Bloodstream infections in children caused by carbapenem-resistant versus carbapenem-susceptible gram-negative microorganisms: Risk factors and outcome

Is the high dose extended infusion of meropenem useful in the treatment of highly resistant gram-negative bacteria in children?

OBJECTIVES

Multidrug resistant infections present a treatment challenge for clinicians. These infections have been associated with increased morbidity and mortality. Recently, there has been increasing discussion in the literature that high dose extended infusion of meropenem may be helpful. We aimed to evaluate the clinical efficacy of high dose extended infusion of meropenem in the treatment of highly resistant Gram-negative infections.

METHODS

This retrospective observational study was conducted between December 2014 and December 2020 at Hacettepe University Ihsan Dogramaci Children's Hospital. Clinical and microbiological data of children diagnosed with invasive multidrug and extremely drug resistant Gram-negative infections were studied. The findings of patients given high dose extended infusion of meropenem were compared with patients who received colistin or tigecycline.

RESULTS

Overall, 158 pediatric patients infected with multidrug and extremely drug resistant gram-negatives were enrolled; 76 treated with high-dose prolonged infusion of meropenem; 60 treated with colistin and 22 with tigecycline. The overall clinical response at the end of the treatment was 81.6 % in meropenem group, 83.3 % in colistin group and 77.3 % in tigecycline group (P = 0.821). Microbiological response at the end of the treatment was 81.1 % in meropenem group, 76.4 % in colistin group and 72.2 % in tigecycline group (P = 0.694).

CONCLUSION

Meropenem, with an adjusted dose (high-dose and extended), seems a crucial and robust fighting agent in the treatment of pediatric patients infected with highly-resistant Gram-negative bacteria. It may also be useful in preventing the use of the latest fighting tools such as colistin and tigecycline during the antibacterial stewardship process.

Anti-Infection of Nasopharyngeal Carcinoma Combined with Non-Tuberculous Mycobacteria: A Case Report and Literature Review

Background

Patients with nasopharyngeal carcinoma (NPC) combined with non-tuberculous Mycobacteria-pulmonary disease (NTM-PD) are very rare in the clinic, and our case is the first patient with NPC combined with NTM-PD. For oncologists, rapid control of the symptoms of infection is essential to the treatment of the primary disease.

Case Presentation

A 58-year-old man who developed a NTM-PD after chemotherapy for nasopharyngeal carcinoma. Granulocytosis after chemotherapy is a major factor in the development of various infectious diseases. Nasopharyngeal tumor was found on MRI of the patient's head, and nasopharyngeal malignant tumor was considered after pathological examination after endoscopic resection of intranasal lesion, and then nasopharyngeal non-keratonic carcinoma (T4N1M0, stage IV) was confirmed in the department of oncology. The patient developed bone marrow suppression after chemotherapy and was admitted to hospital due to septic shock. Chest CT examination indicated pulmonary infection, and empirical antibiotic treatment was not effective. The NGS results showed that the patient was infected with Mycobacterium abscess. We treated with cefoxitin followed by moxifloxacin to reduce the lung lesions significantly.

Conclusion

NPC with NTM-PD is very rare, and the treatment of NTM-PD is very important for the prognosis of the patient's primary disease. Our study provides experience for anti-infection treatment of patients with immunosuppression.

Gram-negative bacteremia, the risk factors, and outcome in children

We aimed to determine the epidemiology and resistance patterns of Gram-negative bacteria, the risk factors and outcome of bloodstream infection (BSI). In all, 412 episodes in children who were hospitalized with the diagnosis of bacteremia were analyzed. The most common microorganisms were Klebsiella spp. (43.9%), Escherichia coli (13.5 %) and Acinetobacter spp. (10.6 %). Among isolates, 41.2 % were multidrug-resistant, 13.5 % were extensively drug-resistant and 0.4 % were pan-drug-resistant. Carbapenem resistance was revealed in 27.6 % of isolates. Carbapenem and colistin resistance increased over the years. The most common risk factors were the presence of a central-venous catheter and pediatric intensive care unit admission. Clinical response and infection-related mortality were significantly different in cases infected with carbapenem-resistant gram-negative (CRGN) vs carbapenem-susceptible gram-negative bacteria. The increase in multi-resistant Klebsiella spp. seems to be the biggest obstacles in fight against nosocomial infections. The increasing number of CRGN infections over the years affects both the clinical response and mortality rate of BSI.

Clinical characteristics and outcomes of carbapenem-resistant Enterobacterales bacteremia in pediatric patients

BACKGROUND/PURPOSE

Clinical data on carbapenem-resistant Enterobacterales (CRE) bacteremia in the pediatric population are limited. This study investigated the clinical characteristics and outcomes of pediatric CRE bacteremia.

