically ill patients. Importantly, enteral nutrition has proven to be more efficient in promoting the homeostasis of the gut microbiome compared to parenteral nutrition. Several nutritional therapies, including prebiotics, probiotics, synbiotics, and fecal microbiota transplantation, are currently being used, showing variable results, possibly due to the unevenness of clinical trial conditions and the fact that the beneficial effects of probiotics are specific to particular species or even strains. Thus, it is of great importance to better understand the mechanisms by which nutrition and supplement therapies can heal the microbiome in critically ill patients in order to finally implement them in clinical practice with optimal safety and efficacy.
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Affiliation(s)
- Rocio Moron
- Servicio Farmacia Hospitalaria, Hospital Universitario Clínico San Cecilio, 18016-Granada, Spain; (R.M.); (J.C.)
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
| | - Julio Galvez
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
- Department of Pharmacology, CIBER-ehd, Center of Biomedical Research (CIBM), University of Granada, 18071 Granada, Spain
| | - Manuel Colmenero
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
- Servicio de Medicina Intensiva, Hospital Universitaro Clinico San Cecilio, 18016 Granada, Spain
| | - Per Anderson
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
- Servicio de Análisis Clínicos e Inmunologia, UGC Laboratorio Clínico, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
| | - José Cabeza
- Servicio Farmacia Hospitalaria, Hospital Universitario Clínico San Cecilio, 18016-Granada, Spain; (R.M.); (J.C.)
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
| | - Maria Elena Rodriguez-Cabezas
- Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain; (M.C.); (P.A.); (M.E.R.-C.)
- Department of Pharmacology, CIBER-ehd, Center of Biomedical Research (CIBM), University of Granada, 18071 Granada, Spain
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12
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Zhen X, Lundborg CS, Sun X, Hu X, Dong H. Economic burden of antibiotic resistance in ESKAPE organisms: a systematic review. Antimicrob Resist Infect Control 2019; 8:137. [PMID: 31417673 PMCID: PMC6692939 DOI: 10.1186/s13756-019-0590-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 02/03/2023] Open
Abstract
Background Antibiotic resistance (ABR) is one of the biggest threats to global health. Infections by ESKAPE (Enterococcus, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and E. coli) organisms are the leading cause of healthcare-acquired infections worldwide. ABR in ESKAPE organisms is usually associated with significant higher morbidity, mortality, as well as economic burden. Directing attention towards the ESKAPE organisms can help us to better combat the wide challenge of ABR, especially multi-drug resistance (MDR). Objective This study aims to systematically review and evaluate the evidence of the economic consequences of ABR or MDR ESKAPE organisms compared with susceptible cases or control patients without infection/colonization in order to determine the impact of ABR on economic burden. Methods Both English-language databases and Chinese-language databases up to 16 January, 2019 were searched to identify relevant studies assessing the economic burden of ABR. Studies reported hospital costs (charges) or antibiotic cost during the entire hospitalization and during the period before/after culture among patients with ABR or MDR ESKAPE organisms were included. The costs were converted into 2015 United States Dollars. Disagreements were resolved by a third reviewer. Results Of 13,693 studies identified, 83 eligible studies were included in our review. The most studied organism was S. aureus, followed by Enterococcus, A. baumannii, E. coli, E. coli or/and K. pneumoniae, P. aeruginosa, and K. pneumoniae. There were 71 studies on total hospital cost or charge, 12 on antibiotic cost, 11 on hospital cost or charge after culture, 4 on ICU cost, 2 on hospital cost or charge before culture, and 2 on total direct and indirect cost. In general, ABR or MDR ESKAPE organisms are significantly associated with higher economic burden than those with susceptible organisms or those without infection or colonization. Nonetheless, there were no differences in a few studies between the two groups on total hospital cost or charge (16 studies), antibiotic cost (one study), hospital cost before culture (one study), hospital cost after culture (one study). Even, one reported that costs associated with MSSA infection were higher than the costs for similar MRSA cases. Conclusions ABR in ESKAPE organisms is not always, but usually, associated with significantly higher economic burden. The results without significant differences may lack statistical power to detect a significant association. In addition, study design which controls for severity of illness and same empirical antibiotic therapy in the two groups would be expected to bias the study towards a similar, even negative result. The review also highlights key areas where further research is needed.
