Blood stream infections due to multidrug-resistant organisms among spinal cord-injured patients, epidemiology over 16 years and associated risks: a comparative study

Acute kidney injury should not be neglected - optimization of quick Pitt bacteremia score for predicting mortality in critically ill patients with bloodstream infection: a retrospective cohort study

Background

Considering the therapeutic difficulties and mortality associated with bloodstream infection (BSI), it is essential to investigate other potential factors affecting mortality in critically ill patients with BSI and examine the utility of the quick Pitt bacteremia (qPitt) score to improve the survival rate.

Objectives

To improve the predictive accuracy of the qPitt scoring system by evaluating the five current components of qPitt and including other potential factors influencing mortality in critically ill patients with BSI.

Design

This was a retrospective cohort study.

Methods

Medical information from the Medical Information Mart for Intensive Care IV database was used in this retrospective cohort study. The risk factors associated with mortality were examined using a multivariate logistic regression model. The area under the receiver operating characteristic curve (AUC) was used to assess the discriminatory capability of the prediction models.

Results

In total, 1240 eligible critically ill patients with BSI were included. After adjustment for age, community-onset BSI, indwelling invasive lines, and Glasgow Coma Scale (GCS) ⩽ 8, acute kidney injury (AKI) was identified as a notable risk factor for 14-day mortality. Except for altered mental status, the four other main components of the original qPitt were significantly associated with 14-day mortality. Hence, we established a modified qPitt (m-qPitt) by adding AKI and replacing altered mental status with GCS ⩽ 8. The AUCs for m-qPitt and qPitt were 0.723 [95% confidence interval (CI): 0.683-0.759] and 0.708 (95% CI: 0.669-0.745) in predicting 14-day mortality, respectively. Moreover, m-qPitt also had acceptable performance and discrimination power [0.700 (95% CI: 0.666-0.732)] in predicting 28-day mortality.

Conclusion

AKI significantly influenced the survival of critically ill patients with BSIs. Compared with the original qPitt, our new m-qPitt was proven to have a better predictive performance for mortality in critically ill patients with BSI. Further studies should be conducted to validate the practicality of m-qPitt.

Intravesical Lactobacillus rhamnosus GG versus Saline Bladder Wash: Protocol for a Randomized, Controlled, Comparative Effectiveness Clinical Trial

Background

Complicated urinary tract infection (cUTI) is pervasive and costly among people with spinal cord injury (SCI) and neurogenic lower urinary tract dysfunction (NLUTD).

Objectives

To describe the protocol for a comparative effectiveness randomized controlled trial of intravesical Lactobacillus rhamnosus GG (LGG) versus saline bladder wash (BW) for self-management of urinary symptoms.

Methods

Comparative effectiveness trial of self-administered LGG versus saline bladder wash among 120 participants with SCI+NLUTD at least 6 months post SCI. The study has both treatment and prophylaxis phases. After predictive enrichment at screening, randomized participants will enter the treatment phase (6 months) in which they instill either LGG or normal saline after trigger symptoms occur (more cloudy or more foul-smelling urine). In the prophylaxis phase (6 months), participants will instill their respective intervention every 3 days after the first occurrence of trigger symptoms.

Results

Study results will provide a comparison of effects on Urinary Symptom Questionnaire for Neurogenic Bladder (USQNB) bladder and urine symptoms and episodes of "presumed UTIs"; number of days antibiotics were used (both self-reported); days of work, school, rehabilitation, or other activity lost due to urinary symptoms; engagement with the health care system; number of instillations; satisfaction; and safety.

Conclusion

cUTI is a variable clinical entity. Unlike clinical trials that assume a single, simple entity (UTI) in inclusion or outcome criteria, this protocol targets the mechanisms underlying cUTI causes and phenotypes. Featuring reliable and valid outcome measures with analytic methods specifically appropriate for quantifying self-report, patient self-management, inclusion of both intervention and prophylactic phases, and predictive enrichment, these design elements may be adopted for future research.