METHODS

Clinical data on bacteremia caused by carbapenem-susceptible and carbapenem-resistant Enterobacterales, including Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia marcescens, Proteus mirabilis, Citrobacter spp., and Morganella spp., in pediatric patients from a children's hospital in Taiwan were retrospectively retrieved and analyzed.

RESULTS

From January 2013 to December 2021, 471 clinical isolates of Enterobacterales bacteremia were identified in 451 episodes from 379 pediatric patients. Among all the isolates, the predominant species were E. coli (199/471, 42.2%), Klebsiella spp. (168/471, 35.6%), and Enterobacter spp. (59/471, 12.5%), with carbapenem-resistance rates of 1.5%, 11.9%, and 25.0%, respectively. Overall, 40 (8.4%) showed a carbapenem resistance phenotype. Patients' all-cause mortality rate at 14 days was significantly higher in CRE bacteremia episodes than non-CRE ones (12.5% vs. 3.6%, p < 0.05). The predicting factor of a CRE bacteremia episode was the causative agent of Enterobacter spp. (adjusted OR of 2.551, CI 1.073-6.066, p < 0.05) and ESBL-producing phenotype (adjusted OR 14.268, CI 5.120-39.762, p < 0.001).

CONCLUSION

Bloodstream infections caused by CRE are associated with a higher mortality rate in the pediatric population. Attention must be paid to preventing and managing pediatric patients with CRE infections.

Methylprednisolone use in children with severe pneumonia caused by severe acute respiratory syndrome coronavirus 2

BACKGROUND

This study aimed to evaluate the effectiveness and optimal use of corticosteroids in children with severe coronavirus disease 2019 (COVID-19) pneumonia, for which effective treatment is still lacking with respect to this population.

METHODS

We conducted a retrospective study and included patients (aged < 18 years) with severe COVID-19 pneumonia and/or acute respiratory distress syndrome (ARDS) who received standard doses (2-4 mg/kg/day) and high doses (>250 mg/day) of methylprednisolone (MPZ). We adjusted for patients on steroid treatments with a propensity score and compared the side effects of different MPZ doses and patient survival.

RESULTS

Fifty-nine patients were included: 61% were male, the median age was 8, interquartile range (IQR) 2-15) years. The overall survival was 84.4% in patients treated with standard-dose MPZ (n = 45, 76.3%) and 92.2% in patients treated with high-dose MPZ (n = 14, 23.7%; p = 0.67). The demographic, clinical, and laboratory data did not differ significantly after propensity score matching, apart from bradycardia, which was a prominent feature of the high-dose group. The clinical and radiological response rates on day 7 were higher and the need for invasive mechanical ventilation (IMV) was lower in the high-dose group.

CONCLUSION

The patients with high-dose MPZ had better clinical and radiological responses than those with standard-dose MPZ, although the mortality rate did not differ between standard and high-dose regimens of MPZ.

Proteus mirabilis resistant to carbapenems isolated from a patient with a venous leg ulcer: a case report

OBJECTIVE

The aim of the study was to phenotypically investigate the expression of the enzyme Klebsiella pneumoniae carbapenemase (KPC) in a Proteus mirabilis sample resistant to carbapenems, isolated from the wound of a patient with a venous leg ulcer (VLU) treated at an outpatient referral service.

METHOD

This was a case study conducted with a patient who had a VLU on the lower left limb. Samples were taken for the examination of microbiological material from the patient's wound, using an aseptic technique. The colonies extracted were submitted to Gram staining and biochemical tests to identify the strain. In addition, an antimicrobial susceptibility test, E-test and a modified Hodge test were performed.

RESULTS

The identified microorganism was Proteus mirabilis, which showed resistance to cefuroxime and the carbapenems imipenem and meropenem. As well as the minimum inhibitory concentration (MIC) of 3.0μg/ml for imipenem, demonstrating resistance, there was no KPC production by the tested isolate, which presented a negative modified Hodge test.

CONCLUSION

The results highlight the importance of microbiological surveillance, aimed at reducing morbidity and mortality rates associated with infection by multiresistant bacteria.

Incidence and All-Cause Mortality Rates in Neonates Infected With Carbapenem Resistant Organisms

Introduction

Multidrug-resistant, Gram-negative infections, particularly due to carbapenem resistant organisms (CRO), have increased globally. Few studies have reported on the burden of CRO in neonates from low-middle income countries (LMIC). This study aimed to determine the incidence and mortality rates of culture-confirmed Gram-negative infections, with a special focus on CRO in a neonatal unit from a LMIC.

