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Schnizer M, Schellong P, Rose N, Fleischmann-Struzek C, Hagel S, Abbas M, Payne B, Evans RN, Pletz MW, Weis S. Long versus short course anti-microbial therapy of uncomplicated Staphylococcus aureus bacteraemia: a systematic review. Clin Microbiol Infect 2024; 30:1254-1260. [PMID: 38823452 DOI: 10.1016/j.cmi.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/25/2024] [Accepted: 05/26/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Current guidelines recommend at least 2 weeks duration of antibiotic therapy (DOT) for patients with uncomplicated Staphylococcus aureus bacteraemia (SAB) but the evidence for this recommendation is unclear. OBJECTIVES To perform a systematic literature review assessing current evidence for recommended DOT for patients with SAB. METHODS The following are the methods used for this study. DATA SOURCES We searched MEDLINE, ISI Web of Science, the Cochrane Database and clinicaltrials.gov from inception to March 30, 2024. References of eligible studies were screened and experts in the field contacted for additional articles. STUDY ELIGIBILITY CRITERIA All clinical studies, regardless of design, publication status and language. PARTICIPANTS Adult patients with uncomplicated SAB. INTERVENTIONS Long (>14 days; >18 days; 11-16 days) vs. short (≤14 days; 10-18 days; 6-10 days, respectively) DOT with the DOT being defined as the first until the last day of antibiotic therapy. ASSESSMENT OF RISK OF BIAS Risk of bias was assessed using the ROBINS-I-tool. METHODS OF DATA SYNTHESIS The primary outcome was 90-day all-cause mortality. Only studies presenting results of adjusted analyses for mortality were included. Data synthesis could not be performed. RESULTS Eleven nonrandomized studies were identified that fulfilled the pre-defined inclusion criteria, of which three studies reported adjusted effect ratios. Only these were included in the final analysis. We did not find any RCT. Two studies with 1230 patients reported the primary endpoint 90-day all-cause mortality. Neither found a statistically significant superiority for longer (>14 days; 11-16 days) or shorter DOT (≤14 days; 6-10 days, respectively) for patients with uncomplicated SAB. Two studies investigated the secondary endpoint 30-day all-cause mortality (>18 days; 11-16 days vs. 10-18 days; 6-10 days, respectively) and did not find a statistically significant difference. All included studies had a moderate risk of bias. CONCLUSIONS Sound evidence that supports any duration of antibiotic treatment for patients with uncomplicated SAB is lacking.
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Affiliation(s)
- Martin Schnizer
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Paul Schellong
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Norman Rose
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Carolin Fleischmann-Struzek
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Stefan Hagel
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Mohamed Abbas
- Infection Control Program and WHO Collaborating Center on AMR and IPC, University of Geneva Hospitals and Faculty of Medicine, Service of Infectious Diseases, Geneva, Switzerland; MRC Centre for Global Infectious Disease Analysis, Jameel Institute, School of Public Health, Imperial College London, London, UK
| | - Brendan Payne
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK; Department of Infection and Tropical Medicine, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Mathias W Pletz
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany; Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute, Jena, Germany.
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Hendriks MMC, Schweren KSA, Kleij A, Berrevoets MAH, de Jong E, van Wijngaarden P, Ammerlaan HSM, Vos A, van Assen S, Slieker K, Gisolf JH, Netea MG, ten Oever J, Kouijzer IJE. Low-Risk Staphylococcus aureus Bacteremia Patients Do Not Require Routine Diagnostic Imaging: A Multicenter, Retrospective, Cohort Study. Clin Infect Dis 2024; 79:43-51. [PMID: 38576380 PMCID: PMC11259217 DOI: 10.1093/cid/ciae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/21/2024] [Accepted: 04/02/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Stratification to categorize patients with Staphylococcus aureus bacteremia (SAB) as low or high risk for metastatic infection may direct diagnostic evaluation and enable personalized management. We investigated the frequency of metastatic infections in low-risk SAB patients, their clinical relevance, and whether omission of routine imaging is associated with worse outcomes. METHODS We performed a retrospective cohort study at 7 Dutch hospitals among adult patients with low-risk SAB, defined as hospital-acquired infection without treatment delay, absence of prosthetic material, short duration of bacteremia, and rapid defervescence. Primary outcome was the proportion of patients whose treatment plan changed due to detected metastatic infections, as evaluated by both actual therapy administered and by linking a adjudicated diagnosis to guideline-recommended treatment. Secondary outcomes were 90-day relapse-free survival and factors associated with the performance of diagnostic imaging. RESULTS Of 377 patients included, 298 (79%) underwent diagnostic imaging. In 15 of these 298 patients (5.0%), imaging findings during patient admission had been interpreted as metastatic infections that should extend treatment. Using the final adjudicated diagnosis, 4 patients (1.3%) had clinically relevant metastatic infection. In a multilevel multivariable logistic regression analysis, 90-day relapse-free survival was similar between patients without imaging and those who underwent imaging (81.0% versus 83.6%; adjusted odds ratio, 0.749; 95% confidence interval, .373-1.504). CONCLUSIONS Our study advocates risk stratification for the management of SAB patients. Prerequisites are follow-up blood cultures, bedside infectious diseases consultation, and a critical review of disease evolution. Using this approach, routine imaging could be omitted in low-risk patients.
