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Reizine F, Massart N, Joussellin V, Machut A, Vacheron CH, Savey A, Friggeri A, Lepape A. Association between selective digestive decontamination and decreased rate of acquired candidemia in mechanically ventilated ICU patients: a multicenter nationwide study. Crit Care 2023; 27:494. [PMID: 38104095 PMCID: PMC10724923 DOI: 10.1186/s13054-023-04775-1] [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: 10/20/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Candidemia is a high-risk complication among intensive care unit (ICU) patients. While selective digestive decontamination (SDD) has been shown to be effective in preventing ICU-acquired bacterial secondary infection, its effects on ICU-acquired candidemia (ICAC) remain poorly explored. Therefore, we sought to assess the effects of SDD on ICAC. METHOD Using the REA-REZO network, we included adult patients receiving mechanical ventilation for at least 48 h from January 2017 to January 2023. Non-parsimonious propensity score matching with a 1:1 ratio was performed to investigate the association between SDD and the rate of ICAC. RESULTS A total of 94 437 patients receiving at least 48 h of mechanical ventilation were included throughout the study period. Of those, 3 001 were treated with SDD and 651 patients developed ICAC. The propensity score matching included 2 931 patients in the SDD group and in the standard care group. In the matched cohort analysis as well as in the overall population, the rate of ICAC was lower in patients receiving SDD (0.8% versus 0.3%; p = 0.012 and 0.7% versus 0.3%; p = 0.006, respectively). Patients with ICAC had higher mortality rate (48.4% versus 29.8%; p < 0.001). Finally, mortality rates as well as ICU length of stay in the matched populations did not differ according to SDD (31.0% versus 31.1%; p = 0.910 and 9 days [5-18] versus 9 days [5-17]; p = 0.513, respectively). CONCLUSION In this study with a low prevalence of ICAC, SDD was associated with a lower rate of ICAC that did not translate to higher survival.
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Affiliation(s)
- Florian Reizine
- Service de Réanimation Polyvalente, Centre Hospitalier de Vannes, 56000, Vannes, France.
| | - Nicolas Massart
- Service de Réanimation Polyvalente, Centre Hospitalier de Saint Brieuc, 22000, Saint-Brieuc, France
| | - Vincent Joussellin
- Service de Réanimation Polyvalente, Centre Hospitalier de Vannes, 56000, Vannes, France
| | - Anaïs Machut
- REA-REZO Infections et Antibiorésistance en Réanimation, Hôpital Henry Gabrielle, 69230, Saint-Genis-Laval, France
| | - Charles-Hervé Vacheron
- REA-REZO Infections et Antibiorésistance en Réanimation, Hôpital Henry Gabrielle, 69230, Saint-Genis-Laval, France
- Département d'Anesthésie Médecine Intensive Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie, Institut National de La Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, PHE3ID, Villeurbanne, France
| | - Anne Savey
- REA-REZO Infections et Antibiorésistance en Réanimation, Hôpital Henry Gabrielle, 69230, Saint-Genis-Laval, France
- Centre International de Recherche en Infectiologie, Institut National de La Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, PHE3ID, Villeurbanne, France
| | - Arnaud Friggeri
- REA-REZO Infections et Antibiorésistance en Réanimation, Hôpital Henry Gabrielle, 69230, Saint-Genis-Laval, France
- Département d'Anesthésie Médecine Intensive Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie, Institut National de La Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, PHE3ID, Villeurbanne, France
| | - Alain Lepape
- REA-REZO Infections et Antibiorésistance en Réanimation, Hôpital Henry Gabrielle, 69230, Saint-Genis-Laval, France
- Département d'Anesthésie Médecine Intensive Réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69310, Pierre-Bénite, France
- Centre International de Recherche en Infectiologie, Institut National de La Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, PHE3ID, Villeurbanne, France
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Massart N, Dupin C, Legris E, Legay F, Cady A, Fillatre P, Reizine F. Prevention of ICU-acquired infection with decontamination regimen in immunocompromised patients: a pre/post observational study. Eur J Clin Microbiol Infect Dis 2023; 42:1163-1172. [PMID: 37597052 DOI: 10.1007/s10096-023-04650-5] [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: 05/22/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE Although the proportion of immunocompromised patients admitted to the ICU is increasing, data regarding specific management, including acquired infection (ICU-AI) prophylaxis, in this setting are lacking. We aim to investigate the effect of multiple-site decontamination regimens (MSD) in immunocompromised patients. METHODS We conducted a prospective pre-/post-observational study in 2 ICUs in Bretagne, western France. Adults who required mechanical ventilation for 24 h or more were eligible. During the study period, MSD was implemented in participating ICUs in addition to standard care. It consists of the administration of topical antibiotics (gentamicin, colistin sulfate, and amphotericin B), four times daily in the oropharynx and the gastric tube, 4% chlorhexidine bodywash once daily, and a 5-day nasal mupirocin course. RESULTS Overall, 295 immunocompromised patients were available for analysis (151 in the post-implementation group vs 143 in the pre-implementation group). Solid organ cancer was present in 77/295 patients while immunomodulatory treatments were noticed in 135/295. They were 35 ICU-AI in 29/143 patients in the standard-care group as compared with 10 ICU-AI in 9/151 patients in the post-implementation group (p < 0.001). In a multivariable Poisson regression model, MSD was independently associated with a decreased incidence of ICU-AI (incidence rate ratio = 0.39; 95%CI [0.20-0.87] p = 0.008). There were 35/143 deaths in the standard-care group as compared with 22/151 in the post-implementation group (p = 0.046), this difference remained in a multivariable Cox model (HR = 0.58; 95CI [0.34-0.95] p = 0.048). CONCLUSION In conclusion, MSD appeared to be associated with improved outcomes in critically ill immunocompromised patients.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France.