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Affiliation(s)
- Xuemei Zhen
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
- Global Health-Health Systems and Policy (HSP): Medicines, focusing antibiotics, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Stålsby Lundborg
- Global Health-Health Systems and Policy (HSP): Medicines, focusing antibiotics, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Xueshan Sun
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
| | - Xiaoqian Hu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, 310058 Zhejiang China
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, No. N1, Shancheng Avenue, Yiwu City, Zhejiang China
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Jannati E, Amirmozaffari N, Saadatmand S, Arzanlou M. Faecal carriage of high-level aminoglycoside-resistant and ampicillin-resistant Enterococcus species in healthy Iranian children. J Glob Antimicrob Resist 2019; 20:135-144. [PMID: 31295581 DOI: 10.1016/j.jgar.2019.06.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES High-level aminoglycoside, ampicillin and vancomycin resistance and virulence genes among enterococcal isolates collected from healthy middle-school children in Ardabil, Iran, during 2016 were investigated. METHODS Totally, 305 faecal specimens were collected. Isolates underwent antimicrobial susceptibility testing, virulence gene detection and molecular typing. RESULTS Totally, 409 enterococcal isolates were collected, comprising Enterococcus faecium (235; 57.5%), Enterococcus faecalis (56; 13.7%) and other Enterococcus spp. (118; 28.9%). Overall, 71 (17.4%), 11 (2.7%) and 10 (2.4%) isolates were identified as high-level streptomycin-resistant (HLSR), high-level gentamicin-resistant (HLGR) and ampicillin-resistant (AR), respectively. Among HLSR isolates, 40 (56.3%), 5 (7.0%) and 26 (36.6%) were E. faecium, E. faecalis and other Enterococcus spp., respectively. Among HLGR isolates 4 (36.4%) and 7 (63.6%) and among AR isolates 7 (70.0%) and 3 (30.0%) were E. faecium and other Enterococcus spp., respectively. Accordingly, 21.6%, 3.6% and 3.3% of subjects were colonised with HLSR, HLGR and AR Enterococcus spp. Carriage of HLGR, HLSR and AR isolates was associated with prior antibiotic consumption (P≤0.05). Additionally, male sex and antacid consumption were associated with AR enterococcal carriage. Moreover, 69 (97.2%), 10 (90.9%) and 9 (90.0%) of HLSR, HLGR and AR isolates were multidrug-resistant, respectively. No vancomycin-resistant enterococci were detected. ERIC-PCR revealed high genetic diversity among isolates. gelE and asa1 were major virulence genes both in E. faecalis and E. faecium. Presence of gelE was associated with HLSR and HLGR phenotypes (P≤0.05). CONCLUSION Community intestinal carriage of HLSR enterococci was high; however, carriage of HLGR and AR enterococci was low.
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Affiliation(s)
- Elham Jannati
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Nour Amirmozaffari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Saadatmand
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mohsen Arzanlou
- Department of Microbiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran.
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14
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Xu R, Tan C, Zhu J, Zeng X, Gao X, Wu Q, Chen Q, Wang H, Zhou H, He Y, Pan S, Yin J. Dysbiosis of the intestinal microbiota in neurocritically ill patients and the risk for death. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:195. [PMID: 31151471 PMCID: PMC6544929 DOI: 10.1186/s13054-019-2488-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/22/2019] [Indexed: 12/15/2022]
Abstract
Background Despite the essential functions of the intestinal microbiota in human physiology, little has been reported about the microbiome in neurocritically ill patients. This investigation aimed to evaluate the characteristics of the gut microbiome in neurocritically ill patients and its changes after admission. Furthermore, we investigated whether the characteristics of the gut microbiome at admission were a risk factor for death within 180 days. Methods This prospective observational cohort study included neurocritically ill patients admitted to the neurological intensive care unit of a large university-affiliated academic hospital in Guangzhou. Faecal samples were collected within 72 h after admission (before antibiotic treatment) and serially each week. Healthy volunteers were recruited from a community in Guangzhou. The gut microbiome was monitored via 16S rRNA gene sequence analysis, and the associations with the clinical outcome were evaluated by a Cox proportional hazards model. Results In total, 98 patients and 84 age- and sex-matched healthy subjects were included in the analysis. Compared with healthy subjects, the neurocritically ill patients exhibited significantly different compositions of intestinal microbiota. During hospitalization, the α-diversity and abundance of Ruminococcaceae and Lachnospiraceae decreased significantly over time in patients followed longitudinally. The abundance of Enterobacteriaceae was positively associated with the modified Rankin Scale at discharge. In the multivariate Cox regression analysis, Christensenellaceae and Erysipelotrichaceae were associated with an increased risk of death. The increases in intestinal Enterobacteriales and Enterobacteriaceae during the first week in the neurological intensive care unit were associated with increases of 92% in the risk of 180-day mortality after adjustments. Conclusions This analysis of the gut microbiome in 98 neurocritically ill patients indicates that the gut microbiota composition in these patients differs significantly from that in a healthy population and that the magnitude of this dysbiosis increases during hospitalization in a neurological intensive care unit. The gut microbiota characteristics seem to have an impact on patients’ 180-day mortality. Gut microbiota analysis could hopefully predict outcome in the future. Electronic supplementary material The online version of this article (10.1186/s13054-019-2488-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruoting Xu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chuhong Tan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiajia Zhu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiuli Zeng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xuxuan Gao
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiheng Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiong Chen
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Huidi Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hongwei Zhou
- State Key Laboratory of Organ Failure Research, Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China
| | - Yan He
- State Key Laboratory of Organ Failure Research, Microbiome Medicine Center, Division of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China.
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Jia Yin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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15
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Nguyen AH, Miller WR, Arias CA. Shape Follows Function: Gastrointestinal Signals for Enterococcal Colonization. Trends Mol Med 2019; 25:464-466. [PMID: 31109795 DOI: 10.1016/j.molmed.2019.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 01/16/2023]
Abstract
Vancomycin-resistant Enterococcus faecium (VRE) is a major cause of nosocomial infections. A new study by McKenney et al. (Cell Host Microbe 2019;25:695-705.e5) reports that VRE undergo a morphotype switch in response to lithocholic acid (LCA) to facilitate gastrointestinal (GI) tract colonization. This metabolic cue is a potential target to decrease VRE colonization and subsequent transmission of antibiotic resistance.