Hyaluronic acid and chondroitin sulphate treatment for recurrent severe urinary tract infections due to multidrug-resistant gram-negative bacilli in a patient with multiple sclerosis: case report and literature review

Urinary tract infections (UTIs) are the most common bacterial infections in patients with neurogenic lower urinary tract dysfunction. Antibiotic options for prophylaxis or curative treatment in case of recurrent UTIs, especially due to multidrug-resistant organisms (MDRO), are scarce. We present the case of a 72-year-old man with neurogenic lower urinary tract dysfunction and history of frequent recurrent UTIs due to multiple MDROs who was successfully treated with hyaluronic acid (HA) and chondroitin sulfate (CS) bladder instillations. We also provide a literature review on the efficacy of HA-CS intravesical instillations for prevention of UTI among this population.

Hip joint infections caused by multidrug-resistant Enterobacterales among patients with spinal cord injury: experience of a reference center in the Greater Paris area

Introduction

We aimed to describe the management and treatment of hip joint infections caused by multidrug-resistant Enterobacterales among patients with spinal cord injury (SCI).

Methods

We included all hip joint infections associated with grade IV decubitus ulcers caused by Extended-Spectrum Beta-Lactamase producing Enterobacterales (ESBL-PE) and Carbapenemase-Producing Enterobacterales (CPE) treated in a reference center for bone and joint infections (BJIs) over 9 years in a retrospective study.

Results

Seventeen SCI patients with ischial pressure ulcers breaching the hip capsule (mean age 52 ± 15 years) were analyzed. In 16 patients, paraplegia was secondary to trauma and one was secondary to multiple sclerosis. Infections were mostly polymicrobial (n=15; 88.2%), notably caused by Klebsiella pneumoniae (n=10) and S. aureus (n=10). The carbapenemases identified were exclusively OXA-48-type (n=3) including 2 isolates co-expressed with ESBL-PE within the same bacterial host.

Multidrug-resistant Enterobacterales were commonly resistant to fluoroquinolones (n=12; 70.6%). Most therapies were based on carbapenems (n=10) and combination therapies (n=13). Median duration of treatment was 45 (6-60) days. Of 17 cases of hip joint infections, 94.1% (n=16) benefited from a femoral head and neck resection.

Infection control was initially achieved in 58.8% (n=10) of cases and up to 88.2% after revision surgeries, after a median follow-up of 3 (1-36) months.

Conclusion

Hip infections among SCI patients caused by multidrug-resistant Enterobacterales are often polymicrobial and fluoroquinolones-resistant infections caused by K. pneumoniae and S. aureus, highlighting the need for expert centers with pluridisciplinary meetings associating experienced surgeons, clinical microbiologists and infectious disease specialists.

Bloodstream infections in older population: epidemiology, outcome, and impact of multidrug resistance

Bloodstream infections (BSIs) among older patients are frequent with high rate of mortality. Infections with multidrug-resistant organisms (MDRO) are associated with higher mortality than with susceptible microorganisms. We aimed to evaluate the prevalence of MDRO infection during BSI in older population and the factors associated with unfavorable outcome. This study is a retrospective cohort of all BSI episodes occurring among older patients (> 65yo), from April 1, 2010, to December 31, 2016, in a French university hospital for geriatric medicine. A total of 255 BSI episodes were analyzed. Mean age was 86.3±6.5 years, and sex ratio (M/F) was 0.96. Main comorbidities were orthopedic device (26.7%), active neoplasia (24.3%), and diabetes mellitus (18.4%). Main primary sites of infection were urinary tract infections (56.9%), respiratory tract infections (10.6%), intra-abdominal infections (7.1%), and skin and soft tissue infections (4.7%). Main bacteria identified were Escherichia coli (45.1%), Staphylococcus aureus (14.1%), enterococci (10.7%), coagulase-negative staphylococci (CoNS) (5.5%), and streptococci (5.1%). MDROs were involved in 17.2% of BSI (gram-negative bacilli: 9.0%; CoNS: 4.3%; and methicillin-resistant S. aureus (MRSA): 3.9%). The main factor associated with MDRO BSI was colonization with MDRO (OR=6.29; 95%CI=2.9-14.32). Total mortality was 18.4% and significantly higher in case of initial severity (OR=3.83; 95%CI=1.75-8.38), healthcare-associated infection (OR=5.29; 95%CI=1.11-25.30), and MRSA BSI (OR=9.16; 95%CI=1.67-50.16). BSI due to MDRO is frequent in older population and is strongly associated with carriage of MDRO. Healthcare-associated BSI, severe episodes, and BSI due to MRSA are associated with unfavorable outcome. In these cases, a broad-spectrum antibiotic should be promptly initiated.