| | - Clarisse Dupin
- Service de Microbiologie, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Eleonore Legris
- Service de Pharmacie, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - François Legay
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Anne Cady
- Service de Microbiologie, CH de Vannes, 20 bvd général maurice guillaudot, 56000, Vannes, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Florian Reizine
- Service de Réanimation, CH de Vannes, 20, Bd Maurice Guillaudot, 56000, Vannes, France
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Belicard F, Pinceaux K, Le Pabic E, Coirier V, Delamaire F, Painvin B, Lesouhaitier M, Maamar A, Guillot P, Quelven Q, Houssel P, Boudjema K, Reizine F, Camus C. Bacterial and fungal infections: a frequent and deadly complication among critically ill acute liver failure patients. Infect Dis (Lond) 2023:1-10. [PMID: 37211670 DOI: 10.1080/23744235.2023.2213326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/03/2023] [Accepted: 05/07/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a rare but life-threatening condition mostly requiring intensive care unit (ICU) admission. ALF induces immune disorders and may promote infection acquisition. However, the clinical spectrum and impact on patients' prognosis remain poorly explored. METHODS We conducted a retrospective single-centre study on patients admitted for ALF to the ICU of a referral University Hospital from 2000 to 2021. Baseline characteristics and outcomes according to the presence of infection until day 28 were analysed. Risk factors for infection were determined using logistic regression. The impact of infection on 28-day survival was assessed using the proportional hazard Cox model. RESULTS Of the 194 patients enrolled, 79 (40.7%) underwent infection: community-acquired, hospital-acquired before ICU and ICU-acquired before/without and after transplant in 26, 23, 23 and 14 patients, respectively. Most infections were pneumonia (41.4%) and bloodstream infection (38.8%). Of a total of 130 microorganisms identified, 55 were Gram-negative bacilli (42.3%), 48 Gram-positive cocci (36.9%) and 21 were fungi (16.2%). Obesity (OR 3.77 [95% CI 1.18-14.40]; p = .03) and initial mechanical ventilation (OR 2.26 [95% CI 1.25-4.12]; p = .007) were independent factors associated with overall infection. SAPSII > 37 (OR 3.67 [95% CI 1.82-7.76], p < .001) and paracetamol aetiology (OR 2.10 [95% CI 1.06-4.22], p = .03) were independently associated with infection at admission to ICU. On the opposite, paracetamol aetiology was associated with lower risk of ICU-acquired infection (OR 0.37 [95% CI 0.16-0.81], p = .02). Patients with any type of infection had lower day 28 survival rates (57% versus 73%; HR 1.65 [1.01-2.68], p = .04). The presence of infection at ICU admission (p = .04), but not ICU-acquired infection, was associated with decreased survival. CONCLUSIONS The prevalence of infection is high in ALF patients which is associated with a higher risk of death. Further studies assessing the use of early antimicrobial therapy are needed.
