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Lei TY, Liao BB, Yang LR, Wang Y, Chen XB. Hypervirulent and carbapenem-resistant Klebsiella pneumoniae: A global public health threat. Microbiol Res 2024; 288:127839. [PMID: 39141971 DOI: 10.1016/j.micres.2024.127839] [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: 06/06/2024] [Revised: 07/08/2024] [Accepted: 07/13/2024] [Indexed: 08/16/2024]
Abstract
The evolution of hypervirulent and carbapenem-resistant Klebsiella pneumoniae can be categorized into three main patterns: the evolution of KL1/KL2-hvKp strains into CR-hvKp, the evolution of carbapenem-resistant K. pneumoniae (CRKp) strains into hv-CRKp, and the acquisition of hybrid plasmids carrying carbapenem resistance and virulence genes by classical K. pneumoniae (cKp). These strains are characterized by multi-drug resistance, high virulence, and high infectivity. Currently, there are no effective methods for treating and surveillance this pathogen. In addition, the continuous horizontal transfer and clonal spread of these bacteria under the pressure of hospital antibiotics have led to the emergence of more drug-resistant strains. This review discusses the evolution and distribution characteristics of hypervirulent and carbapenem-resistant K. pneumoniae, the mechanisms of carbapenem resistance and hypervirulence, risk factors for susceptibility, infection syndromes, treatment regimens, real-time surveillance and preventive control measures. It also outlines the resistance mechanisms of antimicrobial drugs used to treat this pathogen, providing insights for developing new drugs, combination therapies, and a "One Health" approach. Narrowing the scope of surveillance but intensifying implementation efforts is a viable solution. Monitoring of strains can be focused primarily on hospitals and urban wastewater treatment plants.
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Affiliation(s)
- Ting-Yu Lei
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Bin-Bin Liao
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Liang-Rui Yang
- First Affiliated Hospital of Dali University, Yunnan 671000, China.
| | - Ying Wang
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
| | - Xu-Bing Chen
- College of Pharmaceutical Science, Dali University, Dali 671000, China.
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Young EL, Roach DJ, Martinsen MA, McGrath G, Holbrook NR, Cho HE, Seyoum EY, Pierce VM, Bhattacharyya RP. Clinical Pilot of Bacterial Transcriptional Profiling as a Combined Genotypic and Phenotypic Antimicrobial Susceptibility Test. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.10.24310021. [PMID: 39040176 PMCID: PMC11261942 DOI: 10.1101/2024.07.10.24310021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Antimicrobial resistance is a growing health threat, but standard methods for determining antibiotic susceptibility are slow and can delay optimal treatment, which is especially consequential in severe infections such as bacteremia. Novel approaches for rapid susceptibility profiling have emerged that characterize either bacterial response to antibiotics (phenotype) or detect specific resistance genes (genotype). GoPhAST-R is a novel assay, performed directly on positive blood cultures, that integrates rapid transcriptional response profiling with detection of key resistance gene transcripts, thereby providing simultaneous data on both phenotype and genotype. Here, we performed the first clinical pilot of GoPhAST-R on 42 positive blood cultures: 26 growing Escherichia coli, 15 growing Klebsiella pneumoniae, and 1 with both. An aliquot of each positive blood culture was exposed to 9 different antibiotics, lysed, then underwent rapid transcriptional profiling on the NanoString® platform; results were analyzed using an in-house susceptibility classification algorithm. GoPhAST-R achieved 95% overall agreement with standard antimicrobial susceptibility testing methods, with the highest agreement for beta-lactams (98%) and the lowest for fluoroquinolones (88%). Epidemic resistance genes including the extended spectrum beta-lactamase bla CTX-M-15 and the carbapenemase bla KPC were also detected within the population. This study demonstrates the clinical feasibility of using transcriptional response profiling for rapid resistance determination, although further validation with larger and more diverse bacterial populations will be essential in future work. GoPhAST-R represents a promising new approach for rapid and comprehensive antibiotic susceptibility testing in clinical settings.
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Affiliation(s)
- E L Young
- The Broad Institute of MIT and Harvard, Boston, MA, USA
| | - D J Roach
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - M A Martinsen
- The Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Geg McGrath
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - N R Holbrook
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - H E Cho
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - E Y Seyoum
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - V M Pierce
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Current address: Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R P Bhattacharyya
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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Yuan PB, Dai LT, Zhang QK, Zhong YX, Liu WT, Yang L, Chen DQ. Global emergence of double and multi-carbapenemase producing organisms: epidemiology, clinical significance, and evolutionary benefits on antimicrobial resistance and virulence. Microbiol Spectr 2024; 12:e0000824. [PMID: 38860788 PMCID: PMC11218513 DOI: 10.1128/spectrum.00008-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/02/2024] [Indexed: 06/12/2024] Open
Abstract
Redundant carbapenemase-producing (RCP) bacteria, which carry double or multiple carbapenemases, represent a new and concerning phenomenon. The objective of this study is to conduct a comprehensive analysis of the epidemiology and genetic mechanisms of RCP strains to support targeted surveillance and control measures. A retrospective analysis was conducted using surveillance data from 277 articles. Statistical analysis was performed to determine and evaluate species prevalence, proportions of carbapenemases, antibiotic susceptibility profiles, sample information, and patient outcomes. Complete plasmid sequencing data were utilized to investigate potential antimicrobial resistance or virulence advantages that strains may gain from acquiring redundant carbapenemases. RCP bacteria are widely distributed globally, and their prevalence is increasing over time. Several countries, including China, India, Iran, Turkey, and South Korea, have reported more than 100 RCP strains. The most commonly reported RCP species are Klebsiella pneumoniae and Acinetobacter baumannii, which exhibit varying proportions of carbapenemase combinations. Certain species-carbapenemase combinations, such as K. pneumoniae carrying New Delhi metallo-β-lactamase (NDM) + oxacillinase (OXA) (56.76%) and K. pneumoniae carbapenemase (KPC) + Verona integron-encoded metallo-β-lactamase (VIM) (50.00%) carbapenemases, are associated with high mortality rates. In patients with RCP strains isolated from the bloodstream and respiratory system, the mortality rates are 58.70% and 69.23%, respectively. Analysis of plasmids from RCP strains suggests that they may acquire additional antibiotic resistance phenotypes and virulence factors. Carbapenem-resistant bacteria carrying redundant carbapenemases pose a significant global health threat. This study provides valuable insights into the epidemiology and genetic mechanisms of these bacteria, supporting the development of effective control and prevention strategies to mitigate their transmission.IMPORTANCEThis study examined the global distribution patterns of 1,780 bacteria with double or multiple carbapenemases from 277 articles and assessed their clinical impact. The presence of multiple carbapenemases increases the chances of co-resistance to other classes of antibiotics and more virulence factors, further complicating the clinical management of infections.
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Affiliation(s)
- Pei-Bo Yuan
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Li-Ting Dai
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qi-Ke Zhang
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yu-Xia Zhong
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Wan-Ting Liu
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Yang
- Department of Clinical Laboratory, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ding-Qiang Chen
- Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Giacobbe DR, Di Pilato V, Vena A, Marchese A, Bassetti M. Interpreting the results of rapid molecular diagnostic tests for carbapenem-resistant Enterobacterales infection: current clinical perspective while waiting for further evidence. Expert Rev Mol Diagn 2024; 24:583-590. [PMID: 39054637 DOI: 10.1080/14737159.2024.2383851] [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: 05/05/2024] [Accepted: 07/19/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Carbapenem-resistant Enterobacterales (CRE) causing severe infections in humans have represented an important challenge for clinicians worldwide during the past two decades. AREAS COVERED Novel β-lactams and β-lactam/β-lactamase inhibitor combinations have led to a shift in the first-line approach to the treatment of severe CRE infections from polymyxin-based regimens to treatment with less toxic agents. This new scenario offers the opportunity to apply rapid molecular diagnostic tests for CRE infection to identify different types of carbapenemases. Herein, the authors provide an overview of this subject and follow it with their expert perspectives. EXPERT OPINION When considering studies actually measuring the clinical impact of rapid molecular tests in real-life scenarios, high certainty evidence from randomized controlled trials is still limited and not focused on CRE infections. Nonetheless, it is indisputable that rapid molecular tests have been shown to impact early therapeutic choices (in terms of both escalation and de-escalation) when used in real-life settings, thus issues in the clinical interpretation of their results are already relevant. Overall, increased expertise is required for the appropriate interpretation of rapid molecular tests for personalized antibiotic selection by understanding their strengths and limitations.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, IRCCS Ospedale Policlinico, San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, IRCCS Ospedale Policlinico, San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- UO Microbiologia, IRCCS Ospedale Policlinico, San Martino, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, IRCCS Ospedale Policlinico, San Martino, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Moreira NK, Wilhelm CM, Collar GDS, Echevarria AD, Becker J, Barth AL, Caierão J. Detection of KPC directly from positive blood cultures by MALDI-TOF: From research to the clinical microbiology laboratory routine. J Microbiol Methods 2024; 221:106940. [PMID: 38702032 DOI: 10.1016/j.mimet.2024.106940] [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: 09/18/2023] [Revised: 02/23/2024] [Accepted: 04/30/2024] [Indexed: 05/06/2024]
Abstract
Bloodstream infections (BSI) caused by carbapenem-resistant Gram-negative bacilli (CR-GNB) are a subject of major clinical concern, mainly those associated with carbapenemase-producing isolates. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been proposed to detect specific β-lactamases, including KPC. We aimed to detect KPC enzyme directly from positive blood cultures using MALDI-TOF MS. Overall, 146 clinical Gram-negative bacilli (46 CR-GNB) recovered from consecutive blood cultures were evaluated. Proteins were extracted using formic acid, isopropyl alcohol, and water and spotted onto a steel target plate using the double-layer sinapinic acid method. The relative ions intensity ≥120 arbitrary units (a.u.) of a peak close to 28,700 m/z indicated the presence of KPC. The results were compared to HRM-qPCR methodology. This specific peak was observed in 11/14 blood bottles with blaKPC positive isolates (78.6% sensitivity), with 3 false-positive results (97.7% specificity). Analysis from colonies reached identical sensitivity (78.6%), but higher specificity (100%). The detection of KPC peaks directly from positive blood cultures using MALDI-TOF MS is feasible and rapid. It's excellent specificity indicates that positive results are consistently associated with the presence of a KPC producer in positive blood culture.