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Affiliation(s)
- April H Nguyen
- Center for Antimicrobial Resistance and Microbial Genomics, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA; Department of Microbiology and Molecular Genetics, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA
| | - William R Miller
- Center for Antimicrobial Resistance and Microbial Genomics, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA; Division of Infectious Diseases, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA; Department of Microbiology and Molecular Genetics, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA; Division of Infectious Diseases, University of Texas Health Science Center, McGovern School of Medicine, Houston, TX, USA; Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston, TX, USA; Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia.
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Chiang HY, Wu TH, Hsu CY, Chao WC. Association Between Positive Cultures During Admission and 1-Year Mortality in Patients With Cancer Receiving Perioperative Intensive Care. Cancer Control 2018; 25:1073274818794162. [PMID: 30086666 PMCID: PMC6083771 DOI: 10.1177/1073274818794162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The number of patients with cancer being admitted to intensive care units (ICUs)
is increasing worldwide, and these patients are vulnerable to infection. This
study aimed to address the long-term impact of positive cultures during
admission on 1-year mortality among patients with cancer who received
perioperative intensive care. This retrospective cohort study enrolled adult
patients with cancer who were admitted to ICUs and received surgery during 2011
to 2016 at a tertiary hospital in central Taiwan. Cancer-related data were
retrieved from the cancer registry, and data during ICU admissions were obtained
from the electronic medical records. We compared the survival curves between
patients with and without positive clinical cultures using log-rank test and
used a multivariable Cox proportional hazards regression model to evaluate the
influence of positive clinical cultures on 1-year mortality. A total of 638
patients were included for analyses, and 37.9% of them had positive cultures
during the index admission. In-hospital mortality was 9.1%, while 1-year
mortality was 21.0%. Compared with patients who survived, patients who died were
significantly more likely to have positive cultures (59.7% vs 32.1%), to have a
higher Acute Physiology and Chronic Health Evaluation II scores (median 21.8 vs
19.0), and to receive mechanical ventilation (86.6% vs 77.4%). Survival analysis
found that positive cultures of blood, the respiratory tract, the urinary tract,
or the skin and soft tissue were associated with an increased 1-year mortality.
Multivariable Cox proportional hazards regression analysis found that positive
cultures of blood, the respiratory tract, the urinary tract, or the skin and
soft tissue (hazard ratio: 1.621; 95% confidence interval: 1.087-2.419) were
significantly associated with 62.1% increased hazards of death within 1 year
after the ICU admission. A positive culture during admission was associated with
a worsened long-term survival among patients with cancer who received
perioperative intensive care. Further studies are needed to confirm this
association.
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Affiliation(s)
- Hsiu-Yin Chiang
- 1 Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,2 Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Tung-Han Wu
- 3 Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Chiayi, Taiwan
| | - Chiann-Yi Hsu
- 1 Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Cheng Chao
- 1 Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,4 Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,5 Department of Business Administration, National Changhua University of Education, Changhua, Taiwan
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Engler-Hüsch S, Heister T, Mutters NT, Wolff J, Kaier K. In-hospital costs of community-acquired colonization with multidrug-resistant organisms at a German teaching hospital. BMC Health Serv Res 2018; 18:737. [PMID: 30257671 PMCID: PMC6158851 DOI: 10.1186/s12913-018-3549-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/20/2018] [Indexed: 01/02/2023] Open
Abstract
Background Antibiotic resistance is a challenge in the management of infectious diseases and can cause substantial cost. Even without the onset of infection, measures must be taken, as patients colonized with multi-drug resistant (MDR) pathogens may transmit the pathogen. We aim to quantify the cost of community-acquired MDR colonizations using routine data from a German teaching hospital. Methods All 2006 cases of documented MDR colonization at hospital admission recorded from 2011 to 2014 are matched to 7917 unexposed controls with the same primary diagnosis. Cases with an onset MDR infection are excluded from the analysis. Routine data on costs per case is analysed for three groups of MDR bacteria: Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and multidrug-resistant gram-negative bacteria (MDR-GN). Multivariate analyses are conducted to adjust for potential confounders. Results After controlling for main diagnosis group, age, sex, and Charlson Comorbidity Index, MDR colonization is associated with substantial additional costs from the healthcare perspective (€1480.9, 95%CI €1286.4–€1675.5). Heterogeneity between pathogens remains. Colonization with MDR-GN leads to the largest cost increase (€1966.0, 95%CI €1634.6–€2297.4), followed by MRSA with €1651.3 (95%CI €1279.1–€2023.6), and VRE with €879.2 (95%CI €604.1–€1154.2). At the same time, MDR-GN is associated with additional reimbursements of €887.8 (95%CI €722.1–€1053.6), i.e. costs associated with MDR-colonization exceed reimbursement. Conclusions Even without the onset of invasive infection, documented MDR-colonization at hospital admission is associated with increased hospital costs, which are not fully covered within the German DRG-based hospital payment system. Electronic supplementary material The online version of this article (10.1186/s12913-018-3549-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sabine Engler-Hüsch
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Thomas Heister
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany.