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Affiliation(s)
- Félicie Belicard
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Kieran Pinceaux
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | | | - Valentin Coirier
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Flora Delamaire
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Benoît Painvin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | | | - Adel Maamar
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Pauline Guillot
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | - Quentin Quelven
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
| | | | - Karim Boudjema
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France
| | - Florian Reizine
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
- CH Vannes, Service de Réanimation Polyvalente, Vannes, France
| | - Christophe Camus
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, France
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Massart N, Camus C, Nesseler N, Fillâtre P, Flecher E, Mansour A, Verhoye JP, Le Fevre L, Luyt CE. Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support. Ann Intensive Care 2023; 13:27. [PMID: 37024761 PMCID: PMC10079793 DOI: 10.1186/s13613-023-01120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/18/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Acute distress respiratory syndrome (ARDS) patients with veno-venous extra corporeal membrane oxygenation (ECMO) support are particularly exposed to ECMO-associated infection (ECMO-AI). Unfortunately, data regarding AI prophylaxis in this setting are lacking. Selective decontamination regimens decrease AI incidence, including ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) in critically ill patients. We hypothesized that a multiple-site decontamination (MSD) regimen is associated with a reduction in the incidence of AI among VV-ECMO patients. METHODS We conducted a retrospective observational study in three French ECMO referral centers from January 2010 to December 2021. All adult patients (> 18 years old) who received VV-ECMO support for ARDS were eligible. In addition to standard care (SC), 2 ICUs used MSD, which consists of the administration of topical antibiotics four times daily in the oropharynx and the gastric tube, once daily chlorhexidine body-wash and a 5-day nasal mupirocin course. AIs were compared between the 2 ICUs using MSD (MSD group) and the last ICU using SC. RESULTS They were 241 patients available for the study. Sixty-nine were admitted in an ICU that applied MSD while the 172 others received standard care and constituted the SC group. There were 19 ECMO-AIs (12 VAP, 7 BSI) in the MSD group (1162 ECMO-days) compared to 143 AIs (104 VAP, 39 BSI) in the SC group (2376 ECMO-days), (p < 0.05 for all infection site). In a Poisson regression model, MSD was independently associated with a lower incidence of ECMO-AI (IRR = 0.42, 95% CI [0.23-0.60] p < 0.001). There were 30 multidrug resistant microorganisms (MDRO) acquisition in the SC group as compared with two in the MSD group (IRR = 0.13, 95% CI [0.03-0.56] p = 0.001). Mortality in ICU was similar in both groups (43% in the SC group vs 45% in the MSD group p = 0.90). Results were similar after propensity-score matching. CONCLUSION In this cohort of patients from different hospitals, MSD appeared to be safe in ECMO patients and may be associated with improved outcomes including lower ECMO-AI and MDRO acquisition incidences. Since residual confounders may persist, these promising results deserve confirmation by randomized controlled trials.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France.
| | - Christophe Camus
- Service de réanimation médicale, CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France
| | - Pierre Fillâtre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital, University of Rennes 1, Signal and Image Treatment Laboratory (LTSI), Inserm U1099, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital, University of Rennes 1, Signal and Image Treatment Laboratory (LTSI), Inserm U1099, Rennes, France
| | - Lucie Le Fevre
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne-Université, Hôpital Pitié-Salpêtrière, and Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Massart N, Dupin C, Legris E, Fedun Y, Barbarot N, Legay F, Wattecamps G, Le Gall F, La Combe B, Bouju P, Frerou A, Muller L, Rieul G, Fillatre P. Multiple-site decontamination in mechanically ventilated ICU patients: A real-life study. Infect Dis Now 2023; 53:104666. [PMID: 36736667 DOI: 10.1016/j.idnow.2023.104666] [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: 10/12/2022] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Decontamination regimen decreases acquired infection (ICU-AI) incidence but has remained controversial, mostly because it contains a course of intravenous antibiotic. Multiple-site decontamination (MSD), which does not include systemic antibiotics, has been less widely studied but is associated with lower risks of ventilator-associated pneumonia (VAP), bloodstream infection (BSI) and multidrug resistant micro-organism (MDRO) acquisition. We aimed to confirm these favorable outcomes. METHODS A prospective pre/post-observational study was conducted in 5 ICUs in western France. Among them, 4 implemented MSD, whereas the fifth applied standard care (SC) throughout the study period. Patients who required intubation were eligible for study and divided into two groups: the MSD group if they were admitted to an ICU that already implemented MSD, or the SC group. The primary objective was to measure ICU-AI incidence. RESULTS Close to 1400 (1346) patients were available for analysis (334 in the MSD and 1012 patients in the SC group). In a multivariable Poisson regression model, MSD was independently associated with decreased incidence of ICU-AI (IRR = 0.33; 95 %CI [0.18-0.60] p < 0.001). Non-parsimonious propensity-score matching resulted in 334 patient-pairs with well-balanced baseline characteristics. There was a lower incidence of ICU-AI(6.3 % vs 20.7 % p < 0.001), VAP (3.6 % vs 16.2 % p < 0.001) and BSI (3.0 % vs 7.2 % p = 0.029) in the MSD group as compared with the SC group. Five (1.5 %) and 11 (3.3 %) patients respectively acquired MDRO (p = 0.206). CONCLUSION MSD is associated with decreased risk of ICU-AI, VAP and BSI, with no increase in MDRO acquisition.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France.