Materials and Methods

Positive bacterial cultures from sterile sites of infants admitted in the neonatal unit from the 1st January 2018 to 31st December 2019, were reviewed retrospectively. Type of organism, susceptibility and outcomes were recorded. Data on Gram-negative isolates, including the CRO, were extracted. Rates and outcomes were analysed.

Results

There were 2219 neonates with organisms isolated from sterile sites (blood and cerebrospinal fluid), accounting for 30% of all admissions, giving a neonatal sepsis incidence of 17.9/1000 patient-days. There was a total of 1746 positive isolates (excluding coagulase negative Staphyloccocus). Of these, 1706 (98%) were isolated from blood, and 40 (2%) from cerebrospinal fluid. Overall, 1188 (68%) were Gram-negative, 371 (21%) Gram-positive and 187 (10.7%) fungal isolates. The common Gram-negatives were Acinetobacter baumannii (526/1188;44%) and Klebsiella pneumoniae (469/1188;40%). Carbapenem resistance was observed in 359 (68%) of the Acinetobacter baumannii (CRAB) and in 103 (18%) of the Enterobacterales (CRE) isolates, with 98% of CRE being Klebsiella pneumoniae (CR-Klebs). Twenty-four (41%) of Pseudomonas species were carbapenem resistant. Overall, carbapenem resistance was seen in 42% of all Gram-negative organisms. The rate of CRAB and CRE were 2.9 and 0.8/1000 patient-days respectively. The overall, all-cause in-hospital mortality rate in infants with Gram-negative isolates was 22%, with higher mortality rate in those infected with CRO compared to non-CRO (34% vs 13%; OR 3.44; 95% CI 2.58–4.60; p &lt; 0.001). The mortality rate in infants with CRE was higher than those with CRAB (48% vs 33%; OR 1.85; 95% CI 1.18–2.89; p = 0.007).

Conclusion

We observed a high incidence of positive cultures from sterile sites. The common organisms isolated were Gram-negatives, and among these carbapenem resistance was high and was associated with high mortality. Mortality was higher in infants with CRE compared to those with CRAB.

Surgical Site Infection in Children with Neuromuscular Disorders after Laparoscopic Gastrostomy: A Propensity-Matched National Surgical Quality Improvement Program Pediatrics Database Analysis

Background: Prior studies have demonstrated that children with neuromuscular scoliosis have a higher incidence of infection after spine surgery. The purpose of the study is to determine whether children with neuromuscular disorders (NMDs) have higher rate of superficial surgical site infection (SSI) or increased hospital length of stay (LOS) compared with children without NMDs following laparoscopic gastrostomy creation, a common pediatric general surgery operation. Patients and Methods: We performed a retrospective propensity-matched analysis of laparoscopic gastrostomy creation in children from National Surgical Quality Improvement Program Pediatrics database (NSQIP-P) 2018-2019. Patients were stratified based on NMD status. We performed multivariable logistic regression and ordered logistic regression to estimate the odds ratio of superficial SSI within 30 days of surgery and increased LOS. Results: We screened 252,367 patients from the NSQIP-P 2018-2019 dataset. After applying inclusion and exclusion criteria and 1:1 propensity score-matching, there were 991 children with NMDs and 991 children without NMDs. Children with NMDs had higher prevalence of superficial SSI within 30 days of gastrostomy creation: 36 (3.63%) versus 18 (1.82%); p = 0.013. Children with NMDs had increased odds of having a superficial SSI within 30 days of laparoscopic gastrostomy tube (G-tube) placement compared with children without NMD (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.13-3.58; p = 0.018). There was no difference in LOS based on NMD status. Conclusion: Children with NMDs have two-fold increased odds of superficial SSI after laparoscopic gastrostomy creation compared with children without NMDs. Children with NMDs should be the aim of targeted quality improvement initiatives to reduce infection risks.