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Affiliation(s)
- Natália Kehl Moreira
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Bacteriologia Clínica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Camila Mörschbächer Wilhelm
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gabriela da Silva Collar
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Bacteriologia Clínica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Aymê Duarte Echevarria
- Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Júlia Becker
- Laboratório de Pesquisa em Bacteriologia Clínica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Afonso Luís Barth
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Resistência Bacteriana, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Juliana Caierão
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Laboratório de Pesquisa em Bacteriologia Clínica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Tait JR, Anderson D, Nation RL, Creek DJ, Landersdorfer CB. Identifying and mathematically modeling the time-course of extracellular metabolic markers associated with resistance to ceftolozane/tazobactam in Pseudomonas aeruginosa. Antimicrob Agents Chemother 2024; 68:e0108123. [PMID: 38376189 PMCID: PMC10989016 DOI: 10.1128/aac.01081-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024] Open
Abstract
Extracellular bacterial metabolites have potential as markers of bacterial growth and resistance emergence but have not been evaluated in dynamic in vitro studies. We investigated the dynamic metabolomic footprint of a multidrug-resistant hypermutable Pseudomonas aeruginosa isolate exposed to ceftolozane/tazobactam as continuous infusion (4.5 g/day, 9 g/day) in a hollow-fiber infection model over 7-9 days in biological replicates (n = 5). Bacterial samples were collected at 0, 7, 23, 47, 71, 95, 143, 167, 191, and 215 h, the supernatant quenched, and extracellular metabolites extracted. Metabolites were analyzed via untargeted metabolomics, including hierarchical clustering and correlation with quantified total and resistant bacterial populations. The time-courses of five (of 1,921 detected) metabolites from enriched pathways were mathematically modeled. Absorbed L-arginine and secreted L-ornithine were highly correlated with the total bacterial population (r -0.79 and 0.82, respectively, P<0.0001). Ribose-5-phosphate, sedoheptulose-7-phosphate, and trehalose-6-phosphate correlated with the resistant subpopulation (0.64, 0.64, and 0.67, respectively, P<0.0001) and were likely secreted due to resistant growth overcoming oxidative and osmotic stress induced by ceftolozane/tazobactam. Using pharmacokinetic/pharmacodynamic-based transduction models, these metabolites were successfully modeled based on the total or resistant bacterial populations. The models well described the abundance of each metabolite across the differing time-course profiles of biological replicates, based on bacterial killing and, importantly, resistant regrowth. These proof-of-concept studies suggest that further exploration is warranted to determine the generalizability of these findings. The metabolites modeled here are not exclusive to bacteria. Future studies may use this approach to identify bacteria-specific metabolites correlating with resistance, which would ultimately be extremely useful for clinical translation.
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Affiliation(s)
- Jessica R. Tait
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Dovile Anderson
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Darren J. Creek
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Sree RA, Gupta A, Gupta N, Veturi S, Reddy LSK, Begum M, Shravani E, Challa HR, Reddy SS, Singamsetty A, Arumilli M, Reddy PN, Tirlangi PK. Ceftazidime-avibactam alone or in combination with Aztreonam versus Polymyxins in the management of carbapenem-Resistant Klebsiella pneumoniae nosocomial Infections (CAPRI study): a retrospective cohort study from South India. Infection 2024; 52:429-437. [PMID: 37697224 PMCID: PMC10954914 DOI: 10.1007/s15010-023-02094-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections commonly cause hospital-acquired infections. The study aimed to compare the outcomes of CRKP infections between patients receiving ceftazidime avibactam +/- aztreonam and polymyxins in a hospital setting with a high prevalence of New Delhi Metallo Beta Lactamase production. METHODS We conducted a retrospective cohort study from January 2020 to September 2022 in critically ill adult patients admitted to a non-COVID-19 medical intensive care unit with CRKP infection. The patients were followed up for a total of 30 days or death, whichever was later. RESULTS Of a total of 106 patients included in the study, 65 patients received polymyxins and 41 patients received ceftazidime-avibactam +/- aztreonam. Higher 30-day mortality was noted in the polymyxin group (56.9% vs. 29.2%, P = 0.005). The mean time to event (mortality) in ceftazidime-avibactam +/- aztreonam was 23.9 + 1.5 days which was significantly higher compared to polymyxins (17.9 + 1.2 days, p = 0.006). On Cox regression analysis, after adjusting for the covariates, the hazard ratio for time to event with the use of polymyxin was 2.02 (95% CI: 1.03-3.9). CONCLUSION Ceftazidime-avibactam + aztreonam is possibly associated with better clinical outcomes in patients infected with CRKP.
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Affiliation(s)
| | - Anand Gupta
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, Telangana, India
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Sadhana Veturi
- Department of Microbiology, AIG Hospitals, Hyderabad, Telangana, India
| | - L Siva Kumar Reddy
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, Telangana, India
| | - Masrath Begum
- RBVRR Women's College of Pharmacy, Hyderabad, Telangana, India
| | - Etrouth Shravani
- Department of Clinical Pharmacy, AIG Hospitals, Hyderabad, Telangana, India
| | | | | | - Adarsh Singamsetty
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, Telangana, India
| | - Murthy Arumilli
- Critical Care Medicine, AIG Hospitals, Hyderabad, Telangana, India
| | - P Naveen Reddy
- Department of Medicine, AIG Hospitals, Hyderabad, Telangana, India
| | - Praveen Kumar Tirlangi
- Department of Infectious Diseases, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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Piazza A, Mattioni Marchetti V, Bielli A, Biffignandi GB, Piscopiello F, Giudici R, Tartaglione L, Merli M, Vismara C, Migliavacca R. A novel KPC-166 in ceftazidime/avibactam resistant ST307 Klebsiella pneumoniae causing an outbreak in intensive care COVID Unit, Italy. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00067-7. [PMID: 38584042 DOI: 10.1016/j.jmii.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/31/2024] [Accepted: 03/24/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Aim of the study was the molecular characterization of 21 ceftazidime/avibactam resistant (CZA-R) Klebsiella pneumoniae strains, collected in the period October 2021-March 2022 from an Intensive Care COVID Unit in a Northern Italian Hospital. METHODS After growth on selective/chromogenic culture media and susceptibility tests assessment, resistance genes content was ascertained for all the isolates by the HybriSpot 12 multiplexing, PCR and Whole-Genome Sequencing (WGS). Clonality was assessed by PFGE and MLST according to the Pasteur scheme. A SNPs-based phylogenetic tree was obtained comparing representative isolates and global genomes. The blaKPC gene horizontal transmission was evaluated by conjugation experiments. blaKPC-166 was cloned in a pCR2.1 vector and transformed in chemically competent TOP10 cells. RESULTS Sixteen inpatients resulted positive for colonization and/or infection by KPC-producing K. pneumoniae (KPC-Kp) strains. The 21 CZA-R KPC-Kp isolates obtained showed MDR phenotype; susceptibility to meropenem was always retained. All the CZA-R KPC-Kp presented a novel blaKPC variant, named blaKPC-166, showing a single nucleotide substitution (T811C) compared to the blaKPC-94; but related to blaKPC-2. TWO DIFFERENT PULSOTYPES WERE DETECTED A in 18/21 and B in 1/21 cases, two strains from the same patient being untypable by PFGE. Interestingly, the outbreak was sustained by the high-risk clone ST307, although the ST22, ST6342, ST6418 and ST6811 have also been identified and associated to KPC-166. Worryingly, blaKPC-166 could be transferred horizontally and, after cloning, it conferred resistance to CZA. DISCUSSION This novel variant confers CZA-resistance and carbapenems susceptibility restoration. As KPC-166 was found expressed by multiple Kp clones, greater efforts should be made to prevent the further dissemination of such strains in Italian clinical settings.