| | - Nico T Mutters
- Institute for Infection Prevention and Hospital Epidemiology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Wolff
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Centre - University of Freiburg, Freiburg, Germany
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Hygienemaßnahmen zur Prävention der Infektion durch Enterokokken mit speziellen Antibiotikaresistenzen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1310-1361. [DOI: 10.1007/s00103-018-2811-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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The Use of Microbiome Restoration Therapeutics to Eliminate Intestinal Colonization With Multidrug-Resistant Organisms. Am J Med Sci 2018; 356:433-440. [PMID: 30384952 DOI: 10.1016/j.amjms.2018.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/17/2022]
Abstract
Antibiotic resistance (AR) has been described by the World Health Organization as an increasingly serious threat to global public health. Many mechanisms of AR have become widespread due to global selective pressures such as widespread antibiotic use. The intestinal tract is an important reservoir for many multidrug-resistant organisms (MDROs), and next-generation sequencing has expanded understanding of the resistome, defined as the comprehensive sum of genetic determinants of AR. Intestinal decolonization has been explored as a strategy to eradicate MDROs with selective digestive tract decontamination and probiotics being notable examples with mixed results. This review focuses on fecal microbiota transplantation and the early evidence supporting its efficacy in decolonizing MDROs and potential mechanisms of action to reduce AR genes. Current evidence suggests that fecal microbiota transplantation may have promise in restoring healthy microbial diversity and reducing AR, and clinical trials are underway to better characterize its safety and efficacy.
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20
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Zhou MJ, Li J, Salmasian H, Zachariah P, Yang YX, Freedberg DE. The local hospital milieu and healthcare-associated vancomycin-resistant enterococcus acquisition. J Hosp Infect 2018; 101:69-75. [PMID: 30026006 DOI: 10.1016/j.jhin.2018.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Vancomycin-resistant enterococcus (VRE) causes 4% of all healthcare-associated infections in the USA. The process by which the local hospital milieu contributes to VRE acquisition is not fully understood. AIM To determine the importance of specific factors within the local hospital environment for healthcare-associated VRE acquisition. METHODS This retrospective cohort study included patients admitted to six intensive care units at an academic medical centre from January 2012 to December 2016 with negative rectal VRE cultures on admission. VRE acquisition was defined as a positive surveillance swab performed at any time after the initial negative swab during the index hospitalization. The exposures of interest were VRE colonization pressure, VRE importation pressure, and use of vancomycin. Multivariable Cox proportional hazards modelling was performed, with patients followed until VRE acquisition, death, or for up to 30 days. FINDINGS Of 8485 patients who were initially VRE negative, 161 patients acquired VRE. On univariate analysis, patients with VRE acquisition were more likely to have received vancomycin, to have had a neighbouring patient who received vancomycin, to have high VRE importation pressure, or to have high VRE colonization pressure. On multivariable analysis, only high VRE colonization pressure was an independent predictor of VRE acquisition (adjusted hazard ratio: 1.79; 95% confidence interval: 1.19-2.70). CONCLUSION VRE colonization pressure was the most important risk factor for healthcare-associated VRE acquisition, regardless of VRE importation pressure. Interventions seeking to reduce VRE acquisition should focus on minimizing transmission between patients with known VRE and the local hospital environment.
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Affiliation(s)
- M J Zhou
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - J Li
- Biomedical Informatics, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - H Salmasian
- Data Science and Evaluation, Brigham and Women's Hospital, Boston, MA, USA
| | - P Zachariah
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Y-X Yang
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA.
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21
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Axelrad JE, Lebwohl B, Cuaresma E, Cadwell K, Green PHR, Freedberg DE. Gut colonization with vancomycin-resistant Enterococcus and risk for subsequent enteric infection. Gut Pathog 2018; 10:28. [PMID: 30002733 PMCID: PMC6038175 DOI: 10.1186/s13099-018-0259-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 07/03/2018] [Indexed: 02/08/2023] Open
Abstract
Background Gut colonization with vancomycin-resistant Enterococcus (VRE) is associated with poor outcomes. This study evaluated the impact of VRE colonization on subsequent acquisition of enteric pathogens. Methods We performed a retrospective cohort study of adults admitted to an ICU from 2012 to 2017 who were screened for VRE colonization and subsequently underwent stool testing with a gastrointestinal pathogen PCR panel (GI PCR) with or without PCR testing for Clostridium difficile. Our primary outcome was the presence of any enteric pathogen. Cox proportional hazards modeling was used to adjust for factors associated with enteric infection. Results Of 761 patients who underwent VRE screening and subsequent GI PCR, 131 (17%) were colonized with VRE. Patients with VRE colonization were less likely to test positive on GI PCR compared to patients without VRE (9.2% vs 18%, p = 0.01); specifically for E. coli species (p = 0.03) and viral (p = 0.04) enteric infections. In 716 patients who underwent C. difficile testing, there was a trend towards more C. difficile infections in patients colonized with VRE (15% vs 10%, p = 0.11). On multivariable analysis, patients with VRE had a decreased risk of a positive GI PCR (aHR 0.47, 95% CI 0.25-0.88, p = 0.02) but not C. difficile infection, effects which persisted during 5 years of follow-up. Among positive tests, there was a greater proportion of C. difficile with VRE (57% vs 28%, p < 0.01). Conclusions VRE colonization was associated with a decreased risk of subsequent non-C. difficile enteric infection. VRE domination of the gut microbiome may protect against acquisition of common enteric pathogens.