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Affiliation(s)
- Marianne M C Hendriks
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kris S A Schweren
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ayden Kleij
- Department of Internal Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Marvin A H Berrevoets
- Department of Internal Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Emma de Jong
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | | | - Heidi S M Ammerlaan
- Department of Internal Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Anja Vos
- Department of Internal Medicine, Treant, Emmen, The Netherlands
| | | | - Kitty Slieker
- Department of Internal Medicine, Bernhoven Hospital, Uden, The Netherlands
| | - Jet H Gisolf
- Department of Intenal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Jaap ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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Maraolo AE, Ceccarelli G, Venditti M, Oliva A. Short Course Antibiotic Therapy for Catheter-Related Septic Thrombosis: "Caveat Emptor!": Duration of Therapy Should Not Be Set a Priori. Pathogens 2024; 13:529. [PMID: 39057756 PMCID: PMC11280046 DOI: 10.3390/pathogens13070529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/24/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
There is a growing body of evidence showing no significant difference in clinical outcomes in patients with uncomplicated Gram-negative bloodstream infections (BSIs) receiving 7 or 14 days of therapy. However, the scenario may differ when complicated forms of BSI, such as catheter-related BSIs (CRBSIs) burdened by septic thrombosis (ST), are considered. A recent study showed that a short course of antimicrobial therapy (≤3 weeks) had similar outcomes to a prolonged course on CRBSI-ST. From this perspective, starting from the desirable goal of shortening the treatment duration, we discuss how the path to the correct diagnosis and management of CRBSI-ST may be paved with several challenges. Indeed, patients with ST due to Gram-negative bacteria display prolonged bacteremia despite an indolent clinical course, requiring an extended course of antibiotic treatment guided by negative FUBCs results, which should be considered the real driver of the decision-making process establishing the length of antibiotic therapy in CRBSI-ST. Shortening treatment of complicated CRBSIs burdened by ST is ambitious and advisable; however, a dynamic and tailored approach driven by a tangible outcome such as negative FUBCs rather than a fixed-duration paradigm should be implemented for the optimal antimicrobial duration.
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Affiliation(s)
- Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy;
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy; (G.C.); (M.V.)
- Infectious Diseases Department, Azienda Ospedaliero Universitaria Policlinico Umberto I, 00161 Rome, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy; (G.C.); (M.V.)
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy; (G.C.); (M.V.)