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Affiliation(s)
- Aurora Piazza
- Unit of Microbiology and Clinical Microbiology, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
| | - Vittoria Mattioni Marchetti
- Unit of Microbiology and Clinical Microbiology, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
| | - Alessandra Bielli
- Chemical-clinical and Microbiological Analysis, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | | | - Francesca Piscopiello
- Unit of Microbiology and Clinical Microbiology, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Livia Tartaglione
- Chemical-clinical and Microbiological Analysis, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Marco Merli
- Infectious Diseases Clinic, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Chiara Vismara
- Chemical-clinical and Microbiological Analysis, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Roberta Migliavacca
- Unit of Microbiology and Clinical Microbiology, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.
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Teo TH, Ayuni NN, Yin M, Liew JH, Chen JQ, Kurepina N, Rajarethinam R, Kreiswirth BN, Chen L, Bifani P. Differential mucosal tropism and dissemination of classical and hypervirulent Klebsiella pneumoniae infection. iScience 2024; 27:108875. [PMID: 38313058 PMCID: PMC10835444 DOI: 10.1016/j.isci.2024.108875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/28/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024] Open
Abstract
Klebsiella pneumoniae (Kp) infection is an important healthcare concern. The ST258 classical (c)Kp strain is dominant in hospital-acquired infections in North America and Europe, while ST23 hypervirulent (hv)Kp prevails in community-acquired infections in Asia. This study aimed to develop symptomatic mucosal infection models in mice that mirror natural infections in humans to gain a deeper understanding of Kp mucosal pathogenesis. We showed that cKp replicates in the nasal cavity instead of the lungs, and this early infection event is crucial for the establishment of chronic colonization in the cecum and colon. In contrast, hvKp replicates directly in the lungs to lethal bacterial load, and early infection of esophagus supported downstream transient colonization in the ileum and cecum. Here, we have developed an in vivo model that illuminates how differences in Kp tropism are responsible for virulence and disease phenotype in cKp and hvKp, providing the basis for further mechanistic study.
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Affiliation(s)
- Teck-Hui Teo
- Agency for Science, Technology and Research (A∗STAR), Infectious Diseases (ID) Labs, Singapore 429621, Singapore
| | - Nurul N. Ayuni
- Infectious Diseases Translational Research Programme, Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117545, Singapore
| | - Michelle Yin
- Agency for Science, Technology and Research (A∗STAR), Infectious Diseases (ID) Labs, Singapore 429621, Singapore
| | - Jun Hao Liew
- Agency for Science, Technology and Research (A∗STAR), Infectious Diseases (ID) Labs, Singapore 429621, Singapore
- Infectious Diseases Translational Research Programme, Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117545, Singapore
| | - Jason Q. Chen
- Agency for Science, Technology and Research (A∗STAR), Infectious Diseases (ID) Labs, Singapore 429621, Singapore
| | - Natalia Kurepina
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, NJ 07110, USA
| | - Ravisankar Rajarethinam
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A∗STAR), Singapore 138673, Singapore
| | - Barry N. Kreiswirth
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, NJ 07110, USA
| | - Liang Chen
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, NJ 07110, USA
| | - Pablo Bifani
- Agency for Science, Technology and Research (A∗STAR), Infectious Diseases (ID) Labs, Singapore 429621, Singapore
- Infectious Diseases Translational Research Programme, Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117545, Singapore
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E7HT, UK
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10
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Gupta N, Saseedharan S, Paliwal Y. Effectiveness of Ceftazidime-Avibactam in Gram-Negative Nosocomial Pneumonia: A Real-World Study in India. Cureus 2024; 16:e54443. [PMID: 38510907 PMCID: PMC10951683 DOI: 10.7759/cureus.54443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVE The incidences of nosocomial pneumonia in intensive care units (ICUs) in India have been reported to range from 9% to 58% and are associated with a mortality rate of 30-70%. Ceftazidime-avibactam has activity against OXA-48-like carbapenem-resistant Enterobacterales (CRE) and has a safer adverse effect profile as compared to the nephrotoxic colistin. The current study aimed to assess the effectiveness and usage pattern of ceftazidime-avibactam in gram-negative hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in real-world settings in India. METHODS Electronic medical records of hospitalized patients in three prominent medical centers in India (Fortis Memorial Research Centre, Gurugram, S L Raheja Hospital, Mumbai, and Fortis Hospital, Anandapur, Kolkata) with nosocomial pneumonia and documented gram-negative Klebsiella pneumoniae (KP)-confirmed infection were collected. This study assessed the effectiveness, usage pattern of ceftazidime-avibactam, and clinical and microbiological cure rates. RESULTS Among the 116 patients included, 78.45% (91/116) showed clinical cure. Microbiological cure was observed in nine out of 13 (69.23%) patients. In the subset analysis, a clinical cure rate of 84.85% (28/33) and microbiological recovery rate of 62.50% (5/8) were observed when ceftazidime-avibactam was initiated within 72 hours of diagnosis. Ceftazidime-avibactam was administered for a mean (±SD) duration of 7.79 ± 4.43 days, with improvement in signs and symptoms reported among 91.38% (106/116). Ceftazidime-avibactam showed a susceptibility of 56% (28/56) in the study. CONCLUSION The current study showed a better clinical and microbiological cure rate with a safer tolerability profile of ceftazidime-avibactam in carbapenem-resistant KP nosocomial pneumonia and VAP. This study has further demonstrated that ceftazidime-avibactam may be used as one of the viable treatment choices in carbapenem-resistant KP with favorable clinical outcomes.
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Affiliation(s)
- Neha Gupta
- Internal Medicine and Infectious Diseases, Fortis Memorial Research Institute, Gurugram, IND
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11
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Chen J, Hu Q, Zhou P, Deng S. Ceftazidime-avibactam versus polymyxins in treating patients with carbapenem-resistant Enterobacteriaceae infections: a systematic review and meta-analysis. Infection 2024; 52:19-28. [PMID: 37878197 PMCID: PMC10810944 DOI: 10.1007/s15010-023-02108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE Carbapenem-resistant Enterobacteriaceae (CRE) pose a significant threat to human health and have emerged as a major public health concern. We aimed to compare the efficacy and the safety of ceftazidime-avibactam (CAZ-AVI) and polymyxin in the treatment of CRE infections. METHODS A systematic review and meta-analysis was performed by searching the databases of EMBASE, PubMed, and the Cochrane Library. Published studies on the use of CAZ-AVI and polymyxin in the treatment of CRE infections were collected from the inception of the database until March 2023. Two investigators independently screened the literature according to the inclusion and exclusion criteria, evaluated the methodological quality of the included studies and extracted the data. The meta-analysis was performed using RevMan 5.4 software. RESULTS Ten articles with 833 patients were included (CAZ-AVI 325 patients vs Polymyxin 508 patients). Compared with the patients who received polymyxin-based therapy, the patients who received CAZ-AVI therapy had significantly lower 30-days mortality (RR = 0.49; 95% CI 0.01-2.34; I2 = 22%; P < 0.00001), higher clinical cure rate (RR = 2.70; 95% CI 1.67-4.38; I2 = 40%; P < 0.00001), and higher microbial clearance rate (RR = 2.70; 95% CI 2.09-3.49; I2 = 0%; P < 0.00001). However, there was no statistically difference in the incidence of acute kidney injury between patients who received CAZ-AVI and polymyxin therapy (RR = 1.38; 95% CI 0.69-2.77; I2 = 22%; P = 0.36). In addition, among patients with CRE bloodstream infection, those who received CAZ-AVI therapy had significantly lower mortality than those who received polymyxin therapy (RR = 0.44; 95% CI 0.27-0.69, I2 = 26%, P < 0.00004). CONCLUSIONS Compared to polymyxin, CAZ-AVI demonstrated superior clinical efficacy in the treatment of CRE infections, suggesting that CAZ-AVI may be a superior option for CRE infections.
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Affiliation(s)
- Jinglan Chen
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530000, Guangxi Zhuang Autonomous Region, People's Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Qin Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China
- Hospital Institute Administration, Central South University, Changsha, 410008, Hunan, People's Republic of China
| | - Pengxiang Zhou
- Department of Pharmacy, Peking University Third Hospital, Beijing, 100191, People's Republic of China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, 100191, People's Republic of China
| | - Sheng Deng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, People's Republic of China.