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Affiliation(s)
- Jordan E Axelrad
- 1Division of Gastroenterology, Department of Medicine, Inflammatory Bowel Disease Center, NYU Langone Health, 240 East 38th Street, 23rd Floor, New York, NY USA.,2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY USA
| | - Benjamin Lebwohl
- 2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY USA
| | - Edward Cuaresma
- 2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY USA
| | - Ken Cadwell
- 3Kimmel Center for Biology and Medicine at the Skirball Institute, New York University School of Medicine, New York, NY USA.,4Department of Microbiology, New York University School of Medicine, New York, NY USA
| | - Peter H R Green
- 2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY USA
| | - Daniel E Freedberg
- 2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY USA
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22
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Freedberg DE, Zhou MJ, Cohen ME, Annavajhala MK, Khan S, Moscoso DI, Brooks C, Whittier S, Chong DH, Uhlemann AC, Abrams JA. Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection. Intensive Care Med 2018; 44:1203-1211. [PMID: 29936583 DOI: 10.1007/s00134-018-5268-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/05/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. METHODS This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. RESULTS Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). CONCLUSIONS Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.
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Affiliation(s)
- Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.
| | - Margaret J Zhou
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - Margot E Cohen
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Medini K Annavajhala
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Sabrina Khan
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Dagmara I Moscoso
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
| | - Susan Whittier
- Division of Laboratory Medicine, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, USA
| | - David H Chong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Anne-Catrin Uhlemann
- Microbiome and Pathogen Genomics Core, Department of Medicine, Columbia University Medical Center, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Julian A Abrams
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA.,Mailman School of Public Health, New York, USA
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23
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Frakking FNJ, Bril WS, Sinnige JC, Klooster JEV, de Jong BAW, van Hannen EJ, Tersmette M. Recommendations for the successful control of a large outbreak of vancomycin-resistant Enterococcus faecium in a non-endemic hospital setting. J Hosp Infect 2018; 100:e216-e225. [PMID: 29475013 DOI: 10.1016/j.jhin.2018.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/14/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large outbreak of three epidemic vancomycin-resistant Enterococcus faecium (VRE) clones affected the study hospital for almost two years. AIM To describe the strategy to successfully control this outbreak and eradicate VRE from the study hospital. METHODS Infection control interventions started after detection of VRE in three patients. Hospital-wide surveillance was started after ongoing transmission despite isolation precautions, cleaning and contact tracing. Hygiene education and discipline were enhanced. Despite these interventions, additional measures were required to control the outbreak, such as ward disinfection with hydrogen peroxide vapour and the introduction of a VRE quarantine ward. Ultimately, ciprofloxacin prophylaxis for haematological patients on chemotherapy was abandoned. FINDINGS Over a 22-month period, 242 VRE carriers were identified. Of these, 128 (53%) patients were detected by hospital-wide surveillance alone. Three epidemic clones were detected: ST494-vanA (N = 160), ST78-vanA (N = 23) and ST117-vanB (N = 32). In total, 5614 possible contacts were identified. VRE transmission occurred on 13 out of 23 wards. VRE was cultured from clinical specimens in 22 patients (seven with bacteraemia). Since January 2014, no further transmission of these VRE clones has been observed. CONCLUSION Infection control measures according to international guidelines were insufficient to expose the outbreak to its full extent and control it. Its full extent only became apparent after sustained hospital-wide screening. Successful control of this hospital-wide VRE outbreak was feasible, but required great effort. Final containment and eradication of the epidemic clones was achieved by environmental decontamination with hydrogen peroxide vapour, strict isolation precautions, a VRE quarantine ward and antimicrobial stewardship.
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Affiliation(s)
- F N J Frakking
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - W S Bril
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - J C Sinnige
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J E Van't Klooster
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - B A W de Jong
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - E J van Hannen
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
| | - M Tersmette
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein and Utrecht, The Netherlands
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24
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Puchter L, Chaberny IF, Schwab F, Vonberg RP, Bange FC, Ebadi E. Economic burden of nosocomial infections caused by vancomycin-resistant enterococci. Antimicrob Resist Infect Control 2018; 7:1. [PMID: 29312658 PMCID: PMC5755438 DOI: 10.1186/s13756-017-0291-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background Nosocomial infections due to vancomycin-resistant enterococci (VRE) have become a major problem during the last years. The purpose of this study was to investigate the economic burden of nosocomial VRE infections in a European university hospital. Methods A retrospective matched case-control study was performed including patients who acquired nosocomial infection with either VRE or vancomycin-susceptible enterococci (VSE) within a time period of 3 years. 42 cases with VRE infections and 42 controls with VSE infections were matched for age, gender, admission and discharge within the same year, time at risk for infection, Charlson comorbidity index (±1), stay on intensive care units and non-intensive care units as well as for the type of infection, using criteria of the Centers for Disease Control and Prevention. Results The median overall costs per case were significantly higher than for controls (EUR 57,675 vs. EUR 38,344; p = 0.030). Costs were similar between cases and controls before onset of infection (EUR 17,893 vs. EUR 16,600; p = 0.386), but higher after onset of infection (EUR 37,971 vs. EUR 23,025; p = 0.049). The median attributable costs per case for vancomycin-resistance were EUR 13,157 (p = 0.036). The most significant differences in costs between cases and controls turned out to be for pharmaceuticals (EUR 6030 vs. EUR 2801; p = 0.008) followed by nursing staff (EUR 8956 vs. EUR 4621; p = 0.032), medical products (EUR 3312 vs. EUR 1838; p = 0.020), and for assistant medical technicians (EUR 3766 vs. EUR 2474; p = 0.023). Furthermore, multivariate analysis revealed that costs were driven independently by vancomycin-resistance (1.4 fold; p = 0.034). Conclusions This analysis suggested that nosocomial VRE infections significantly increases hospital costs compared with VSE infections. Therefore, hospital personal should implement control measures to prevent VRE transmission.