- Infectious Diseases Department, Azienda Ospedaliero Universitaria Policlinico Umberto I, 00161 Rome, Italy
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Kim T, Lee SR, Park SY, Moon SM, Jung J, Kim MJ, Sung H, Kim MN, Kim SH, Choi SH, Lee SO, Kim YS, Song EH, Chong YP. Validation of a new risk stratification system-based management for methicillin-resistant Staphylococcus aureus bacteraemia: analysis of a multicentre prospective study. Eur J Clin Microbiol Infect Dis 2024; 43:841-851. [PMID: 38411778 DOI: 10.1007/s10096-024-04790-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Distinguishing between complicated and uncomplicated Staphylococcus aureus bacteraemia (SAB) is therapeutically essential. However, this distinction has limitations in reflecting the heterogeneity of SAB and encouraging targeted diagnostics. Recently, a new risk stratification system for SAB metastatic infection, involving stepwise approaches to diagnosis and treatment, has been suggested. We assessed its applicability in methicillin-resistant SAB (MRSAB) patients. METHODS We retrospectively analysed data of a 3-year multicentre, prospective cohort of hospitalised patients with MRSAB. We classified the patients into three risk groups: low, indeterminate, and high, based on the new system and compared between-group management and outcomes. RESULTS Of 380 patients with MRSAB, 6.3% were classified as low-, 7.6% as indeterminate-, and 86.1% as high-risk for metastatic infection. No metastatic infection occurred in the low-, 6.9% in the indeterminate-, and 19.6% in the high-risk groups (P < 0.001). After an in-depth diagnostic work-up, patients were finally diagnosed as 'without metastatic infection (6.3%)', 'with metastatic infection (17.4%)', and 'uncertain for metastatic infection (76.3%)'. 30-day mortality increased as the severity of diagnosis shifted from 'without metastatic infection' to 'uncertain for metastatic infection' and 'with metastatic infection' (P = 0.09). In multivariable analysis, independent factors associated with metastatic complications were suspicion of endocarditis in transthoracic echocardiography, clinical signs of metastatic infection, Pitt bacteraemia score ≥ 4, and persistent bacteraemia. CONCLUSIONS The new risk stratification system shows promise in predicting metastatic complications and guiding work-up and management of MRSAB. However, reducing the number of cases labelled as 'high-risk' and 'uncertain for metastatic infection' remains an area for improvement.
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Affiliation(s)
- Taeeun Kim
- Division of Infectious Diseases, Department of Medicine, Nowon Eulji University Hospital, Seoul, Republic of Korea
| | - Sang-Rok Lee
- Division of Infectious Diseases, Department of Internal Medicine, Cheongju St Mary's Hospital, Cheongju, Chungcheongbuk-do, Republic of Korea
| | - Seong Yeon Park
- Division of Infectious Diseases, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Gyeonggi-do, Republic of Korea
| | - Song Mi Moon
- Department of Internal Medicine at Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
- Department of Internal Medicine, Gil Medical Center, Gachon University School of Medicine, Incheon, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Eun Hee Song
- Departments of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Republic of Korea.
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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van der Vaart TW, Prins JM, Goorhuis A, Lemkes BA, Sigaloff KCE, Spoorenberg V, Stijnis C, Bonten MJM, van der Meer JTM. The Utility of Risk Factors to Define Complicated Staphylococcus aureus Bacteremia in a Setting With Low Methicillin-Resistant S. aureus Prevalence. Clin Infect Dis 2024; 78:846-854. [PMID: 38157401 PMCID: PMC11006106 DOI: 10.1093/cid/ciad784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/06/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION Recommended duration of antibiotic treatment of Staphylococcus aureus bacteremia (SAB) is frequently based on distinguishing uncomplicated and complicated SAB, and several risk factors at the onset of infection have been proposed to define complicated SAB. Predictive values of risk factors for complicated SAB have not been validated, and consequences of their use on antibiotic prescriptions are unknown. METHODS In a prospective cohort, patients with SAB were categorized as complicated or uncomplicated through adjudication (reference definition). Associations and predictive values of 9 risk factors were determined, compared with the reference definition, as was accuracy of Infectious Diseases Society of America (IDSA) criteria that include 4 risk factors, and the projected consequences of applying IDSA criteria on antibiotic use. RESULTS Among 490 patients, 296 (60%) had complicated SAB. In multivariable analysis, persistent bacteremia (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.9-12.0), community acquisition of SAB (OR, 2.9; 95% CI, 1.9-4.7) and presence of prosthetic material (OR, 2.3; 95% CI, 1.5-3.6) were associated with complicated SAB. Presence of any of the 4 risk factors in the IDSA definition of complicated SAB had a positive predictive value of 70.9% (95% CI, 65.5-75.9) and a negative predictive value of 57.5% (95% CI, 49.1-64.8). Compared with the reference, IDSA criteria yielded 24 (5%) false-negative and 90 (18%) false-positive classifications of complicated SAB. Median duration of antibiotic treatment of these 90 patients was 16 days (interquartile range, 14-19), all with favorable clinical outcome. CONCLUSIONS Risk factors have low to moderate predictive value to identify complicated SAB and their use may lead to unnecessary prolonged antibiotic use.