Carbapenem-resistant Pseudomonas aeruginosa strains: a worrying health problem in intensive care units

Pseudomonas aeruginosa is one of the most common bacterium with a broad spectrum of human-associated infections. It is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. The emergence and dissemination of carbapenemases among P. aeruginosa clinical isolates is a serious public health concern as it limits the options for the treatment of bacterial infections. Here, we described the molecular and epidemiological characteristics of 28 carbapenem-resistant P. aeruginosa strains isolated from patients hospitalized in an intensive care unit (ICU). The antimicrobial susceptibility of carbapenem-resistant P. aeruginosa strains was determined by broth microdilution. The presence of resistance genes was evaluated by PCR and DNA sequencing. Additionally, alterations in genes encoding P. aeruginosa outer membrane proteins were analyzed by PCR as well as SDS-PAGE. Clinical characteristics of the patients and the economic impact of hospitalization on the public health system were evaluated. PCR amplification showed that the blaKPC-2 and blaTEM genes were identified in three isolates (11%) and blaSHV gene in two isolates (7%). Outer membrane profiles obtained by SDS-PAGE indicated that the OprD porin was either absent or was produced at very low levels. A PCR assay using oprD-specific primers failed to show the presence of mutations in this gene. P. aeruginosa strains were isolated from 28 patients, among whom 43% (12/28) had sepsis, 31% (9/28) had respiratory failure, and 31% (9/28) had systemic arterial hypertension. A high mortality rate (39%) was observed in these patients, with an average duration of hospitalization of 34.6 days and a median cost of 3.275 dollars per patient. The production of carbapenemase was not the main mechanism of resistance in these strains. All carbapenem-resistant P. aeruginosa were isolated from patients hospitalized in the ICU. Besides the high mortality rate, many patients remained hospitalized for several days, resulting in a high cost of hospitalization for the public health system. Therefore, the evolution of this resistance and its dissemination should be actively monitored among critically ill patients to improve their health conditions.

Escalating antimicrobial resistance among Enterobacteriaceae: focus on carbapenemases

Introduction: Over the past few decades, antimicrobial resistance (AMR) has skyrocketed globally among bacteria within the Family Enterobacteriaceae (i.e. Enterobacter spp, Klebsiella spp, Escherichia coli, Proteus spp, Serratia marcescens, Citrobacter spp, and others). Enterobacteriaceae are intestinal flora and are important pathogens in nosocomial and community settings. Enterobacteriaceae spread easily between humans and may acquire AMR via plasmids or other mobile resistance elements. The emergence and spread of multidrug resistant (MDR) clones have greatly limited therapeutic options. Some infections are untreatable with existing antimicrobials.Areas covered: The authors discuss the escalation of CRE globally, the epidemiology and outcomes of CRE infections, the optimal therapy, and the potential role of several new antimicrobials to combat MDR organisms. An exhaustive search for literature related to Enterobacteriaceae was performed using PubMed, using the following key words: antimicrobial resistance; carbapenemases; Enterobacterales; Enterobacteriaceae; Klebsiella pneumoniae; Escherichia coli; global epidemiology; metallo-β-lactamases; multidrug resistance; New Delhi Metalloproteinase-1 (NDM-1); plasmidsExpert opinion: Innovation and development of new classes of antibacterial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antibiotics and aggressive infection-control measures are essential to minimize the spread of AMR.

Predictors of mortality and clinical characteristics among carbapenem-resistant or carbapenemase-producing Enterobacteriaceae bloodstream infections in Spanish children

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) are an emerging problem in the paediatric population worldwide with high mortality rates in bloodstream infection (BSI).

OBJECTIVES

To evaluate predictors of 30 day mortality in CRE BSI in a paediatric cohort.

METHODS

A retrospective observational single-centre study (December 2005-August 2018) was conducted. Cases of CRE BSI in children 0 to 16 years were included. Microbiological identification (MALDI Biotyper) and antimicrobial susceptibility testing (Vitek2® and MicroScan panel NBC44) according to EUCAST breakpoints were performed. PCR OXVIKP® was used to confirm carbapenemase genes (OXA-48, VIM, KPC, NDM). Demographic characteristics, underlying diseases, source of bacteraemia, antimicrobial therapy and outcomes were collected from medical records. Survival analysis to establish predictors of 30 day mortality was performed.

RESULTS

Thirty-eight cases were included; 76.3% were hospital-acquired infections and 23.7% related to healthcare. All patients had at least one underlying comorbidity and 52.6% were recipients of an organ transplant. VIM carbapenemase was the predominant mechanism (92.1%). Previous CRE colonization or infection rate was 52.6%. Intestinal tract (26.3%) and vascular catheter (21.1%) were the most common sources of infection. Crude mortality within 30 days was 18.4% (7/38); directly related 30 day mortality was 10.5%. Conditions associated with an increment in 30 day mortality were intensive care admission and inadequate empirical therapy (P < 0.05). Combination-antibiotic targeted treatment and a low meropenem MIC were not related to improved survival.

CONCLUSIONS

CRE BSI mortality rate is high. The most important factor related to 30 day survival in our CRE BSI cohort in children was empirical treatment that included at least one active antibiotic.