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Affiliation(s)
- Laura Puchter
- Department of Anesthesiology and Intensive Care Medicine, KRH Klinikum Hannover, Hannover, Germany
| | - Iris Freya Chaberny
- Institute of Infection Control and Hospital Epidemiology, Leipzig University Hospital, Leipzig, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Franz-Christoph Bange
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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25
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Soares FS, Amaral FC, Silva NLC, Valente MR, Santos LKR, Yamashiro LH, Scheffer MC, Castanheira FVES, Ferreira RG, Gehrke L, Alves-Filho JC, Silva LP, Báfica A, Spiller F. Antibiotic-Induced Pathobiont Dissemination Accelerates Mortality in Severe Experimental Pancreatitis. Front Immunol 2017; 8:1890. [PMID: 29375557 PMCID: PMC5770733 DOI: 10.3389/fimmu.2017.01890] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/11/2017] [Indexed: 12/23/2022] Open
Abstract
Although antibiotic-induced dysbiosis has been demonstrated to exacerbate intestinal inflammation, it has been suggested that antibiotic prophylaxis may be beneficial in certain clinical conditions such as acute pancreatitis (AP). However, whether broad-spectrum antibiotics, such as meropenem, influence the dissemination of multidrug-resistant (MDR) bacteria during severe AP has not been addressed. In the currently study, a mouse model of obstructive severe AP was employed to investigate the effects of pretreatment with meropenem on bacteria spreading and disease outcome. As expected, animals subjected to biliopancreatic duct obstruction developed severe AP. Surprisingly, pretreatment with meropenem accelerated the mortality of AP mice (survival median of 2 days) when compared to saline-pretreated AP mice (survival median of 7 days). Early mortality was associated with the translocation of MDR strains, mainly Enterococcus gallinarum into the blood stream. Induction of AP in mice with guts that were enriched with E. gallinarum recapitulated the increased mortality rate observed in the meropenem-pretreated AP mice. Furthermore, naïve mice challenged with a mouse or a clinical strain of E. gallinarum succumbed to infection through a mechanism involving toll-like receptor-2. These results confirm that broad-spectrum antibiotics may lead to indirect detrimental effects during inflammatory disease and reveal an intestinal pathobiont that is associated with the meropenem pretreatment during obstructive AP in mice.
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Affiliation(s)
- Fernanda S Soares
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Flávia C Amaral
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Natália L C Silva
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Matheus R Valente
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Lorena K R Santos
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Lívia H Yamashiro
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Mara C Scheffer
- Microbiology Laboratory, University Hospital, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Fernanda V E S Castanheira
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Raphael G Ferreira
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Laura Gehrke
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - José C Alves-Filho
- Department of Pharmacology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Luciano P Silva
- Embrapa Genetic Resources and Biotechnology, Brasilia, Brazil.,Institute of Biological Sciences, University of Brasilia, Brasilia, Brazil
| | - André Báfica
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Department of Microbiology, Immunology and Parasitology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
| | - Fernando Spiller
- Laboratory of Immunobiology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil.,Department of Pharmacology, Federal University of Santa Catarina (UFSC), Florianópolis, Brazil
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Vancomycin-Resistant Enterococci (VRE) in The Intensive Care Unit in a Nonoutbreak Setting: Identification of Potential Reservoirs and Epidemiological Associations Between Patient and Environmental VRE. Infect Control Hosp Epidemiol 2017; 39:40-45. [DOI: 10.1017/ice.2017.248] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAmong nosocomial bloodstream infections caused by enterococcal species, Ireland has the highest proportion caused by vancomycin-resistant enterococci (VRE) in Europe at 45.8%. The contribution of the near-patient environment to VRE transmission outside of outbreaks was investigated.DESIGNA prospective observational study was conducted during 7 sampling periods.METHODSRecovery of VRE isolates by swabbing the near-patient environment and patients in the intensive care unit (ICU) was conducted to identify reservoirs, clinical and molecular epidemiological associations, and the success of active surveillance cultures (ASCs).RESULTSOf 289 sampling occasions involving 157 patients and their bed spaces, VRE isolates were recovered from patient bed spaces, clinical samples, or both on 114 of 289 sampling occasions (39.4%). The patient and their bed space were positive for VRE on 34 of 114 VRE-associated sampling occasions (29.8%). Of 1,647 environment samples, 107 sites (6.5%) were VRE positive, with significantly greater VRE recovery from isolation rooms than from the open-plan area (9.1% vs 4.1%;P< .0001). The most frequently VRE-contaminated sites were the drip stand, bed control panel, and chart holders, which together accounted for 61% of contaminated sites. The use of ASCs resulted in a 172% increase in identification of VRE-colonized patients. Molecular typing revealed 2 environmental clusters, 1 cluster involving 3 patients and generally greater heterogeneity of patient isolates compared to environmental isolates.CONCLUSIONEven outside of outbreaks, near-patient ICU environmental contamination with VRE is common. Better infection control policies that limit environmental transmission of VRE in the ICU and that are supported by molecular epidemiological studies, in real time, are needed.Infect Control Hosp Epidemiol2018;39:40–45