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Affiliation(s)
- Thomas W van der Vaart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bregtje A Lemkes
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Veroniek Spoorenberg
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis Stijnis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan T M van der Meer
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Quiñonez-Flores A, Martinez-Guerra BA, Román-Montes CM, Tamez-Torres KM, González-Lara MF, Ponce-de-León A, Rajme-López S. Cephalotin Versus Dicloxacillin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteraemia: A Retrospective Cohort Study. Antibiotics (Basel) 2024; 13:176. [PMID: 38391562 PMCID: PMC10885996 DOI: 10.3390/antibiotics13020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND First-line treatments for methicillin-susceptible S. aureus (MSSA) bacteraemia are nafcillin, oxacillin, or cefazolin. Regional shortages of these antibiotics force clinicians to use other options like dicloxacillin and cephalotin. This study aims to describe and compare the safety and efficacy of cephalotin and dicloxacillin for the treatment of MSSA bacteraemia. METHODS This retrospective study was conducted in a referral centre in Mexico City. We identified MSSA isolates in blood cultures from 1 January 2012 to 31 December 2022. Patients ≥ 18 years of age, with a first episode of MSSA bacteraemia, who received cephalotin or dicloxacillin as the definitive antibiotic treatment, were included. The primary outcome was in-hospital all-cause mortality. RESULTS We included 202 patients, of which 48% (97/202) received cephalotin as the definitive therapy and 52% (105/202) received dicloxacillin. In-hospital all-cause mortality was 20.7% (42/202). There were no differences in all-cause in-hospital mortality between patients receiving cephalotin or dicloxacillin (20% vs. 21%, p = 0.43), nor in 30-day all-cause mortality (14% vs. 18%, p = 0.57) or 90-day all-cause mortality (24% vs. 22%, p = 0.82). No severe adverse reactions were associated with either antibiotic. CONCLUSIONS Cephalotin and dicloxacillin were equally effective for treating MSSA bacteraemia, and both showed an adequate safety profile.
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Affiliation(s)
- Alejandro Quiñonez-Flores
- Internal Medicine Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Bernardo A Martinez-Guerra
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Carla M Román-Montes
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Karla M Tamez-Torres
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - María F González-Lara
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Alfredo Ponce-de-León
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Sandra Rajme-López
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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Hackemann VCJ, Hagel S, Jandt KD, Rödel J, Löffler B, Tuchscherr L. The Controversial Effect of Antibiotics on Methicillin-Sensitive S. aureus: A Comparative In Vitro Study. Int J Mol Sci 2023; 24:16308. [PMID: 38003500 PMCID: PMC10671744 DOI: 10.3390/ijms242216308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Methicillin-sensitive Staphylococcus (S.) aureus (MSSA) bacteremia remains a global challenge, despite the availability of antibiotics. Primary treatments include β-lactam agents such as cefazolin and flucloxacillin. Ongoing discussions have focused on the potential synergistic effects of combining these agents with rifampicin or fosfomycin to combat infections associated with biofilm formation. Managing staphylococcal infections is challenging due to antibacterial resistance, biofilms, and S. aureus's ability to invade and replicate within host cells. Intracellular invasion shields the bacteria from antibacterial agents and the immune system, often leading to incomplete bacterial clearance and chronic infections. Additionally, S. aureus can assume a dormant phenotype, known as the small colony variant (SCV), further complicating eradication and promoting persistence. This study investigated the impact of antibiotic combinations on the persistence of S. aureus 6850 and its stable small colony variant (SCV strain JB1) focusing on intracellular survival and biofilm formation. The results from the wild-type strain 6850 demonstrate that β-lactams combined with RIF effectively eliminated biofilms and intracellular bacteria but tend to select for SCVs in planktonic culture and host cells. Higher antibiotic concentrations were associated with an increase in the zeta potential of S. aureus, suggesting reduced membrane permeability to antimicrobials. When using the stable SCV mutant strain JB1, antibiotic combinations with rifampicin successfully cleared planktonic bacteria and biofilms but failed to eradicate intracellular bacteria. Given these findings, it is reasonable to report that β-lactams combined with rifampicin represent the optimal treatment for MSSA bacteremia. However, caution is warranted when employing this treatment over an extended period, as it may elevate the risk of selecting for small colony variants (SCVs) and, consequently, promoting bacterial persistence.