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12
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Shi Y, Wu J, Mi W, Zhang X, Ren X, Shen C, Lu C. Ceftazidime-avibactam induced renal disorders: past and present. Front Pharmacol 2024; 15:1329307. [PMID: 38318141 PMCID: PMC10838962 DOI: 10.3389/fphar.2024.1329307] [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: 10/30/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
With the increasing prevalence of multidrug-resistant Gram-negative bacterial pathogens worldwide, antimicrobial resistance has become a significant public health concern. Ceftazidime-avibactam (CAZ-AVI) exhibited excellent in vitro activity against many carbapenemase-producing pathogens, and was widely used for the treatment of various complicated infections. CAZ-AVI is well tolerated across all dosing regimens, and its associated acute kidney injury (AKI) in phase II/III clinical trials is rare. However, recent real-world studies have demonstrated that CAZ-AVI associated AKI was more frequent in real-world than in phase II and III clinical trials, particularly in patients receiving concomitant nephrotoxic agents, with critically ill patients being at a higher risk. Herein, we reviewed the safety data related to renal impairment of CAZ-AVI, and discussed its pharmacokinetic/pharmacodynamic targets and dosage adjustment in patients with impaired renal function. This review aimed to emphasize the importance for healthcare professionals to be aware of this adverse event of CAZ-AVI and provide practical insights into the dosage optimization in critically ill patients with renal dysfunction.
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Affiliation(s)
- Yanrong Shi
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jichao Wu
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Wei Mi
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xusheng Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiuli Ren
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chengwu Shen
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Cuicui Lu
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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13
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Witt LS, Sexton ME, Smith G, Farley M, Jacob JT. Evaluating indwelling devices and other risk factors for mortality in invasive Carbapenem-resistant Enterobacterales infections in Georgia, 2012-2019. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 3:e254. [PMID: 38178877 PMCID: PMC10762638 DOI: 10.1017/ash.2023.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024]
Abstract
Objective Carbapenem-resistant Enterobacterales (CRE) infections are a public health threat due to the risk of transmission between patients and high associated mortality. We sought to identify risk factors for mortality in patients with invasive CRE infections and to specifically evaluate whether there was an association between indwelling medical devices and 90-day mortality. Design Retrospective observational cohort study of patients infected with CRE in the eight-county metropolitan Atlanta area between 2012 and 2019. Methods Patients with invasive CRE infections were identified via the Georgia Emerging Infections Program's active, population- and laboratory-based surveillance system and linked with the Georgia Vital Statistics database. We used bivariate analysis to identify risk factors for mortality and completed log binomial multivariable regression to estimate risk ratios (RR) for the association between indwelling devices and mortality. Results In total, 154 invasive CRE infections were identified, with indwelling devices present in most patients (87.7%) around the time of infection. Admission to an intensive care unit was found to be associated with 90-day mortality (adjusted RR [aRR] 1.55, 95% CI 1.07, 2.24); however, the presence of any indwelling device was not associated with increased risk of 90-day mortality in multivariable analysis (aRR 1.22, 95% CI 0.55, 2.73). Having at least two indwelling devices was associated with increased mortality (aRR 1.79, 95% CI 1.05, 3.05). Conclusions Indwelling devices were prevalent in our cohort but were not consistently associated with an increased risk of mortality. Further studies are needed to examine this relationship and the role of device removal.
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Affiliation(s)
- Lucy S. Witt
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Gillian Smith
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Monica Farley
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Jesse T. Jacob
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
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14
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Boattini M, Bianco G, Bastos P, Comini S, Corcione S, Almeida A, Costa C, De Rosa FG, Cavallo R. Prevalence and mortality of ceftazidime/avibactam-resistant KPC-producing Klebsiella pneumoniae bloodstream infections (2018-2022). Eur J Clin Microbiol Infect Dis 2024; 43:155-166. [PMID: 37985552 PMCID: PMC10774640 DOI: 10.1007/s10096-023-04712-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/10/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Ceftazidime/avibactam-resistance in Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) is a topic of great interest for epidemiological, diagnostic, and therapeutical reasons. However, data on its prevalence and burden on mortality in patients with bloodstream infection (BSI) are lacking. This study was aimed at identifying risk factors for mortality in patients suffering from ceftazidime/avibactam-resistant KPC-Kp BSI. METHODS An observational retrospective study (January 2018-December 2022) was conducted at a tertiary hospital including all consecutive hospitalized adult patients with a ceftazidime/avibactam-resistant KPC-Kp BSI. Data on baseline clinical features, management, and admission outcomes were analyzed. RESULTS Over the study period, among all the KPC-Kp BSI events recorded, 38 (10.5%) were caused by ceftazidime/avibactam-resistant KPC-Kp strains, 37 events being finally included. The ceftazidime/avibactam-resistant KPC-Kp strains revealed susceptibility restoration to at least one carbapenem in more than 60% of cases. In-hospital and 30-day all-cause mortality rates were 22% and 16.2%, respectively. Non-survivors suffered from more baseline comorbidities and experienced a more severe ceftazidime/avibactam-resistant KPC-Kp BSI presentation (i.e., both the Pitt Bacteremia and INCREMENT-CPE scores were significantly higher). Presenting with a higher Charlson Comorbidity Index, chronic kidney disease-KDIGO stage 3A or worse-having recently gone through renal replacement therapy, having suffered from an acute kidney injury following the ceftazidime/avibactam-resistant KPC-Kp BSI, and being admitted for cardiac surgery were the strongest predictors of mortality. CONCLUSION Ceftazidime/avibactam resistance in KPC-Kp BSI easily emerged in our highly KPC-Kp endemic area with remarkable mortality rates. Our findings might provide physicians possibly actionable information when managing patients with a ceftazidime/avibactam-resistant KPC-Kp BSI.
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Affiliation(s)
- Matteo Boattini
- Microbiology and Virology Unit, University Hospital Città Della Salute E Della Scienza Di Torino, Corso Bramante 88/90, 10126, Turin, Italy.
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy.
- Lisbon Academic Medical Centre, Lisbon, Portugal.
| | - Gabriele Bianco
- Microbiology and Virology Unit, University Hospital Città Della Salute E Della Scienza Di Torino, Corso Bramante 88/90, 10126, Turin, Italy
| | - Paulo Bastos
- CEDOC, Chronic Diseases Research Centre, NOVA Medical School, Lisbon, Portugal
| | - Sara Comini
- Microbiology and Virology Unit, University Hospital Città Della Salute E Della Scienza Di Torino, Corso Bramante 88/90, 10126, Turin, Italy
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126, Turin, Italy
| | - André Almeida
- Department of Internal Medicine 4, Hospital de Santa Marta, Central Lisbon Hospital Centre, Lisbon, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Campo Dos Mártires da Pátria 130, 1169-056, Lisbon, Portugal
| | - Cristina Costa
- Microbiology and Virology Unit, University Hospital Città Della Salute E Della Scienza Di Torino, Corso Bramante 88/90, 10126, Turin, Italy
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126, Turin, Italy
- Unit of Infectious Diseases, Cardinal Massaia, 14100, Asti, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University Hospital Città Della Salute E Della Scienza Di Torino, Corso Bramante 88/90, 10126, Turin, Italy
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
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15
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Russo C, Humphries R. Approaches to Testing Novel β-Lactam and β-Lactam Combination Agents in the Clinical Laboratory. Antibiotics (Basel) 2023; 12:1700. [PMID: 38136734 PMCID: PMC10740869 DOI: 10.3390/antibiotics12121700] [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: 10/31/2023] [Revised: 11/25/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
The rapid emergence of multi-drug resistant Gram-negative pathogens has driven the introduction of novel β-lactam combination agents (BLCs) to the antibiotic market: ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol, and sulbactam-durlobactam. These agents are equipped with innovative mechanisms that confer broad Gram-negative activity, notably against certain challenging carbapenemases. While their introduction offers a beacon of hope, clinical microbiology laboratories must navigate the complexities of susceptibility testing for these agents due to their diverse activity profiles against specific β-lactamases and the possibility of acquired resistance mechanisms in some bacterial isolates. This review explores the complexities of these novel antimicrobial agents detailing the intricacies of their application, providing guidance on the nuances of susceptibility testing, interpretation, and result reporting in clinical microbiology laboratories.