| | - Clarisse Dupin
- Service de Microbiologie, CH de St BRIEUC, 10, rue marcel Proust 22000 Saint-Brieuc, France
| | - Eleonore Legris
- Service de Pharmacie, CH de St BRIEUC, 10, rue marcel Proust 22000 Saint-Brieuc, France
| | - Yannick Fedun
- Service de Réanimation, CH de Vannes, 20, bd Maurice Guillaudot,56000 Vannes, France
| | - Nicolas Barbarot
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
| | - François Legay
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
| | - Guilhem Wattecamps
- Service de Réanimation, CH de QUIMPER, 14bis Avenue Yves Thépot, 29107 Quimper, France
| | - Florence Le Gall
- Service de Microbiologie, CH de QUIMPER, 14bis Avenue Yves Thépot, 29107 Quimper, France
| | - Béatrice La Combe
- Service de Réanimation, CH bretagne SUD, LORIENT, 5 avenue de choiseul, 56322 Lorient, France
| | - Pierre Bouju
- Service de Réanimation, CH bretagne SUD, LORIENT, 5 avenue de choiseul, 56322 Lorient, France
| | - Aurélien Frerou
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne 35400 Saint-Malo, France
| | - Laura Muller
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne 35400 Saint-Malo, France
| | - Guillaume Rieul
- Service de Réanimation, CH de Vannes, 20, bd Maurice Guillaudot,56000 Vannes, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
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Girona‐Alarcón M, Fresán E, Garcia‐Garcia A, Bobillo‐Perez S, Balaguer M, Felipe A, Esteban ME, Jordan I. Device-associated multidrug-resistant bacteria surveillance in critically ill children: 10 years of experience. Acta Paediatr 2021; 110:203-209. [PMID: 32383199 DOI: 10.1111/apa.15342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 12/21/2022]
Abstract
AIM Multidrug-resistant bacterial infections are a public health problem worldwide. However, most of the information available refers to adults. The main objectives were to determine the incidence, risk factors, and outcomes for device-associated infections, especially those involving multidrug-resistant bacteria. METHODS This is a prospective, observational study. Children aged ≥1 month and <18 years admitted to the paediatric intensive care unit from 2008 to 2017, with a device-associated infection microbiologically confirmed were included. Patients infected with resistant bacteria were compared with those who had a drug-susceptible infection. RESULTS The study included 213 patients. Out of all the device-associated infections, 22% (48 patients) were caused by multidrug-resistant bacteria. The most frequent were extended-spectrum beta-lactamase (ESBL)-producing enterobacteria. Cardiovascular diseases, age under 1year, comorbidity, prolonged use of invasive device, and length of stay until infection were risk factors for resistant bacteria, but not specifically for ESBL-producing bacteria. Length of stay and mortality was increased in patients with multidrug-resistant bacteria. CONCLUSION Being under 1-year-old and having a cardiovascular disease were the two major risk factors for resistant bacterial infection. ESBL-producing bacteria were the most frequent multidrug-resistant agents. However, patients with ESBL-producing bacteria did not have any additional risk factors, so they may have been colonised in the community.
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Affiliation(s)
- Mònica Girona‐Alarcón
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Elena Fresán
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Ana Garcia‐Garcia
- Immunology Department Hospital Sant Joan de Déu‐Clínic University of Barcelona Barcelona Spain
| | - Sara Bobillo‐Perez
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Monica Balaguer
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Aida Felipe
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Maria Esther Esteban
- Zoology and Anthropology Section Department of Evolutionary Biology, Ecology and Environmental Sciences Faculty of Biology GREAB‐ Biological Anthropology Research Group Institut de Recerca de la Biodiversitat (IRBio) University of Barcelona Barcelona Spain
| | - Iolanda Jordan
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
- Paediatric Intensive Care Unit CIBERESP, Hospital Sant Joan de Déu‐Clínic University of Barcelona Barcelona Spain
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Abstract
Objective The aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection. Methods We searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words “chlorhexidine bathing” and MeSH terms “cross-infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31. Results Our findings focused on health care–associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means. Conclusions There is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing’s impact on outcomes, such as mortality and length of stay.