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27
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Both A, Franke GC, Mirwald N, Lütgehetmann M, Christner M, Klupp EM, Belmar Campos C, Büttner H, Aepfelbacher M, Rohde H. Two-tier approach combining molecular and culture-based techniques for optimized detection of vancomycin-resistant enterococci. Diagn Microbiol Infect Dis 2017; 89:253-257. [DOI: 10.1016/j.diagmicrobio.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 11/29/2022]
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28
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Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis. J Orthop Trauma 2017; 31:64-70. [PMID: 27984449 DOI: 10.1097/bot.0000000000000750] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
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29
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Lee H, Lee H. Clinical and Economic Evaluation of Multidrug-Resistant Acinetobacter baumannii Colonization in the Intensive Care Unit. Infect Chemother 2016; 48:174-180. [PMID: 27659440 PMCID: PMC5047998 DOI: 10.3947/ic.2016.48.3.174] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 12/02/2022] Open
Abstract
Background The clinical and economic impact of multidrug-resistant (MDR) Acinetobacter baumannii colonization remains unclear. This study aimed to estimate and compare the mortality rates, length of stay (LOS), and hospitalization costs in the intensive care unit (ICU) for MDR A. baumannii colonized patients and a matched population. Materials and Methods We performed a retrospective propensity score matched cohort study comparing the outcomes of patients with MDR A. baumannii colonization with those of uncolonized subjects matched at the time they were admitted to the ICU between January 2012 and December 2014. Results During the study period, 375 (7.5%) of the 4,779 patients were colonized with MDR A. baumannii. One hundred and twenty-two MDR A. baumannii colonized patients were compared with 122 uncolonized patients using propensity score matching. MDR A. baumannii colonized patients were likely to have a higher mortality rate compared to uncolonized patients (49.2% vs 32.0%; odds ratio [OR], 3.64). A longer ICU LOS and total admission days were observed in the MDR A. baumannii colonized patient group (4.14 and 4.67 days increase, OR 1.41 and 1.19). MDR A. baumannii colonization patients had an average extra ICU and total admission cost of $1,179 (₩1,261,334) and $1,333 (₩1,422,032) according to a multivariable regression model (OR, 1.27 and 1.17). Multivariable analysis identified the factors affecting ICU cost, which included, MDR A. baumannii colonization (OR = 1.33; P = 0.001), ICU LOS (OR = 1.97; P <0.001), valvular heart disease (OR = 1.12; P = 0.005), invasive devices (OR = 1.15; P = 0.018), and surgery (OR = 1.1; P <0.001). Conclusion MDR A. baumannii colonization was associated with increased mortality, LOS, and costs in the ICU. A strict infection control program including preemptive isolation for high-risk groups would be helpful for reducing the burden of this infection.
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Affiliation(s)
- Hojin Lee
- Division of Infectious Diseases, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Hyuck Lee
- Division of Infectious Diseases, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea.
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30
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Dubberke ER, Mullane KM, Gerding DN, Lee CH, Louie TJ, Guthertz H, Jones C. Clearance of Vancomycin-Resistant Enterococcus Concomitant With Administration of a Microbiota-Based Drug Targeted at Recurrent Clostridium difficile Infection. Open Forum Infect Dis 2016; 3:ofw133. [PMID: 27703995 PMCID: PMC5047394 DOI: 10.1093/ofid/ofw133] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Background. Vancomycin-resistant Enterococcus (VRE) is a major healthcare-associated pathogen and a well known complication among transplant and immunocompromised patients. We report on stool VRE clearance in a post hoc analysis of the Phase 2 PUNCH CD study assessing a microbiota-based drug for recurrent Clostridium difficile infection (CDI). Methods. A total of 34 patients enrolled in the PUNCH CD study received 1 or 2 doses of RBX2660 (microbiota suspension). Patients were requested to voluntarily submit stool samples at baseline and at 7, 30, and 60 days and 6 months after the last administration of RBX2660. Stool samples were tested for VRE using bile esculin azide agar with 6 µg/mL vancomycin and Gram staining. Vancomycin resistance was confirmed by Etest. Results. VRE status (at least 1 test result) was available for 30 patients. All stool samples for 19 patients (63.3%, mean age 61.7 years, 68% female) tested VRE negative. Eleven patients (36.7%, mean age 75.5 years, 64% female) were VRE positive at the first test (baseline or 7-day follow-up). Of these patients, 72.7%, n = 8 converted to negative as of the last available follow-up (30 or 60 days or 6 months). Of the other 3: 1 died (follow-up data not available); 1 patient remained positive at all follow-ups; 1 patient retested positive at 6 months with negative tests during the interim. Conclusions. Although based on a small sample size, this secondary analysis demonstrated the possibility of successfully converting a high percentage of VRE-positive patients to negative in a recurrent CDI population with RBX2660.