Differentiating Asymptomatic Bacteriuria From Urinary Tract Infection in the Pediatric Neurogenic Bladder Population: NGAL As a Promising Biomarker

Objective: To evaluate whether urinary antimicrobial peptides (AMPs) can discriminate between asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) in pediatric patients with neurogenic bladder (NGB). Design/Methods: Bladder urine was collected from pediatric patients (≤18 years old) with NGB without augmentation cystoplasty. Patients were divided into the following groups based on symptomatology and results of urinalysis/urine culture: (a) UTI, (b) ASB, and (c) sterile. Urine AMPs β defense 1 (BD-1), neutrophil gelatinase-associated lipocalin (NGAL), cathelicidin (LL-37), hepatocarcinoma-intestine-pancreas/pancreatitis-associated protein (HIP/PAP), and human α defensin 5 (HD-5) were compared between groups by enzyme-linked immunosorbent assays. In addition, urines from pediatric controls without NGB or UTI were also analyzed. Significance was determined using Student's t test for parametric or Mann-Whitney U test for nonparametric data. A p value of <.05 was considered significant. Results: Thirty-six patients with NGB from a spinal dysraphism were evaluated: UTI, n = 6; ASB, n = 18; sterile, n = 12. These groups did not differ significantly by age but did significantly differ by gender (p = .0139). NGAL significantly differed between UTI and ASB groups (median 38.5 ng/mg vs 15.5 ng/mg, respectively; p = .0197) with a sensitivity and specificity of 82.4% and 83.3%, respectively. HIP/PAP, BD-1, HD-5, LL-37, and NGAL levels were all significantly higher in sterile NGB urines compared to 17 non-NGB pediatric controls (p < .0001, p = .0020, p = .0035, p = .0006, and p = .0339, respectively). Conclusion: All five urinary AMPs evaluated were significantly elevated in NGB patients compared to controls. NGAL levels may help differentiate between UTI and ASB in pediatric NGB patients.

Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

Factors associated with bacteraemia due to multidrug-resistant organisms among bacteraemic patients with multidrug-resistant organism carriage: a case control study

Background

Infections caused by multidrug-resistant organisms (MDRO) are emerging worldwide. Physicians are increasingly faced with the question of whether patients need empiric antibiotic treatment covering these pathogens. This question is especially essential among MDRO carriers. We aim to determine the occurrence of MDRO bacteraemia among bacteraemic patients colonized with MDRO, and the associated factors with MDRO bacteraemia among this population.

Methods

We performed a retrospective monocentric study among MDRO carriers hospitalized with bacteraemia between January 2013 and August 2016 in a French hospital. We compared characteristics of patients with MDRO and non-MDRO bacteraemia.

Results

Overall, 368 episodes of bacteraemia were reviewed; 98/368 (26.6%) occurred among MDRO carriers.

Main colonizing bacteria were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (40/98; 40.8%), ESBL-producing Klebsiella pneumoniae (35/98; 35.7%); methicillin-resistant Staphylococcus aureus (26/98; 26.5%) and multidrug-resistant Pseudomonas aeruginosa (PA) (12/98; 12.2%).

There was no significant difference considering population with MDRO bacteraemia vs. non-MDRO bacteraemia, except for immunosuppression [OR 2.86; p = 0.0207], severity of the episode [OR 3.13; p = 0.0232], carriage of PA [OR 5.24; p = 0.0395], and hospital-acquired infection [OR 2.49; p = 0.034].

In the multivariate analysis, factors significantly associated with MDRO bacteraemia among colonized patient were only immunosuppression [OR = 2.96; p = 0.0354] and the hospital-acquired origin of bacteraemia [OR = 2.62; p = 0.0427].