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Massart N, Camus C, Benezit F, Moriconi M, Fillatre P, Le Tulzo Y. Incidence and risk factors for acquired colonization and infection due to extended-spectrum beta-lactamase-producing Gram-negative bacilli: a retrospective analysis in three ICUs with low multidrug resistance rate. Eur J Clin Microbiol Infect Dis 2020; 39:889-895. [PMID: 31898797 PMCID: PMC7222057 DOI: 10.1007/s10096-019-03800-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022]
Abstract
The purpose of this study is to assess risk factors for the acquisition of extended-spectrum β-lactamase-producing Gram-negative bacilli (ESBL-GNB) colonization and infection (AI) in ICUs with low ESBL-GNB prevalence rate. We conducted a retrospective observational study in three ICUs in Bretagne, France. All patients admitted from January 2016 to September 2017 with a length of stay of 2 days or more were included. Universal screening for ESBL-GNB colonization was performed in all participating ICUs. Of the 3250 included patients, 131 (4.0%) were colonized at admission, 59 acquired colonization while hospitalized (1.9%; 95% CI [1.5–2.5%]), and 15 (0.5%; 95% CI [0.3–0.8%]) acquired ESBL-GNB infections. In the case of infection, the specificity and the negative predictive values of preexistent colonization for the ESBL-GNB etiology were 93.2% [91.5–95.1%] and 95.2% [93.5–97.1%], respectively. Colonization was the main risk factor for ESBL-GNB AI (OR = 9.61; 95% CI [2.86–32.29]; p < 0.001). Antimicrobial susceptibility of non-ESBL-GNB isolates responsible for AI was similar for any non-carbapenem β-lactam (95%) and imipenem (94%). ESBL-GNB AIs were rare in ICUs with low ESBL-GNB prevalence rate. Prior colonization was the main risk factor for subsequent infection. Empirical carbapenem therapy could be avoided in non ESBL-GNB colonized patients with suspected AI.
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Affiliation(s)
- Nicolas Massart
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France. .,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.
| | - Christophe Camus
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
| | - François Benezit
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
| | - Mikael Moriconi
- Service de Réanimation, CH de Quimper, 14bis Avenue Yves Thépot, 29107, Quimper, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St Brieuc, 10, rue Henry le Guilloux, 22000, Saint-Brieuc, France
| | - Yves Le Tulzo
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
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9
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Boutrot M, Azougagh K, Guinard J, Boulain T, Barbier F. Antibiotics with activity against intestinal anaerobes and the hazard of acquired colonization with ceftriaxone-resistant Gram-negative pathogens in ICU patients: a propensity score-based analysis. J Antimicrob Chemother 2019; 74:3095-3103. [DOI: 10.1093/jac/dkz279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Intestinal colonization resistance is mainly exerted by commensal anaerobes.
Objectives
To assess whether exposure to non-carbapenem antibiotics with activity against intestinal anaerobes (namely, piperacillin/tazobactam, amoxicillin/clavulanate and metronidazole) may promote the acquisition of gut colonization with ceftriaxone-resistant Gram-negative bacteria (CFR-GNB) in ICU patients.
Patients and methods
All patients with a first stay >3 days in a single surgical ICU over a 30 month period were retrospectively included. Rectal carriage of CFR-GNB (i.e. ESBL-producing Enterobacteriaceae, AmpC-hyperproducing Enterobacteriaceae, Pseudomonas aeruginosa, Stenotrophomonas maltophilia and CFR Acinetobacter baumannii) was routinely screened for at admission then weekly. The impact of anti-anaerobe antibiotics was investigated in propensity score (PS)-matched cohorts of patients exposed and not exposed to these drugs and through PS-based inverse probability of treatment weighting on the whole study cohort, treating in-ICU death or discharge as competing risks for CFR-GNB acquisition.