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Affiliation(s)
| | - Stefan Hagel
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany
| | - Klaus D Jandt
- Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena School for Microbial Communication (JSMC), 07743 Jena, Germany
| | - Jürgen Rödel
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
| | - Bettina Löffler
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
| | - Lorena Tuchscherr
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
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8
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Westgeest AC, Buis DTP, Sigaloff KCE, Ruffin F, Visser LG, Yu Y, Schippers EF, Lambregts MMC, Tong SYC, de Boer MGJ, Fowler VG. Global Differences in the Management of Staphylococcus aureus Bacteremia: No International Standard of Care. Clin Infect Dis 2023; 77:1092-1101. [PMID: 37310693 PMCID: PMC10573727 DOI: 10.1093/cid/ciad363] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Despite being the leading cause of mortality from bloodstream infections worldwide, little is known about regional variation in treatment practices for Staphylococcus aureus bacteremia (SAB). The aim of this study was to identify global variation in management, diagnostics, and definitions of SAB. METHODS During a 20-day period in 2022, physicians throughout the world were surveyed on SAB treatment practices. The survey was distributed through listservs, e-mails, and social media. RESULTS In total, 2031 physicians from 71 different countries on 6 continents (North America [701, 35%], Europe [573, 28%], Asia [409, 20%], Oceania [182, 9%], South America [124, 6%], and Africa [42, 2%]) completed the survey. Management-based responses differed significantly by continent for preferred treatment of methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) bacteremia, use of adjunctive rifampin for prosthetic material infection, and use of oral antibiotics (P < .01 for all comparisons). The 18F-FDG PET/CT scans were most commonly used in Europe (94%) and least frequently used in Africa (13%) and North America (51%; P < .01). Although most respondents defined persistent SAB as 3-4 days of positive blood cultures, responses ranged from 2 days in 31% of European respondents to 7 days in 38% of Asian respondents (P < .01). CONCLUSIONS Large practice variations for SAB exist throughout the world, reflecting the paucity of high-quality data and the absence of an international standard of care for the management of SAB.
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Affiliation(s)
- Annette C Westgeest
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - David T P Buis
- Amsterdam UMC, Department of Internal Medicine, Division of Infectious Diseases, Vrije Universiteit Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Kim C E Sigaloff
- Amsterdam UMC, Department of Internal Medicine, Division of Infectious Diseases, Vrije Universiteit Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Felicia Ruffin
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Emile F Schippers
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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9
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Sequential oral antibiotic in uncomplicated Staphylococcus aureus bacteraemia: a propensity-matched cohort analysis. Clin Microbiol Infect 2023:S1198-743X(23)00054-X. [PMID: 36773773 DOI: 10.1016/j.cmi.2023.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/01/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES We aimed to analyse the efficacy and safety of oral sequential therapy (OST) in uncomplicated Staphylococcus aureus bacteraemia (SAB). METHODS Single-centre observational cohort at a tertiary hospital in Spain, including all patients with the first SAB episode from January 2015 to December 2020. We excluded patients with complicated SAB and those who died during the first week. Patients were classified into the OST group (patients who received oral therapy after initial intravenous antibiotic therapy [IVT]), and IVT group (patients who received exclusively IVT). We performed a propensity-score matching to balance baseline differences. The primary composite endpoint was 90-day mortality or microbiological failure. Secondary endpoints included 90-day SAB relapse. RESULTS Out of 407 SAB first episodes, 230 (56.5%) were included. Of these, 112 (n = 48.7%) received OST and 118 (51.3%) IVT exclusively. Transition to oral therapy was performed after 7 days (interquartile range, 4-11). The primary endpoint occurred in 10.7% (11/112) in OST vs. 30.5% (36/118) in IVT (p < 0.001). SAB relapses occurred in 3.6% (4/112) vs. 1.7% (2/118) (p 0.436). None of the deaths in OST were related to SAB or its complications. After propensity-score matching, the primary endpoint was not more frequent in the OST group (relative risk, 0.42; 95% CI, 0.22-0.79). Ninety-day relapses occurred similarly in both groups (relative risk, 1.35; 95% CI, 0.75-2.39). DISCUSSION After an initial intravenous antibiotic, patients with uncomplicated SAB can safely be switched to oral antibiotics without apparent adverse outcomes. This strategy could save costs and complications of prolonged hospital stays. Prospective randomized studies are needed.