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Affiliation(s)
- Erik R Dubberke
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kathleen M Mullane
- Section of Infectious Diseases and Global Health, University of Chicago Medicine
| | - Dale N Gerding
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois
| | - Christine H Lee
- Department of Medicine, McMaster University, Hamilton, Ontario
| | - Thomas J Louie
- Departments of Medicine and Microbiology-Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
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Sutcu M, Akturk H, Acar M, Salman N, Aydın D, Akgun Karapınar B, Ozdemir A, Cihan R, Citak A, Somer A. Impact of vancomycin-resistant enterococci colonization in critically ill pediatric patients. Am J Infect Control 2016; 44:515-9. [PMID: 26781220 DOI: 10.1016/j.ajic.2015.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND We aimed to determine the frequency of vancomycin-resistant enterococci (VRE) infection occurrence in previously VRE-colonized children in a pediatric intensive care unit (PICU) and to identify associated risk factors. METHODS Infection control nurses have performed prospective surveillance of health care-associated infections and rectal VRE carriage in PICUs from January 2010-December 2014. This database was reviewed to obtain information about VRE-colonized and subsequently infected patients. A case-control study was performed to identify risk factors associated with VRE infection development in previously VRE-colonized patients. RESULTS Out of 1,134 patients admitted to the PICU, 108 (9.5%) were found to be colonized with VRE throughout the study period. Systemic VRE infections developed in 11 VRE-colonized patients (10.2%), and these included primary bloodstream infection (n = 6), urinary tract infection (n = 3), meningitis and bloodstream infection (n = 1), and meningitis (n = 1). Logistic regression analysis indicated long hospital stay (≥30 days) and glycopeptide use after detection of VRE colonization as risk factors for developing VRE infection in VRE-colonized patients (odds ratio [OR], 5.76; 95% confidence interval [CI], 1.6-15.8; P = .017 and OR, 12.8; 95% CI, 1.9-26.6; P = .012, respectively). CONCLUSIONS VRE colonization has important consequences in pediatric critically ill patients. Strict infection control measures should be implemented to prevent VRE colonization and thereby VRE infections. Furthermore, irrational antibiotic use and particularly glycopeptide use in VRE-colonized patients should be restricted.
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Dickinson KJ, Taswell JB, Allen MS, Blackmon SH, Nichols FC, Shen R, Wigle DA, Cassivi SD. Factors influencing length of stay after surgery for benign foregut disease. Eur J Cardiothorac Surg 2016; 50:124-9. [DOI: 10.1093/ejcts/ezv453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/04/2015] [Indexed: 12/14/2022] Open
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Mahmoodian A, Abbasi S, Farsaei S. A new approach to Vancomycin utilization evaluation: A cross-sectional study in intensive care unit. J Res Pharm Pract 2016; 5:279-284. [PMID: 27843965 PMCID: PMC5084486 DOI: 10.4103/2279-042x.192453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective: The risk of methicillin-resistant Staphylococcus aureus infections in Intensive Care Unit (ICU) is increasing in recent years with high rate of morbidity and mortality. Therefore, in this study, we aimed to evaluate the rationale use of vancomycin in ICU patients. Methods: A total of 200 patients who received at least 48 h intravenous vancomycin were randomly selected from ICU wards, during 9 months. Vancomycin administration and related clinical and laboratory data were gathered from patients' charts and health information system to evaluate the appropriateness of different aspects of vancomycin use during all days which vancomycin were ordered. Findings: During the study, 15,230 ± 1216 mg (mean ± standard error of the mean [SEM]) vancomycin was administered for 200 patients in the mean period of 9.79 ± 0.64 (SEM) days of ICU stay, for prophylaxis and empiric therapy. Results showed the appropriateness of vancomycin uses were 30.5%, 9%, and 5.5% in the first 24 h, after 72 h and during the whole time of treatment, respectively. In addition, infectious consultation was the only significantly different parameter between appropriate and inappropriate vancomycin administration groups (P < 0.001). Conclusion: Although vancomycin utilization evaluation were mentioned in previous studies, but data related to ICU patients and during all days of vancomycin therapy are limited. High prevalence of inappropriate use of vancomycin in ICU is alarming for health systems and necessitates implementation of antibiotic policies.
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Affiliation(s)
- Atefeh Mahmoodian
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Abbasi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Farsaei
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Jiménez R, Ortín A, Rebollo S, Herrera L, Fernández A, Galindo M, Moreno S, Ojados A, Tárraga L, Bonilla Y, Sánchez-Argente S, Ortíz MM, Del Amor MJ, Allegue JM. Risk factors for non-vancomycin-resistant enterococcus faecium infection. Intensive Care Med Exp 2015. [PMCID: PMC4798433 DOI: 10.1186/2197-425x-3-s1-a124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Papadimitriou-Olivgeris M, Spiliopoulou I, Christofidou M, Logothetis D, Manolopoulou P, Dodou V, Fligou F, Marangos M, Anastassiou ED. Co-colonization by multidrug-resistant bacteria in two Greek intensive care units. Eur J Clin Microbiol Infect Dis 2015; 34:1947-55. [DOI: 10.1007/s10096-015-2436-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 06/22/2015] [Indexed: 11/28/2022]
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