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Affiliation(s)
| | - Romney Humphries
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
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16
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Gill CM, Rajkotia P, Roberts AL, Tenover FC, Nicolau DP. Directed carbapenemase testing is no longer just for Enterobacterales: cost, labor, and workflow assessment of expanding carbapenemase testing to carbapenem-resistant P. aeruginosa. Emerg Microbes Infect 2023; 12:2179344. [PMID: 36786132 PMCID: PMC9980414 DOI: 10.1080/22221751.2023.2179344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Molecular carbapenem-resistance testing, such as for the presence of carbapenemases genes, is commonly implemented for the detection of carbapenemase-producing Enterobacterales. Carbapenemase-producing P. aeruginosa is also associated with significant morbidity and mortality, although; prevalence may be underappreciated in the United States due to a lack of carbapenemase testing. The present study sought to compare hands-on time, cost and workflow implementation of carbapenemase gene testing in Enterobacterales and P. aeruginosa isolates versus sending out isolates to a public health laboratory (PHL) for testing to assess if in-house can provide actionable results. The time to carbapenemase gene results were compared. Differences in cost for infection prevention measures were extrapolated from the time of positive carbapenemase gene detection in-house versus PHL. The median time to perform carbapenemase gene testing was 7.5 min (range 5-14) versus 10 min (range 8-22) for preparation to send isolates to the PHL. In-house testing produced same day results compared with a median of 6 days (range 3-14) to receive results from PHL. Cost of in-house testing and send outs were similar ($46.92 versus $40.53, respectively). If contact precautions for patients are implemented until carbapenemase genes are ruled out, in-house testing can save an estimated $76,836.60 annually. Extension of in-house carbapenemase testing to include P. aeruginosa provides actionable results 3-14 days earlier than PHL Standard Pathway testing, facilitating guided therapeutic decisions and infection prevention measures. Supplemental phenotypic algorithms can be implemented to curb the cost of P. aeruginosa carbapenemases testing by identifying isolates most likely to harbour carbapenemases.
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Affiliation(s)
- Christian M. Gill
- Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA, Christian M. Gill Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA
| | - Poonam Rajkotia
- Microbiology Laboratory Services, Hartford Healthcare Ancillary Microbiology Laboratory, Newington, CT, USA
| | - Amity L. Roberts
- Microbiology Laboratory Services, Hartford Healthcare Ancillary Microbiology Laboratory, Newington, CT, USA
| | | | - David P. Nicolau
- Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA,Department of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Xu J, Luo C, Huang L, Xiao X, Liu L, Yang Z. Clinical Efficacy and Safety Evaluation of Ceftazidime-Avibactam in the Treatment of Klebsiella pneumoniae Infection: A Retrospective Analysis from a Hospital in China. Infect Drug Resist 2023; 16:7227-7237. [PMID: 38023408 PMCID: PMC10656859 DOI: 10.2147/idr.s435882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Ceftazidime-avibactam (CAZ-AVI) is a new cephalosporin/β-lactamase inhibitor combination that received clinical approval in China in 2019. This study aims to investigate the efficacy and safety of CAZ-AVI in the treatment of Klebsiella pneumoniae (KP) infection in a hospital, and differences in efficacy among various infection sites and between monotherapy and combination therapy, providing valuable insights for its further application. Methods Patients who used CAZ-AVI between January 2019 and April 2023 were identified through the hospital information system. Demographic information, details of the infection site, KP strain's drug sensitivity report, treatment duration, combination therapies, adverse drug reactions (ADR), and 28-day survival were recorded. Clinical and microbiological efficacies were analyzed using SPSS 23.0 software to compare different infection sites and combination therapies. Results The overall effective clinical response (CR) rate of CAZ-AVI against KP infection was 62.13%, with a favorable microbial response (MR) rate was 65.68% and a 28-day survival rate was 63.91%. No significant difference occurred in effective CR and 28-day survival rate among different infection sites (P = 0.709 and 0.862, respectively). The favorable MR rate for abdominal infections was slightly lower than that for other sites of infection (P = 0.021). No significant differences in effective CR, favorable MR, and 28-day survival between monotherapy and combination therapy were present (P values were 0.649, 0.123, and 0.280, respectively). The incidence of ADR was 1.78%, including increased creatinine, elevated transaminase, hematuria, and thrombocytopenia. Conclusion CAZ-AVI demonstrates good clinical efficacy and safety in the treatment of KP infections. The clinical efficacy of CAZ-AVI was similar across different infection sites, and combination therapy did not show an advantage over monotherapy. Further studies are warranted. It should be noted that CAZ-AVI may induce thrombocytopenia and hematuria.
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Affiliation(s)
- Jia Xu
- Department of Clinical Pharmacy, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
| | - Chengjia Luo
- Department of Clinical Pharmacy, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
| | - Liang Huang
- Department of Rehabilitation, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
| | - Xi Xiao
- Department of Clinical Laboratory, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
| | - Ling Liu
- Department of Clinical Pharmacy, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
| | - Zhiling Yang
- Department of Clinical Pharmacy, Hunan Provincial People’s Hospital (The First-Affiliated Hospital of Hunan Normal University), Changsha, 410016, People’s Republic of China
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Gottesdiener LS, Satlin MJ. Global impact of antibacterial resistance in patients with hematologic malignancies and hematopoietic cell transplant recipients. Transpl Infect Dis 2023; 25 Suppl 1:e14169. [PMID: 37864309 PMCID: PMC10844985 DOI: 10.1111/tid.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/20/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023]
Abstract
Patients with hematologic malignancies and hematopoietic cell transplant (HCT) recipients are at high risk of developing bacterial infections. These patients may suffer severe consequences from these infections if they do not receive immediate effective therapies, and thus are uniquely threatened by antimicrobial-resistant bacteria. Here, we outline how the emergence of specific resistant bacteria threatens the effectiveness of established approaches to prevent and treat infections in this population. The emergence of fluoroquinolone resistance among Enterobacterales and viridans group streptococci may decrease the effectiveness of fluoroquinolone prophylaxis during neutropenia. The emergence of Enterobacterales that produce extended-spectrum β-lactamases or carbapenemases and of increasingly resistant Pseudomonas aeruginosa may result in neutropenic patients experiencing delayed time to active antibacterial therapy, and consequently worse clinical outcomes. The ability to select targeted antibacterial therapies after the availability of susceptibility data may be limited in patients infected with metallo-β-lactamase-producing Enterobacterales and difficult-to-treat P. aeruginosa. Vancomycin-resistant enterococci and Stenotrophomonas maltophilia can cause breakthrough infections in patients already being treated with broad-spectrum β-lactam antibiotics. Resistance can also limit the ability to provide oral stepdown antibacterial therapy for patients who could otherwise be discharged from hospitalization. We also outline strategies that have the potential to mitigate the negative impact of antimicrobial resistance, including interventions based on active screening for colonization with resistant bacteria and the use of novel rapid diagnostic assays. Additional research is needed to better understand how these strategies can be leveraged to combat the emerging crisis of antimicrobial resistance in patients with hematologic malignancies and HCT recipients.
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Affiliation(s)
- Lee S. Gottesdiener
- Division of Infectious Diseases, Weill Cornell Medicine,
New York, NY, USA
- NewYork-Presbyterian Hospital, Weill Cornell Medical
Center, New York, NY, USA
| | - Michael J. Satlin
- NewYork-Presbyterian Hospital, Weill Cornell Medical
Center, New York, NY, USA
- Transplantation-Oncology Infectious Diseases Program,
Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA
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19
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Cartagena AJ, Taylor KL, Smith JT, Manson AL, Pierce VM, Earl AM, Bhattacharyya RP. The carbapenem inoculum effect provides insight into the molecular mechanisms underlying carbapenem resistance in Enterobacterales. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.23.541813. [PMID: 37292717 PMCID: PMC10245868 DOI: 10.1101/2023.05.23.541813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Carbapenem-resistant Enterobacterales (CRE) are important pathogens that can develop resistance via multiple molecular mechanisms, including hydrolysis or reduced antibiotic influx. Identifying these mechanisms can improve pathogen surveillance, infection control, and patient care. We investigated how resistance mechanisms influence the carbapenem inoculum effect (IE), a phenomenon where inoculum size affects antimicrobial susceptibility testing (AST). We demonstrated that seven different carbapenemases impart a meropenem IE in Escherichia coli. Across 110 clinical CRE isolates, the carbapenem IE strictly depended on resistance mechanism: all carbapenemase-producing CRE (CP-CRE) exhibited a strong IE, whereas porin-deficient CRE displayed none. Concerningly, 50% and 24% of CP-CRE isolates changed susceptibility classification to meropenem and ertapenem, respectively, across the allowable inoculum range in clinical guidelines. The meropenem IE, and the ratio of ertapenem to meropenem minimal inhibitory concentration (MIC) at standard inoculum, reliably identified CP-CRE. Understanding how resistance mechanisms affect AST could improve diagnosis and guide therapies for CRE infections.