Efficacy of colistin in multidrug-resistant neonatal sepsis: experience from a tertiary care center in Karachi, Pakistan

OBJECTIVE

Infections with multidrug-resistant organisms (MDROs) such as Gram-negative bacteria have high morbidity and mortality with limited treatment options. Colistin, an antibiotic active against MDRO, was rarely used due to frequent adverse effects, but its use has now been recommended among adults. In this study, we determined the efficacy of colistin for the treatment of sepsis in neonates.

DESIGN/SETTING/PATIENTS/OUTCOMES

We conducted a retrospective record review of all neonates admitted to the neonatal intensive care unit of Aga Khan University Hospital, Karachi, Pakistan, between June 2015 and June 2018, who had sepsis and received colistin by intravenous, inhalation and/or intrathecal routes. Predictors of colistin efficacy, for neonatal survival and microbial clearance, were assessed using multiple logistic regression.

RESULTS

153 neonates received colistin; 120 had culture-proven sepsis; and 93 had MDR-GNB (84 colistin-sensitive). 111 (72.5%) neonates survived and were discharged from hospital; 82.6% had microbial clearance. Neonates with colistin-sensitive bacteria (adjusted OR (AOR)=3.2, 95% CI 2.8 to 4.0), and those in which colistin therapy started early (AOR=7.2, 95% CI 3.5 to 13.6) were more likely to survive. Neonates with increased gestational age (AOR=1.9, 95% CI 1.5 to 3.0), higher weight (AOR=5.4, 95% CI 3.3 to 11.8) and later onset of sepsis (AOR=4.3, 95% CI 2.0 to 9.0) had higher survival. Adverse events included nephrotoxicity in 5.2%; 13.7% developed seizures and 18.3% had electrolyte imbalance.

CONCLUSIONS

Colistin therapy was associated with survival among neonates suffering from MDR-GNB sepsis. The frequency of side effects was moderate.

Profile of Enterobacteria Resistant to Beta-Lactams

A serious emerging problem worldwide is increased antimicrobial resistance. Acquisition of coding genes for evasion methods of antimicrobial drug mechanisms characterizes acquired resistance. This phenomenon has been observed in Enterobacteriaceae family. Treatment for bacterial infections is performed with antibiotics, of which the most used are beta-lactams. The aim of this study was to correlate antimicrobial resistance profiles in Enterobacteriaceae by phenotypic methods and molecular identification of 14 beta-lactamase coding genes. In this study, 70 exclusive isolates from Brazil were used, half of which were collected in veterinary clinics or hospitals Phenotypic methodologies were used and real-time PCR was the molecular methodology used, through the Sybr Green system. Regargding the results found in the tests it was observed that 74.28% were resistant to ampicillin, 62.85% were resistant to amoxicillin associated with clavalunate. The mechanism of resistance that presented the highest expression was ESBL (17.14%). The genes studied that were detected in a greater number of species were blaGIM and blaSIM (66.66% of the samples) and the one that was amplified in a smaller number of samples was blaVIM (16.66%). Therefore, high and worrying levels of antimicrobial resistance have been found in enterobacteria, and a way to minimize the accelerated emergence of their resistance includes developing or improving techniques that generate diagnoses with high efficiency and speed.

Carbapenem-Resistant Gram-Negative Bacterial Infections in Children

Carbapenem-resistant organisms (CRO) are a major global public health threat. Enterobacterales hydrolyze almost all β-lactams through carbapenemase production. Infections caused by CRO are challenging to treat due to the limited number of antimicrobial options. This leads to significant morbidity and mortality. Over the last few years, several new antibiotics effective against CRO have been approved. Some of them (e.g., plazomicin or imipenem-cilastatin-relebactam) are currently approved for use only by adults; others (e.g., ceftazidime-avibactam) have recently been approved for use by children. Recommendations for antibiotic therapy of CRO infections in pediatric patients are based on evidence mainly from adult studies. The availability of pediatric pharmacokinetic and safety data is the cornerstone to broaden the use of proposed agents in adults to the pediatric population. This article provides a comprehensive review of the current knowledge regarding infections caused by CRO with a focus on children, which includes epidemiology, risk factors, outcomes, and antimicrobial therapy management, with particular attention being given to new antibiotics.