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10
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Kouijzer IJE, Fowler VG, Ten Oever J. Redefining Staphylococcus aureus bacteremia: A structured approach guiding diagnostic and therapeutic management. J Infect 2023; 86:9-13. [PMID: 36370898 PMCID: PMC11105116 DOI: 10.1016/j.jinf.2022.10.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/20/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
The current duration of therapy in patients with Staphylococcus aureus bacteremia (SAB) is based on differentiating complicated from uncomplicated disease. While this approach allows clinicians and investigators to group SAB patients into broadly similar clinical categories, it fails to account for the intrinsic heterogeneity of SAB. This is due in part to the fact that risk factors for metastatic infection and confirmed metastatic infection are considered as equivalent in most scoring systems. In this viewpoint, we propose a two-step system of categorizing patients with SAB. Initially, patients with SAB would be categorized as 'high risk' or 'low risk' for metastatic infection based upon an initial set of diagnostic procedures. In the second step, patients identified as 'high-risk' would undergo additional diagnostic evaluation. The results of this stepwise diagnostic evaluation would define a 'final clinical diagnosis' to inform an individualized final treatment plan.
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Affiliation(s)
- Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands
| | - Vance G Fowler
- Department of Medicine, Duke University, Durham North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, the Netherlands.
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11
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Maeda M, Nakata M, Naito Y, Yamaguchi K, Yamada K, Kinase R, Takuma T, On R, Tokimatsu I. Days of Antibiotic Spectrum Coverage Trends and Assessment in Patients with Bloodstream Infections: A Japanese University Hospital Pilot Study. Antibiotics (Basel) 2022; 11:1745. [PMID: 36551402 PMCID: PMC9774691 DOI: 10.3390/antibiotics11121745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/11/2022] Open
Abstract
The antibiotic spectrum is not reflected in conventional antimicrobial metrics. Days of antibiotic spectrum coverage (DASC) is a novel quantitative metric for antimicrobial consumption developed with consideration of the antibiotic spectrum. However, there were no data regarding disease and pathogen-specific DASC. Thus, this study aimed to evaluate the DASC trend in patients with bloodstream infections (BSIs). DASC and days of therapy (DOT) of in-patients with positive blood culture results during a 2-year interval were evaluated. Data were aggregated to calculate the DASC, DOT, and DASC/DOT per patient stratified by pathogens. During the 2-year study period, 1443 positive blood culture cases were identified, including 265 suspected cases of contamination. The overall DASC, DASC/patient, DOT, DOT/patient, and DASC/DOT metrics were 226,626; 157.1; 28,778; 19.9; and 7.9, respectively. A strong correlation was observed between DASC and DOT, as well as DASC/patient and DOT/patient. Conversely, DASC/DOT had no correlation with other metrics. The combination of DASC and DOT would be a useful benchmark for the overuse and misuse evaluation of antimicrobial therapy in BSIs. Notably, DASC/DOT would be a robust metric to evaluate the antibiotic spectrum that was selected for patients with BSIs.
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Affiliation(s)
- Masayuki Maeda
- Division of Infection Control Sciences, Department of Clinical Pharmacy, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Mari Nakata
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Yuika Naito
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Kozue Yamaguchi
- Division of Infection Control Sciences, Department of Clinical Pharmacy, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Kaho Yamada
- Division of Infection Control Sciences, Department of Clinical Pharmacy, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Ryoko Kinase
- Division of Infection Control Sciences, Department of Clinical Pharmacy, Showa University School of Pharmacy, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Takahiro Takuma
- Division of Infection Diseases, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Rintaro On
- Division of Infection Diseases, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Issei Tokimatsu
- Division of Infection Diseases, Department of Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
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12
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Abstract