Results
Among the 352 included patients [median ICU stay 16 (9–30) days, in-ICU mortality 12.2%], 120 (34.1%) acquired one or more CFR-GNB, mostly AmpC-hyperproducing Enterobacteriaceae (17.6%) and P. aeruginosa (14.8%). Exposure to anti-anaerobe antibiotics was the main predictor of CFR-GNB acquisition in both the PS-matched cohorts [adjusted HR (aHR) 3.92, 95% CI 1.12–13.7, P = 0.03] and the whole study cohort (aHR 4.30, 95% CI 1.46–12.63, P = 0.01). Exposure to other antimicrobials—especially ceftriaxone and imipenem/meropenem—exerted no independent impact on the likelihood of CFR-GNB acquisition.
Conclusions
Exposure to non-carbapenem antibiotics with activity against intestinal anaerobes may predispose to CFR-GNB acquisition in ICU patients. Restricting the use of these drugs appears to be an antibiotic stewardship opportunity.
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Affiliation(s)
- Maxime Boutrot
- Surgical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Khalid Azougagh
- Surgical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Jérôme Guinard
- Department of Microbiology, La Source Hospital, CHR Orléans, Orléans, France
| | - Thierry Boulain
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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10
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Prevel R, Boyer A, M'Zali F, Lasheras A, Zahar JR, Rogues AM, Gruson D. Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:170. [PMID: 31088542 PMCID: PMC6518813 DOI: 10.1186/s13054-019-2460-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU. METHODS Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy. RESULTS Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting. CONCLUSION Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
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Affiliation(s)
- Renaud Prevel
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France. .,UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France. .,, Bordeaux, France.
| | - Alexandre Boyer
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
| | - Fatima M'Zali
- UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France
| | - Agnès Lasheras
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France
| | - Jean-Ralph Zahar
- Unité INSERM - IAME UMR 1137, Université Paris-13, Bobigny, France
| | - Anne-Marie Rogues
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France.,Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000, Bordeaux, France
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
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11
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Sánchez-Ramírez C, Hípola-Escalada S, Cabrera-Santana M, Hernández-Viera MA, Caipe-Balcázar L, Saavedra P, Artiles-Campelo F, Sangil-Monroy N, Lübbe-Vázquez CF, Ruiz-Santana S. Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance. Crit Care 2018; 22:141. [PMID: 29843808 PMCID: PMC5975678 DOI: 10.1186/s13054-018-2057-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/09/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB). METHODS In this cohort study, which was conducted in a 30-bed medical-surgical ICU, clinical outcomes before (1 year, non-SDD group) and after (4 years) implementation of SDD were compared. ICU patients who were expected to require tracheal intubation for > 48 hours were given a standard prophylactic SDD regimen. Oropharyngeal and rectal swabs were obtained on admission and once weekly thereafter. RESULTS ICU-acquired infections occurred in 110 patients in the non-SDD group and in 258 in the SDD group. A significant (P < 0.001) reduction of infections caused by MDRB (risk ratio [RR], 0.31; 95% CI, 0.23-0.41) was found after SDD and was associated with low rates of colistin- and tobramycin-resistant colonization. Colistin- and tobramycin-acquired increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at admission, was nonsignificant (0.82; 95% CI, 0.56 to 1.95; 1.13; 95% CI, 0.75 to 1.70, respectively). SDD was also a protective factor for ICU-acquired infections caused by MDR gram-negative pathogens and Acinetobacter baumannii in the multivariate analysis. In addition, a significant (P < 0.001) reduction of ventilator-associated pneumonia (VAP) (RR, 0.43; 95% CI, 0.32-0.59) and secondary bloodstream infection (BSI) (RR, 0.35; 95% CI, 0.24-0.52) was found. A decrease in antibiotic consumption was also observed. CONCLUSIONS Treatment with SDD during 4 years was effective in an ICU setting with a high level of resistance, with clinically relevant reductions of infections caused by MDRB, and with low rates of colistin- and tobramycin-resistant colonization with nonsignificant increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at ICU admission. In addition, VAP and secondary BSI rates were significantly lower after SDD. Notably, a decrease in antimicrobial consumption was also observed.
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Affiliation(s)
- Catalina Sánchez-Ramírez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Silvia Hípola-Escalada
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Miriam Cabrera-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - María Adela Hernández-Viera
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Liliana Caipe-Balcázar
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Pedro Saavedra
- Mathematics Department, Universidad de las Palmas de Gran Canaria, Las Palmas, Spain
| | - Fernando Artiles-Campelo
- Microbiology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Nayra Sangil-Monroy
- Pharmacy Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Carlos Federico Lübbe-Vázquez
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
| | - Sergio Ruiz-Santana
- Intensive Care Unit, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, La Ballena s/n, E-35010 Las Palmas, Spain
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