Risk factors for polymyxin-resistant carbapenemase-producing Enterobacteriaceae in critically ill patients: An epidemiological and clinical study

This study aimed to assess the clinical impact and potential risk factors associated with polymyxin-resistant Enterobacteriaceae strains isolated from patients hospitalized in adult and neonatal intensive care units. A case-control study was conducted from September 2015 to January 2017. Antimicrobial susceptibility of polymyxin-resistant Enterobacteriaceae strains was determined by broth microdilution. The presence of resistance genes was evaluated by polymerase chain reaction and DNA sequencing. Renal failure [P=0.02, odds ratio (OR) 11.37, 95% confidence interval (CI) 1.0-128.63], use of a urinary catheter (P<0.01, OR 4.16, 95% CI 38.82-366.07), transfer between hospital units (P=0.03, OR 9.98, 95% CI 1.01-98.42), carbapenem use (P<0.01, OR 45.49, 95% CI 6.93-298.62) and surgical procedure (P<0.01, OR 16.52, 95% CI 2.83-96.32) were found to be risk factors for the acquisition of polymyxin-resistant strains in adult patients. For neonatal patients, use of a central venous catheter (P<0.01, OR 69.59, 95% CI 7.33-660.30) was the only risk factor associated with the acquisition of polymyxin-resistant strains. Analysis of the outcomes revealed that the mortality rate was significantly higher in adult (66.6%) and neonatal (23.5%) patients with polymyxin-resistant strains than in those with polymyxin-susceptible strains. In addition, carbapenem exposure (P<0.01, OR 50.93, 95% CI 2.26->999.999) was strongly associated with mortality. On the other hand, aminoglycoside use (P<0.03, OR 0.06, 95% CI 0.004-0.97) was a protective factor against mortality from polymyxin-resistant strains. Several risk factors were associated with polymyxin-resistant strains. The high mortality rates showed that acquisition of these strains is a predictor for unfavourable outcomes. Combination treatment with an aminoglycoside and polymyxin might be a better combination to improve patient outcomes.

Gram-negative Bacteremia in Children With Hematologic Malignancies and Following Hematopoietic Stem Cell Transplantation: Epidemiology, Resistance, and Outcome

Gram-negative rod (GNR) infections adversely affect the outcome of patients with malignancies and following hematopoietic stem cell transplantation (HSCT). This retrospective observational study aimed to describe the epidemiology, outcome, and resistance patterns of GNR bacteremia in children with hematologic malignancies (HM) and after HSCT during the period spanning from 2010 to 2014 in a tertiary children's hospital. A total of 270 children were included in the analysis; 65 (24%) developed 85 episodes of GNR bacteremia; the rate was 36/122 (29.5%) in post-HSCT and 29/178 (16.3%) in HM patients (P<0.05). Overall, 10% of the GNRs were carbapenem resistant. In multivariate analysis, prolonged neutropenia (≥7 d; odds ratio: 19.5, 95% confidence interval: 2.6-148.4) and total hospitalization for a duration of >30 days in the last 3 months (odds ratio: 17.5, 95% confidence interval: 1.4-224.4) were associated with carbapenem-resistant GNR bacteremia. Thirty-day mortality following GNR bacteremia was 0% in HM and 7/52 episodes (13.5%) in HSCT patients (P<0.05). Carbapenem-resistant versus carbapenem-sensitive bacteremia was associated with longer duration of bacteremia (mean: 3.8 vs. 1.7 d), higher risk for intensive care unit hospitalization (44.4% vs. 10.1%), and higher mortality rate (33% vs. 5.8%) (P<0.05). To summarize, GNR bacteremia was frequent, especially in post-HSCT children. Carbapenem resistance adversely affects patients' outcome, increasing morbidity and mortality. Empirical antibiotic therapy must be adjusted to the local resistance patterns.

Strategic Trials to Define the Best Available Treatment for Neonatal and Pediatric Sepsis Caused by Carbapenem-resistant Organisms

The optimal standard of care for carbapenem-resistant bloodstream infections in children is currently unknown. This systematic review, aiming to define the best available treatments to be compared with new antibiotics in clinical trials, clearly points out the paucity of available data. The simplification and a wider harmonization of study design are a global priority to inform the best strategies to treat these life-threatening infections in children.

Prior antibiotic use and acquisition of multidrug-resistant organisms in hospitalized children: A systematic review

Objective:

Multidrug-resistant organisms (MDROs) cause ~5%–10% of infections in hospitalized children, leading to an increased risk of death, prolonged hospitalization, and additional costs. Antibiotic exposure is considered a driving factor of MDRO acquisition; however, consensus regarding the impact of antibiotic factors, especially in children, is lacking. We conducted a systematic review to examine the relationship between antibiotic use and subsequent healthcare-associated infection or colonization with an MDRO in children.

Design:

Systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.

Methods:

We searched PubMed and Embase for all English, peer-reviewed original research studies published before September 2018. Included studies evaluated hospitalized children, antibiotic use as an exposure, and bacterial MDRO as an outcome.