Conclusions

According to our study, occurrence of bacteraemia due to MDRO among MDRO carriers was high. Factors associated with MDRO bacteraemia were severity of the episode and hospital-acquired origin of the bacteraemia. Thus, during bacteraemia among patients colonized with MDRO, if such characteristics are present, broad-spectrum antimicrobial treatment is recommended.

[Original strategy for prevention of recurrent symptomatic urinary tract infections in patients with neurogenic bladder: Bacterial interference, state of the art]

PURPOSE

Urinary tract infection (UTI) is the most common complication in patients with neurogenic bladder. The long-term use of antibiotic drugs induces an increase in antimicrobial resistance and adverse drug reactions. Bacterial interference is a new concept to prevent recurrent UTI which consists in a bladder colonization with low virulence bacteria. We performed a literature review on this emerging therapy.

MATERIALS AND METHODS

Literature review of bacterial interference to prevent symptomatic urinary tract infection in neurological population.

RESULTS

Seven prospectives study including 3 randomized, double-blind and placebo controlled trial were analyzed. The neurological population was spinal cord injured in most cases. The bladder colonization was performed with 2 non-pathogen strains of Escherichia coli: HU 2117 and 83972. At 1 month, 38 to 83% of patients were colonized. Mean duration of colonization was 48.5 days to 12.3 months. All studies showed that colonization might reduce the number of urinary tract infections and is safe with absence of serious side effects.

CONCLUSION

Bacterial interference is a promising alternative therapy for the prevention of recurrent symptomatic urinary tract infections in neurogenic patients. This therapy should have developments for a daily use practice and for a long-term efficacy.

Ceftolozane/tazobactam for febrile UTI due to multidrug-resistant Pseudomonas aeruginosa in a patient with neurogenic bladder

INTRODUCTION

Urinary tract infections (UTI) are a major public health problem among spinal cord injury (SCI) patients. They frequently involve multidrug-resistant (MDR) bacteria. Ceftolozane/tazobactam (C/T) is a novel antibiotic combination approved for complicated intra-abdominal and UTI caused by Gram-positive and Gram-negative organisms, including some MDR strains. Little is known about the use of this agent for complicated febrile UTI occurring among SCI patients with neurogenic bladder due to MDR Pseudomonas aeruginosa (PSA).

CASE PRESENTATION

We describe the case of a 35-year-old man with SCI due to multiple sclerosis, with a neurogenic bladder necessitating a bilateral nephrostomy and double J catheter, who developed a febrile UTI due to a MDR PSA, which was susceptible only to amikacin and colistin. Because of this MDR phenotype and the underlying kidney disease, a 1000 mg (1000 mg per 500 mg) dose of C/T was given as monotherapy every 8 h for 7 days, after 3 days of colistin and amikacin. Thanks to this treatment, the patient had a favorable outcome with no clinical signs of UTI or positive urine culture up to 1 month after diagnosis.

DISCUSSION

C/T seems to be an effective and safe therapeutic option for febrile UTI due to MDR PSA in SCI patients with neurogenic bladder, even when administered in monotherapy for 10 days.

Outcome of bloodstream infections among spinal cord injury patients and impact of multidrug-resistant organisms

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Our study aimed to describe the outcome of bloodstream infection (BSI) in spinal cord injury (SCI) patients and their associated risk factors for severity and mortality.

SETTING

A French University Hospital.

METHODS

We conducted a retrospective cohort study of all BSIs occurring in hospitalized SCI patients. We analyzed their outcome and risk factors especially the impact of multidrug-resistant organisms (MDROs).