PURPOSE OF REVIEW To review recently published evidence relevant to Staphylococcus aureus bacteremia (SAB). RECENT FINDINGS Staphylococcus aureus is the most common pathogen causing co-infections and superinfections in patients with COVID-19. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia ratios have sharply risen during the pandemic. SAB mortality is 18% at 1 month and 27% at 3 months but has gradually decreased over the last 30 years. Recurrences and reinfections are common (9%). Standardised items to define complicated SAB, and a new cut-off defining persisting bacteremia after 2 days with positive blood cultures have been proposed. Multiple antibiotic combinations have been trialled including vancomycin or daptomycin with β-lactams, fosfomycin, or clindamycin, without significant results. In the recently published guidelines, vancomycin remains the first line of treatment for MRSA bacteremia. For the management of methicillin-susceptible Staphylococcus aureus , cefazolin less frequently causes acute kidney injury than flucloxacillin, and when susceptibility is demonstrated, de-escalation to penicillin G is suggested. SUMMARY Our review confirms that Staphylococcus aureus represents a special aetiology among all causes of bloodstream infections. Pending results of platform and larger trials, its distinct epidemiology and determinants mandate careful integration of clinical variables and best available evidence to optimize patient outcomes.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services
- Queensland University of Technology
- Faculty of Medicine, University of Queensland
| | - Kevin B Laupland
- Queensland University of Technology
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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13
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Weis S, Hagel S, Palm J, Scherag A, Kolanos S, Bahrs C, Löffler B, Schmitz RPH, Rißner F, Brunkhorst FM, Pletz MW. Effect of Automated Telephone Infectious Disease Consultations to Nonacademic Hospitals on 30-Day Mortality Among Patients With Staphylococcus aureus Bacteremia: The SUPPORT Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2218515. [PMID: 35749114 PMCID: PMC9233240 DOI: 10.1001/jamanetworkopen.2022.18515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Staphylococcus aureus bacteremia (SAB) is a common and potentially severe infectious disease (ID). Retrospective studies and derived meta-analyses suggest that bedside infectious disease consultation (IDC) for SAB is associated with improved survival; however, such IDCs might not always be possible because of the lack of ID specialists, particularly at nonacademic hospitals. OBJECTIVES To investigate whether unsolicited telephone IDCs (triggered by an automated blood stream infection reporting system) to nonacademic hospitals improved 30-day all-cause mortality in patients with SAB. DESIGN, SETTING, AND PARTICIPANTS This patient-blinded, multicenter, interventional, cluster randomized, controlled, crossover clinical trial was conducted in 21 rural, nonacademic hospitals in Thuringia, Germany. From July 1, 2016, to December 31, 2018, 1029 blood culture reports were assessed for eligibility. A total of 386 patients were enrolled, whereas 643 patients were not enrolled for the following reasons: death before enrollment (n = 59); palliative care (n = 41); recurrence of SAB (n = 9); discharge from the hospital before enrollment (n = 77); age younger than 18 years (n = 5); duplicate report from a single patient (n = 26); late report (n = 17); blood culture reported during the washout phase (n = 48); and no signed informed consent for other or unknown reasons (n = 361). INTERVENTIONS During the ID intervention phase, ID specialists from Jena University Hospital provided unsolicited telephone IDCs to physicians treating patients with SAB. During the control phase, patients were treated according to local standards. Crossover was performed after including 15 patients or, at the latest, 1 year after the first patient was included. MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality. RESULTS A total of 386 patients (median [IQR] age, 75 [63-82] years; 261 [67.6%] male) were included, with 177 randomized to the IDC group and 209 to the control group. The 30-day all-cause mortality rate did not differ between the IDC and control groups (relative risk reduction [RRR], 0.12; 95% CI, -2.17 to 0.76; P = .81). No evidence was found of a difference in secondary outcomes, including 90-day mortality (RRR, 0.17; 95% CI, -0.59 to 0.57; P = .62), 90-day recurrence (RRR, 0.10; 95% CI, -2.51 to 0.89; P = .89), and hospital readmission (RRR, 0.04; 95% CI, -0.63 to 0.48; P = .90). Exploratory evidence suggested that indicators of quality of care were potentially realized more often in the IDC group than in the control group (relative quality improvement, 0.16; 95% CI, 0.08-0.26; P = .01). CONCLUSIONS AND RELEVANCE In this cluster randomized clinical trial, unsolicited telephone IDC, although potentially enhancing quality of care, did not improve 30-day all-cause mortality in patients with SAB. TRIAL REGISTRATION drks.de Identifier: DRKS00010135.
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Affiliation(s)
- Sebastian Weis
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Julia Palm
- Institute of Medical Statistics, Computer, and Data Sciences, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - André Scherag
- Institute of Medical Statistics, Computer, and Data Sciences, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Steffi Kolanos
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Christina Bahrs
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Roland P. H. Schmitz
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Florian Rißner
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Frank M. Brunkhorst
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Mathias W. Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
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