Results:

Of the 535 studies initially identified, 29 met the inclusion criteria. Overall, a positive association was identified in most studies evaluating a specific antibiotic exposure (17 of 21, 81%), duration of antibiotics (9 of 12, 75%), and number of antibiotics received (2 of 3, 67%). Those studies that evaluated any antibiotic exposure had mixed results (5 of 10, 50%). Study sites, populations, and definitions of antibiotic use and MDROs varied widely.

Conclusions:

Published studies evaluating this relationship are limited and are of mixed quality. Limitations include observation bias in recall of antibiotic exposure, variations in case definitions, and lack of evaluation of antibiotic dosing and appropriateness. Additional studies exploring the impact of antibiotic use and MDRO acquisition may be needed to develop effective antibiotic stewardship programs for hospitalized children.

Multidrug-resistant Gram-negative Bacterial Bloodstream Infections in Children's Hospitals in Japan, 2010-2017

BACKGROUND

The risk factors of multidrug-resistant (MDR) Gram-negative bacilli (GNB) bloodstream infection (BSI) are not yet known in children. Our aim was to evaluate risk factors and outcomes associated with MDR GNB BSI in children.

METHODS

Patients with GNB BSI were enrolled between April 2010 and March 2017 at 8 children's hospitals in Japan. Clinical and microbiologic data were collected retrospectively. The risk factors and outcomes of MDR and non-MDR GNB BSI were compared.

RESULTS

In total, 629 GNB BSI episodes met the case definition. The median age and proportion of males were 2 years (interquartile range, 0.3-8.7) and 50.7%, respectively. An underlying disease was found in 94% of patients. The proportion of BSI cases that developed >48 hours after admission was 76.2%. MDR comprised 24.5% of BSI cases. The MDR rate did not change over time (P = 0.540). The effective coverage rate of the initial empiric therapy for the MDR and non-MDR BSI cases was 60.4% and 83.4%, respectively (P < 0.001). The all-cause mortality rate at 28 days for all BSI, MDR-BSI and non-MDR BSI cases was 10.7%, 13.6% and 9.7%, respectively (P = 0.167). MDR BSI was independently associated with cancer chemotherapy within 30 days (odds ratio [OR] 43.90), older age (OR 1.05) and admission to the neonatal ward (OR 0.019).

CONCLUSIONS

One-fourth of GNB BSI cases were MDR. Cancer chemotherapy and older age were risk factors for MDR GNB BSI in children's hospitals. MDR did not increase the all-cause mortality rate.

The use of predictive scores in the management of patients with carbapenem-resistant Klebsiella pneumoniae infection

INTRODUCTION

Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections are associated with high morbidity and mortality rates. A therapeutic approach based on the patient risk stratification could improve outcome and avoid antibiotic misuse. Areas covered: English literature search, from 2008 to 2018, was done using PubMed database. Risk factors for developing CR-KP infection in several settings were reviewed. Since, rectal carriage was a main risk factor for developing infection, we revised in deep clinical score to predict infection among colonized patients. Furthermore, we investigated overall and treatment-related risk factors for poor outcome in patients with CR-KP infection, in particular the carbapenem producing Enterobacteriacieae (CPE)-INCREMENT score. Finally, an algorithm, based on such scores, for the therapeutic management of patients with CR-KP colonization was commented. Expert opinion: The therapeutic approach analyzed in this review could help physicians to avoid antibiotic overuse as well as to start promptly with the most appropriate antibiotic regimen. However, it has to be validated in further studies, mainly among special population such as immunocompromised patients. The availability of new drugs, fast microbiology, and analysis of gut microbiome could significantly improve the management of CR-KP colonized and/or infected patients.

The use of polymyxins to treat carbapenem resistant infections in neonates and children

INTRODUCTION

The incidence of healthcare-associated multidrug resistant bacterial infections, particularly due to carbapenem resistant organisms, has been on the rise globally. Among these are the carbapenem resistant Acinetobacter baumannii and Enterobacteriaceae, which have been responsible for numerous outbreaks in neonatal units. The polymyxins (colistin and polymyxin B) are considered to be the last resort antibiotics for treating such infections. However, pharmacokinetic and pharmacodynamic data on the use of polymyxins in neonates and children are very limited, and there are safety concerns.

AREAS COVERED

In this review, the authors summarize the global burden of multidrug resistance, particularly carbapenem resistance, in the neonatal and paediatric population, and the potential wider use of polymyxins in treating these infections.