RESULTS

Overall, 318 BSIs occurring among 256 patients were included in the analysis. Mean age was 50.8 years and gender ratio (M/F) was 2.70, with a mean injury duration of 11.6 years.Severity and 30-day mortality of BSI episodes were, respectively, 43.4% and 7.9%. BSI severity was significantly more frequent when caused by respiratory tract infections (RTIs) (odds ratio (OR)=1.38; 95% confidence interval (CI): 1.13-1.44) and significantly lower when caused by urinary tract infections (UTIs) (OR=0.47; 95% CI: 0.28-0.76). BSI mortality was significantly higher when caused by RTIs (OR=3.08; 95% CI: 1.05-8.99), catheter-related bloodstream infections (OR=3.54; 95% CI: 1.36-9.18) or Pseudomonas aeruginosa infections (OR=3.79; 95% CI: 1.14-12.55).MDROs were responsible for 41.2% of all BSI. They have no impact on severity and mortality, whichever be the primary site of infection.In multivariate analysis, mortality was higher when BSI episodes were due to RTIs (OR=3.26; 95% CI: 1.29-8.22) and Pseudomonas aeruginosa infections (OR=3.53; 95% CI: 1.06-11.70), or when associated with immunosuppressive therapy (OR=2.57; 95% CI: 1.14-5.78) or initial severity signs (OR=1.68; 95% CI: 1.01-2.81).

CONCLUSION

BSI occurring in SCI population were often severe but mortality remained low. MDROs were frequent but not associated with severity or mortality of BSI episodes. Risk factors associated with mortality were initial severe presentation, RTI, immunosuppressive therapy and BSI due to Pseudomonas aeruginosa.

Implementation of a simple innovative system for postprescription antibiotic review based on computerized tools with shared access

BACKGROUND

Controlling antibiotic use in healthcare establishments limits their consumption and the emergence of bacterial resistance.

AIM

To evaluate the efficiency of an innovative antibiotic stewardship strategy implemented over three years in a university hospital.

METHODS

An antimicrobial multi-disciplinary team (AMT) [pharmacist, microbiologist and infectious disease specialist (IDS)] conducted a postprescription review. Specific coding of targeted antibiotics (including broad-spectrum β-lactams, glycopeptides, lipopeptides, fluoroquinolones and carbapenems) in the computerized physician order entry allowed recording of all new prescriptions. The data [patient, antibiotic(s), prescription start date, etc.] were registered on an AMT spreadsheet with shared access, where the microbiologist's opinion on the drug choice, based on available microbiology results, was entered. When the microbiologist and pharmacist did not approve the antibiotic prescribed, a same-day alert was generated and sent to the IDS. That alert led the IDS to re-evaluate the treatment.

FINDINGS

From 2012 to 2014, 2106 targeted antibiotic prescriptions were reviewed. Among them, 389 (18.5%) generated an alert and 293 (13.9%) were re-evaluated by the IDS. Recommendations (mostly de-escalation or discontinuation) were necessary for 136 (46.4%) and the prescribers' acceptance rate was 97%. The estimated intervention time was <30 min/day for each AMT member. This system allowed correct use of targeted antibiotics for 91.8% of prescriptions, but had no significant impact on targeted antibiotic consumption.

CONCLUSION

This computerized, shared access, antibiotic stewardship strategy seems to be time saving, and effectively limited misuse of broad-spectrum antibiotics.

Gut dysbiosis impairs recovery after spinal cord injury

Kigerl et al. show that spinal cord injury causes profound changes in gut microbiota and that these changes in gut ecology are associated with activation of GALT immune cells. They show that feeding mice probiotics after SCI confers neuroprotection and improves functional recovery.

The trillions of microbes that exist in the gastrointestinal tract have emerged as pivotal regulators of mammalian development and physiology. Disruption of this gut microbiome, a process known as dysbiosis, causes or exacerbates various diseases, but whether gut dysbiosis affects recovery of neurological function or lesion pathology after traumatic spinal cord injury (SCI) is unknown. Data in this study show that SCI increases intestinal permeability and bacterial translocation from the gut. These changes are associated with immune cell activation in gut-associated lymphoid tissues (GALTs) and significant changes in the composition of both major and minor gut bacterial taxa. Postinjury changes in gut microbiota persist for at least one month and predict the magnitude of locomotor impairment. Experimental induction of gut dysbiosis in naive mice before SCI (e.g., via oral delivery of broad-spectrum antibiotics) exacerbates neurological impairment and spinal cord pathology after SCI. Conversely, feeding SCI mice commercial probiotics (VSL#3) enriched with lactic acid–producing bacteria triggers a protective immune response in GALTs and confers neuroprotection with improved locomotor recovery. Our data reveal a previously unknown role for the gut microbiota in influencing recovery of neurological function and neuropathology after SCI.