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Affiliation(s)
| | - Kyra L. Taylor
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Joshua T. Smith
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Abigail L. Manson
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Virginia M. Pierce
- Microbiology Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Pathology and Clinical Laboratories, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ashlee M. Earl
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Roby P. Bhattacharyya
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Önal U, Tüzemen Ü, Kaya PK, İşçimen R, Girgin NK, Özakın C, Kahveci F, Akalın H. OXA-48 Dominance Meets Ceftazidime-Avibactam: A Battle Against Life-Threatening Carbapenem-Resistant Klebsiella pneumoniae Infections in the Intensive Care Unit. Cureus 2023; 15:e46780. [PMID: 37822692 PMCID: PMC10563373 DOI: 10.7759/cureus.46780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 10/13/2023] Open
Abstract
Objective In this study, we aimed to describe the outcomes in ICU patients with bloodstream infection (BSI) or ventilatory-associated pneumonia (VAP) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) who received ceftazidime-avibactam treatment at a tertiary care university hospital. Methods Patients aged 18 years or older who were admitted to the Anesthesiology and Reanimation ICU at Bursa Uludag University Faculty of Medicine Hospital between June 13, 2021, and July 16, 2023, and diagnosed with BSI or VAP due to CRKP were included in this study. Results A total of 42 patients treated with ceftazidime-avibactam were included. Total crude mortality rates were 33.3% on day 14 and 54.8% on day 30. Mortality rates on the 14th and 30th days were 37.5% and 62.5% in patients with BSI and 27.8% and 44.4% in patients with VAP, respectively. There was no statistically significant difference between monotherapy and combination therapy in terms of mortality rates on days 14 and 30, respectively (3/11 vs. 11/31, p=0.620; 5/11 vs. 18/31, p=0.470). Immunosuppression (10/11 vs. 13/31, p=0.005), the Sequential Organ Failure Assessment (SOFA) score ≥8 (at the initiation of treatment; 19/25 vs. 4/17, p<0.001), INCREMENT-CPE score ≥10 (12/16 vs. 3/10, p=0.024) and longer duration (in days) from culture collection to treatment initiation (5.0 ± 0.61 vs. 3.11 ± 0.48, p=0.024) were found to have a statistically significant effect on 30-day mortality. In multivariate analysis, a SOFA score ≥8 at the initiation of treatment (p=0.037, OR: 17.442, 95% CI: 1.187-256.280) was found to be a significant risk factor affecting mortality (30-day). Conclusion The mortality rates of patients with CRKP infection who were followed up in the ICU were found to be high, and it was observed that whether ceftazidime-avibactam treatment was given as a combination or monotherapy did not affect mortality. Further multicentre studies with a larger number of patients are needed to gain a comprehensive understanding of the topic, given that this treatment is typically reserved for documented infections.
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Affiliation(s)
- Uğur Önal
- Infectious Diseases, Uludag University Faculty of Medicine, Bursa, TUR
| | - Ülkü Tüzemen
- Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
| | - Pınar K Kaya
- Anesthesiology and Critical Care, Uludag University, Bursa, TUR
| | - Remzi İşçimen
- Intensive Care Unit, Uludag University Faculty of Medicine, Bursa, TUR
- Anesthesiology and Critical Care, Uludag University Faculty of Medicine, Bursa, TUR
- Anesthesiology and Reanimation, Uludag University Faculty of Medicine, Bursa, TUR
| | - Nermin K Girgin
- Anesthesiology and Reanimation, Uludag University, Bursa, TUR
| | - Cüneyt Özakın
- Medical Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
| | - Ferda Kahveci
- Anesthesiology and Reanimation, Uludag University, Bursa, TUR
| | - Halis Akalın
- Infectious Diseases and Clinical Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
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Ye J, Jin L, Li Y, Xu H, Lin Y, Zhou T, Zheng B, Wang M, Wang Z. Complete-genome sequencing and comparative genomic characterization of bla NDM-5 carrying Citrobacter freundii isolates from a patient with multiple infections. BMC Genomics 2023; 24:506. [PMID: 37649002 PMCID: PMC10466682 DOI: 10.1186/s12864-023-09579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND The emergence and wide spread of carbapenemase-producing Enterobacteriaceae (CPE) poses a growing threat to global public health. However, clinically derived carbapenemase-producing Citrobacter causing multiple infections has rarely been investigated. Here we first report the isolation and comparative genomics of two blaNDM-5 carrying Citrobacter freundii (C. freundii) isolates from a patient with bloodstream and urinary tract infections. RESULTS Antimicrobial susceptibility testing showed that both blaNDM-5 carrying C. freundii isolates were multidrug-resistant. Positive modified carbapenem inactivation method (mCIM) and EDTA-carbapenem inactivation method (eCIM) results suggested metallo-carbapenemase production. PCR and sequencing confirmed that both metallo-carbapenemase producers were blaNDM-5 positive. Genotyping and comparative genomics analyses revealed that both isolates exhibited a high level of genetic similarity. Plasmid analysis confirmed that the blaNDM-5 resistance gene is located on IncX3 plasmid with a length of 46,161 bp, and could successfully be transferred to the recipient Escherichia coli EC600 strain. A conserved structure sequence (ISAba125-IS5-blaNDM-5-trpF-IS26-umuD-ISKox3) was found in the upstream and downstream of the blaNDM-5 gene. CONCLUSIONS The data presented in this study showed that the conjugative blaNDM-5 plasmid possesses a certain ability to horizontal transfer. The dissemination of NDM-5-producing C. freundii isolates should be of close concern in future clinical surveillance. To our knowledge, this is the first study to characterize C. freundii strains carrying the blaNDM-5 gene from one single patient with multiple infections.
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Affiliation(s)
- Jianzhong Ye
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang Street, Ouhai District, Wenzhou, 325000, Zhejiang Province, China
| | - Lulu Jin
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Dongyang, 322100, Zhejiang Province, China
| | - Yaling Li
- Department of Health Screening Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, China
| | - Hao Xu
- Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
- State Key Laboratory for Diagnosis and Treatment of Infectious DiseasesCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesSchool of Medicine, National Clinical Research Center for Infectious Diseasesthe First Affiliated HospitalZhejiang University, No. 79 Qingchun Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China
| | - Yishuai Lin
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang Street, Ouhai District, Wenzhou, 325000, Zhejiang Province, China
| | - Tieli Zhou
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang Street, Ouhai District, Wenzhou, 325000, Zhejiang Province, China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious DiseasesCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesSchool of Medicine, National Clinical Research Center for Infectious Diseasesthe First Affiliated HospitalZhejiang University, No. 79 Qingchun Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China.
| | - Maofeng Wang
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, No. 60 Wuning West Road, Dongyang, 322100, Zhejiang Province, China.
| | - Zhongyong Wang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang Street, Ouhai District, Wenzhou, 325000, Zhejiang Province, China.
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Bălan AM, Bodolea C, Nemes A, Crăciun R, Hagău N. Rapid Point-of-Care PCR Testing of Drug-Resistant Strains on Endotracheal Aspirate Samples: A Repurposed Effective Tool in the Stepwise Approach of Healthcare-Acquired Pneumonia-A Pilot Study. Int J Mol Sci 2023; 24:13393. [PMID: 37686203 PMCID: PMC10487584 DOI: 10.3390/ijms241713393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
Healthcare-associated pneumonia (HCAP) is a common nosocomial infection with high morbidity and mortality. Culture-based detection of the etiologic agent and drug susceptibility is time-consuming, potentially leading to the inadequate use of broad-spectrum empirical antibiotic regimens. The aim was to evaluate the diagnostic capabilities of rapid point-of-care multiplex polymerase chain reaction (PCR) assays from the endotracheal aspirate of critically ill patients with HCAP. A consecutive series of 29 intensive care unit (ICU) patients with HCAP and a control group of 28 patients undergoing elective surgical procedures were enrolled in the study. The results of the PCR assays were compared to the culture-based gold standard. The overall accuracy of the PCR assays was 95.12%, with a sensitivity of 92.31% and a specificity of 97.67%. The median time was 90 min for the rapid PCR tests (p < 0.001), while for the first preliminary results of the cultures, it was 48 h (46-72). The overall accuracy for rapid PCR testing in suggesting an adequate antibiotic adjustment was 82.98% (95% CI 69.19-92.35%), with a specificity of 90% (95% CI 55.50-99.75%), a positive predictive value of 96.77% (95% CI 83.30-99.92%), and a negative predictive value of 56.25 (95% CII 29.88-80.25%). This method of rapid point-of-care PCR could effectively guide antimicrobial stewardship in patients with healthcare-acquired pneumonia.
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Affiliation(s)
- Andrei-Mihai Bălan
- Department of Anaesthesia and Intensive Care 2, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania; (A.-M.B.); (C.B.); (N.H.)
- Department of Anaesthesia and Intensive Care, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Constantin Bodolea
- Department of Anaesthesia and Intensive Care 2, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania; (A.-M.B.); (C.B.); (N.H.)
- Department of Anaesthesia and Intensive Care, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Andrada Nemes
- Department of Anaesthesia and Intensive Care 2, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania; (A.-M.B.); (C.B.); (N.H.)
- Department of Anaesthesia and Intensive Care, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Rareș Crăciun
- Department of Internal Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania;
- Gastroenterology Clinic, ”Prof. Dr. O. Fodor” Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Natalia Hagău
- Department of Anaesthesia and Intensive Care 2, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400012 Cluj-Napoca, Romania; (A.-M.B.); (C.B.); (N.H.)