EXPERT OPINION

Both colistin and polymyxin B have similar efficacy in treating multidrug resistant infections but have safety concerns. However, polymyxin B appears to be a better therapeutic option, with more rapid and higher steady state concentrations achieved compared to colistin and less reported nephrotoxicity. There is virtually no data in neonates and children currently; there is therefore an urgent need for pharmacokinetic and safety trials in these populations to determine the optimal drug and dosing regimens and provide recommendations for their use against carbapenem resistant infections.

Risk factors for multidrug-resistant Gram-negative bacteria infection in intensive care units: A meta-analysis

AIMS

To identify the risk factors for multidrug-resistant Gram-negative bacteria systematically and provide suggestions and an evidence-base for clinical measures.

BACKGROUND

With the increase in the social population, changes in human behaviour and ecosystems, as well as economic development, bacteria have gradually produced drug resistance genes. These have swept through intensive care units causing high mortality.

METHODS

Relevant literature which included case-control and cohort studies published from January 1999 to March 2017 were searched in the Cochrane Library, PubMed, Web of Science, and Medline. Meta-analysis was performed by using StataSE version 12.0 software.

RESULTS

Eighteen studies of 235 publications were eligible. Male gender (OR 1.40, 95%CI 1.09, 1.80), having an operative procedure (OR 1.31, 95%CI 1.10, 1.56), a central venous catheter (OR 1.22, 95%CI 1.01, 1.48), mechanical ventilation (OR 1.25, 95%CI 1.07, 1.46), previous antibiotic therapy (OR 1.66, 95%CI 1.41, 1.96), length of ICU stay (weighted mean difference 8.18, 95%CI 0.27, 16.10), and types of health-associated infections were the identified risk factors for multidrug-resistant Gram-negative bacterial infection in intensive care units; moreover, diabetes mellitus was not.

CONCLUSION

Six risk factors were associated with multidrug-resistant Gram-negative bacterial infection in intensive care units. Antimicrobial stewardship, infection control, and medical staff prevention care are needed.

The prospective evaluation of risk factors and clinical influence of carbapenem resistance in children with gram-negative bacteria infection

BACKGROUND

Carbapenem-resistant gram-negative (CRGN) infections have been increasing in recent years and associated with significant morbidity, mortality, and health care costs. The aim of this study was to evaluate the epidemiologic and clinical risk characteristics, risk factors, and outcome of CRGN infections and to compare with carbapenem-sensitive gram-negative (CSGN) infections in children.

METHODS

Newly diagnosed CRGN infections in hospitalized children younger than age 18 years were prospectively recorded and all patients infected with a CSGN pathogen in the same unit within 48 hours of diagnosis were included in a control group between April 1, 2014, and December 31, 2014.

RESULTS

Twenty-seven patients with CRGN infections and 28 patients with CSGN infections were enrolled in this study. Ventilator-associated pneumonia was the most common type of infection in both groups. Prior exposure to carbapenems (relative risk [RR], 11.368; 95% confidence interval [CI], 1.311-98.589), prolonged hospitalization (RR, 5.100; 95% CI, 1.601-16.242) were found to be independent risk factors for acquiring CRGN infections. Septic shock was significantly more frequent in the CRGN group (RR, 9.450; 95% CI, 1.075-83.065). The in-hospital mortality was higher in the CRGN group (RR, 7.647; 95% CI, 1.488-39.290).

CONCLUSIONS

Prior carbapenem exposure and prolonged hospitalization are the most important risk factors for acquiring CRGN infections in our hospital. This study demonstrated, similar to previous reports, that carbapenem resistance increases morbidity, mortality, and health care costs.

The difference in medical costs between carbapenem-resistant Acinetobacter baumannii and non-resistant groups: a case study from a hospital in Zhejiang province, China

This retrospective study aims to compare differences in the medical costs between inpatients infected/colonised with carbapenem-resistant (CRAB) and carbapenem-susceptible (CSAB) Acinetobacter baumannii in a hospital in Zhejiang province, China. Because the patient population was large, we randomly selected 60% of all inpatients with clinical specimens between 2013 and 2015. We classified the A. baumannii cases as CRAB or CSAB based on antibiotic susceptibility testing. Univariate and multivariate analyses were used to identify factors associated with the total medical cost (TMC). Those included in the study totalled 2980 inpatients, 71.3% of whom had CRAB infection/colonisation. Differences in the TMC between the CRAB and CSAB groups were lower by multivariate analyses than the differences obtained by univariate analyses. Carbapenem resistance was significantly associated with an approximately 1.5-fold increase in the TMC after accounting for confounding factors. Our study highlights the heavy financial burden imposed by A. baumannii and carbapenem resistance on the Chinese healthcare system.