- Department of Anaesthesia and Intensive Care, ”Regina Maria” Hospital, 400221 Cluj-Napoca, Romania
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Lapin JS, Smith RD, Hornback KM, Johnson JK, Claeys KC. From bottle to bedside: Implementation considerations and antimicrobial stewardship considerations for bloodstream infection rapid diagnostic testing. Pharmacotherapy 2023; 43:847-863. [PMID: 37158053 DOI: 10.1002/phar.2813] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023]
Abstract
Antimicrobial stewardship (AMS) programs have been quick to adopt novel molecular rapid diagnostic technologies (mRDTs) for bloodstream infections (BSIs) to improve antimicrobial management. As such, most of the literature demonstrating the clinical and economic benefits of mRDTs for BSI is in the presence of active AMS intervention. Leveraging mRDTs to improve antimicrobial therapy for BSI is increasingly integral to AMS program activities. This narrative review discusses available and future mRDTs, the relationship between the clinical microbiology laboratory and AMS programs, and practical considerations for optimizing the use of these tools within a health system. Antimicrobial stewardship programs must work closely with their clinical microbiology laboratories to ensure that mRDTs are used to their fullest benefit while remaining cognizant of their limitations. As more mRDT instruments and panels become available and AMS programs continue to expand, future efforts must consider the expansion beyond traditional settings of large academic medical centers and how combinations of tools can further improve patient care.
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Affiliation(s)
- Jonathan S Lapin
- Department of Pharmacy Practice, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Richard D Smith
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Krutika M Hornback
- Department of Pharmacy Practice, Medical University of South Carolina (MUSC) Health, Charleston, South Carolina, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Barbier F, Hraiech S, Kernéis S, Veluppillai N, Pajot O, Poissy J, Roux D, Zahar JR. Rationale and evidence for the use of new beta-lactam/beta-lactamase inhibitor combinations and cefiderocol in critically ill patients. Ann Intensive Care 2023; 13:65. [PMID: 37462830 DOI: 10.1186/s13613-023-01153-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Healthcare-associated infections involving Gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) phenotype are associated with impaired patient-centered outcomes and poses daily therapeutic challenges in most of intensive care units worldwide. Over the recent years, four innovative β-lactam/β-lactamase inhibitor (BL/BLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, imipenem-relebactam and meropenem-vaborbactam) and a new siderophore cephalosporin (cefiderocol) have been approved for the treatment of certain DTR-GNB infections. The literature addressing their microbiological spectrum, pharmacokinetics, clinical efficacy and safety was exhaustively audited by our group to support the recent guidelines of the French Intensive Care Society on their utilization in critically ill patients. This narrative review summarizes the available evidence and unanswered questions on these issues. METHODS A systematic search for English-language publications in PUBMED and the Cochrane Library database from inception to November 15, 2022. RESULTS These drugs have demonstrated relevant clinical success rates and a reduced renal risk in most of severe infections for whom polymyxin- and/or aminoglycoside-based regimen were historically used as last-resort strategies-namely, ceftazidime-avibactam for infections due to Klebsiella pneumoniae carbapenemase (KPC)- or OXA-48-like-producing Enterobacterales, meropenem-vaborbactam for KPC-producing Enterobacterales, ceftazidime-avibactam/aztreonam combination or cefiderocol for metallo-β-lactamase (MBL)-producing Enterobacterales, and ceftolozane-tazobactam, ceftazidime-avibactam and imipenem-relebactam for non-MBL-producing DTR Pseudomonas aeruginosa. However, limited clinical evidence exists in critically ill patients. Extended-infusion scheme (except for imipenem-relebactam) may be indicated for DTR-GNB with high minimal inhibitory concentrations and/or in case of augmented renal clearance. The potential benefit of combining these agents with other antimicrobials remains under-investigated, notably for the most severe presentations. Other important knowledge gaps include pharmacokinetic information in particular situations (e.g., pneumonia, other deep-seated infections, and renal replacement therapy), the hazard of treatment-emergent resistance and possible preventive measures, the safety of high-dose regimen, the potential usefulness of rapid molecular diagnostic tools to rationalize their empirical utilization, and optimal treatment durations. Comparative clinical, ecological, and medico-economic data are needed for infections in whom two or more of these agents exhibit in vitro activity against the causative pathogen. CONCLUSIONS New BL/BLI combinations and cefiderocol represent long-awaited options for improving the management of DTR-GNB infections. Several research axes must be explored to better define the positioning and appropriate administration scheme of these drugs in critically ill patients.
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Affiliation(s)
- François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'Hôpital, 45000, Orléans, France.
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France.
| | - Sami Hraiech
- Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, and Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, Université Aix-Marseille, Marseille, France
| | - Solen Kernéis
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Nathanaël Veluppillai
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Olivier Pajot
- Réanimation Polyvalente, Hôpital Victor Dupouy, Argenteuil, France
| | - Julien Poissy
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Lille, Inserm U1285, Université de Lille, and CNRS/UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Damien Roux
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- DMU ESPRIT, Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, Colombes, and INSERM/CNRS, Institut Necker Enfants Malades, Université Paris Cité, Paris, France
| | - Jean-Ralph Zahar
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- Département de Microbiologie Clinique, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny and INSERM/IAME, Université de Paris, Paris, France
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Yang P, Li Y, Wang X, Chen N, Lu X. Efficacy and safety of ceftazidime-avibactam versus polymyxins in the treatment of carbapenem-resistant Enterobacteriaceae infection: a systematic review and meta-analysis. BMJ Open 2023; 13:e070491. [PMID: 37137556 PMCID: PMC10163451 DOI: 10.1136/bmjopen-2022-070491] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVES Carbapenem-resistant Enterobacteriaceae is increasingly recognised as a significant public health concern. Ceftazidime-avibactam (CAZ-AVI) and polymyxins are considered as the last therapeutic options worldwide. This is the first meta-analysis of recently published data to compare the clinical efficacy and safety of CAZ-AVI with polymyxins in the treatment of carbapenem-resistant Enterobacteriaceae infections. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase and the Cochrane Library were systematically searched, for publications in any language, from database inception to February 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies comparing the clinical efficacy and safety of CAZ-AVI with polymyxins were included. Mortality, clinical success, microbiological eradication and nephrotoxicity were assessed as the main outcomes. DATA EXTRACTION AND SYNTHESIS Literature screening, data extraction and the quality evaluation of studies were conducted by two researchers independently, with disagreements resolved by another researcher. The Newcastle-Ottawa Scale was used to assess the bias risk for the included studies. Review Manager V.5.3 was employed for the meta-analysis. RESULTS The meta-analysis included seven retrospective and four prospective cohort studies with 1111 patients enrolled. The CAZ-AVI groups demonstrated a lower 30-day mortality (risk ratio (RR)=0.48, 95% CI of 0.37 to 0.63, I2=10%, p<0.0001) in nine studies with 766 patients; higher clinical success (RR=1.71, 95% CI 1.33 to 2.20, I2=35%, p<0.0001) in four studies with 463 patients; and lower nephrotoxicity in seven studies with 696 patients (RR=0.42, 95% CI 0.23 to 0.77, I2=35%, p<0.05). However, no significant difference in microbiological eradication rates was observed in 249 patients from two studies (RR=1.16, 95% CI 0.97 to 1.39, I2=0, p>0.05). CONCLUSION Available evidence suggested that CAZ-AVI treatment held a dominant position with respect to efficacy and safety compared with polymyxins in carbapenem-resistant Enterobacteriaceae infections. However, the analysis included only observational studies, and high-quality, large-scale, multicentre, double-blind randomised controlled trials are needed to confirm the advantage of CAZ-AVI.
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Affiliation(s)
- Ping Yang
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, People's Republic of China
| | - Yinyan Li
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaojuan Wang
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Na Chen
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoyang Lu
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Routray A, Mane A. Knowledge, Attitude, and Practice (KAP) Survey on the Management of Multidrug-Resistant Gram-Negative Infections With Innovative Antibiotics: Focus on Ceftazidime-Avibactam. Cureus 2023; 15:e39245. [PMID: 37378116 PMCID: PMC10292104 DOI: 10.7759/cureus.39245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major public health dilemma and a chief health concern globally. The rising incidence of resistance against carbapenems, which are considered most effective against gram-negative bacteria, has added to the concern and has limited the number of available treatment options. Newer antibiotic options may be required to tackle the mounting concern of antibiotic resistance. However, only a few antimicrobials are in the pipeline for managing infections instigated by multidrug-resistant (MDR) gram-negative bacteria. This justifies the prudent application of already available antibiotics. Among newer antibiotics available to healthcare professionals (HCPs), ceftazidime-avibactam (CAZ-AVI) has shown good efficacy in the management of MDR gram-negative infections. METHOD A cross-sectional survey on the knowledge, attitude, and practices (KAP) among HCPs was carried out using a questionnaire comprising 21 parameters related to AMR patterns on the need for innovative antibiotics to manage MDR gram-negative infections and the usage of CAZ-AVI by HCPs while managing such infections. The KAP scores were calculated to rank respondents' KAP levels. RESULT Out of the 204 study respondents, the majority (~80%) (n=160) believed that renewed efforts should be made to seek antimicrobial agents that will add to the armamentarium of treatment options for MDR gram-negative infections. CAZ-AVI is an important treatment alternative for managing MDR gram-negative infections (n=90, 45%). Further, it can be the first choice of definitive therapy for oxacillinases (OXA)-48-producing carbapenem-resistant Enterobacterales (n=84, 42%). HCPs also believed that the use of CAZ-AVI in clinical practice will require high levels of antimicrobial stewardship (n=100, 49%). CONCLUSION Novel and innovative antibiotics are the need of the hour in the management of MDR gram-negative infections. CAZ-AVI has established its effectiveness in treating these infections; however, the molecule must be utilized prudently while keeping stewardship principles in mind.
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Boattini M, Bianco G, Charrier L, Comini S, Iannaccone M, Almeida A, Cavallo R, De Rosa FG, Costa C. Rapid diagnostics and ceftazidime/avibactam for KPC-producing Klebsiella pneumoniae bloodstream infections: impact on mortality and role of combination therapy. Eur J Clin Microbiol Infect Dis 2023; 42:431-439. [PMID: 36806056 DOI: 10.1007/s10096-023-04577-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Abstract
This study was aimed at investigating risk factors for mortality in patients suffering from KPC-producing Klebsiella pneumoniae (KPC-Kp) bloodstream infections (BSIs), evaluating the impact of rapid diagnostics and ceftazidime/avibactam use. This observational retrospective study (January 2017-May 2021) included all patients with a KPC-Kp BSI. Uni-multivariable analyses were carried out to evaluate the effect of clinical variables on both in-hospital death (IHD) and 30-day all-cause mortality, and the role of the combination of ceftazidime/avibactam plus polymyxin. One hundred and ninety-six patients met the study's inclusion criteria. Older age, having undergone renal replacement therapy during the 30 days preceding the KPC-Kp BSI onset, having an INCREMENT-CPE score ≥ 8, and having suffered from a superimposed and/or following KPC-Kp BSI treatment candidemia were found to be the main factors associated with both mortality rates. Among protective factors, the centrality of ceftazidime/avibactam in monotherapy (IHD: OR: 0.34; CI 95%: 0.11-1.00-30-day all-cause mortality: OR: 0.18; CI 95%: 0.04-0.77) or combination (IHD: OR: 0.51; CI 95%: 0.22-1.19-30-day all-cause mortality: OR: 0.62; CI 95%: 0.21-1.84) emerged and became even more evident once the effect of ceftazidime/avibactam plus polymyxin was removed. Rapid diagnostics may be useful to adopt more effective strategies for the treatment of KPC-Kp BSI patients and implement infection control measures, even if not associated with higher patient survival. Ceftazidime/avibactam, even when used alone, represents an important option against KPC-Kp, while combined use with polymyxin might not have altered its efficacy. Patient comorbidities, severity of BSI, and complications such as candidemia were confirmed to have a significant burden on survival.
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Affiliation(s)
- Matteo Boattini
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy. .,Department of Public Health and Paediatrics, University of Torino, Turin, Italy.
| | - Gabriele Bianco
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy
| | - Lorena Charrier
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Sara Comini
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Marco Iannaccone
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy
| | - André Almeida
- Department of Internal Medicine 4, Hospital de Santa Marta, Central Lisbon Hospital Centre, Lisbon, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056, Lisbon, Portugal
| | - Rossana Cavallo
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126, Turin, Italy.,Unit of Infectious Diseases, Cardinal Massaia, 14100, Asti, Italy
| | - Cristina Costa
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
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Rebold N, Lagnf AM, Alosaimy S, Holger DJ, Witucki P, Mannino A, Dierker M, Lucas K, Kunz Coyne AJ, El Ghali A, Caniff KE, Veve MP, Rybak MJ. Risk Factors for Carbapenem-Resistant Enterobacterales Clinical Treatment Failure. Microbiol Spectr 2023; 11:e0264722. [PMID: 36622246 PMCID: PMC9927167 DOI: 10.1128/spectrum.02647-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/29/2022] [Indexed: 01/10/2023] Open
Abstract
The Centers for Disease Control and Prevention (CDC) categorized carbapenem-resistant Enterobacterales (CRE) infections as an "urgent" health care threat requiring public attention and research. Certain patients with CRE infections may be at higher risk for poor clinical outcomes than others. Evidence on risk or protective factors for CRE infections are warranted in order to determine the most at-risk populations, especially with newer beta-lactam/beta-lactamase inhibitor (BL/BLI) antibiotics available to treat CRE. We aimed to identify specific variables involved in CRE treatment that are associated with clinical failure (either 30-day mortality, 30-day microbiologic recurrence, or clinical worsening/failure to improve throughout antibiotic treatment). We conducted a retrospective, observational cohort study of hospitalized patients with CRE infection sampled from 2010 to 2020 at two medical systems in Detroit, Michigan. Patients were included if they were ≥18 years old and culture positive for an organism in the Enterobacterales order causing clinical infection with in vitro resistance by Clinical and Laboratory Standards Institute (CLSI) breakpoints to at least one carbapenem. Overall, there were 140 confirmed CRE infections of which 39% had clinical failure. The most common infection sources were respiratory (38%), urinary (20%), intra-abdominal (16%), and primary bacteremia (14%). A multivariable logistic regression model was developed to identify statistically significant associated predictors with clinical failure, and they included Sequential Organ Failure Assessment (SOFA) score (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.06 to 1.32), chronic dialysis (aOR, 5.86; 95% CI, 1.51-22.7), and Klebsiella pneumoniae in index culture (aOR, 3.09; 95% CI, 1.28 to 7.47). Further research on CRE infections is needed to identify best practices to promote treatment success. IMPORTANCE This work compares carbapenem-resistant Enterobacterales (CRE) infections using patient, clinical, and treatment variables to understand which characteristics are associated with the highest risk of clinical failure. Knowing which risk factors are associated with CRE infection failure can provide clinicians better prognostic and targeted interventions. Research can also further investigate why certain risk factors cause more clinical failure and can help develop treatment strategies to mitigate associated risk factors.
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Affiliation(s)
- Nicholas Rebold
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M. Lagnf
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Sara Alosaimy
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Dana J. Holger
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Paige Witucki
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Andrew Mannino
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Michelle Dierker
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kristen Lucas
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Ashlan J. Kunz Coyne
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Amer El Ghali
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kaylee E. Caniff
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Michael P. Veve
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy, Henry Ford Hospital, Henry Ford Health System, Detroit, Michigan, USA
| | - Michael J. Rybak
- College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
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29
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Characteristics of Environmental Klebsiella pneumoniae and Klebsiella oxytoca Bacteriophages and Their Therapeutic Applications. Pharmaceutics 2023; 15:pharmaceutics15020434. [PMID: 36839755 PMCID: PMC9960720 DOI: 10.3390/pharmaceutics15020434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
In recent years, multidrug-resistant (MDR) strains of Klebsiella pneumoniae have spread globally, being responsible for the occurrence and severity of nosocomial infections. The NDM-1-kp, VIM-1 carbapenemase-producing isolates as well as extended-spectrum beta lactamase-producing (ESBL) isolates along with Klebsiella oxytoca strains have become emerging pathogens. Due to the growing problem of antibiotic resistance, bacteriophage therapy may be a potential alternative to combat such multidrug-resistant Klebsiella strains. Here, we present the results of a long-term study on the isolation and biology of bacteriophages active against K. pneumoniae, as well as K. oxytoca strains. We evaluated biological properties, morphology, host specificity, lytic spectrum and sensitivity of these phages to chemical agents along with their life cycle parameters such as adsorption, latent period, and burst size. Phages designated by us, vB_KpnM-52N (Kpn52N) and VB_KpnM-53N (Kpn53N), demonstrated relatively broad lytic spectra among tested Klebsiella strains, high burst size, adsorption rates and stability, which makes them promising candidates for therapeutic purposes. We also examined selected Klebsiella phages from our historical collection. Notably, one phage isolated nearly 60 years ago was successfully used in purulent cerebrospinal meningitis in a new-born and has maintained lytic activity to this day. Genomic sequences of selected phages were determined and analyzed. The phages of the sequenced genomes belong to the Slopekvirus and Jiaodavirus genus, a group of phages related to T4 at the family level. They share several features of T4 making them suitable for antibacterial therapies: the obligatorily lytic lifestyle, a lack of homologs of known virulence or antibiotic resistance genes, and a battery of enzymes degrading host DNA at infection.
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30
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Hu Q, Chen J, Sun S, Deng S. Mortality-Related Risk Factors and Novel Antimicrobial Regimens for Carbapenem-Resistant Enterobacteriaceae Infections: A Systematic Review. Infect Drug Resist 2022; 15:6907-6926. [PMID: 36465807 PMCID: PMC9717588 DOI: 10.2147/idr.s390635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/09/2022] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE Carbapenem-resistant Enterobacteriaceae (CRE) has become a significant public health problem in the last decade. We aimed to explore the risk factors of mortality in patients with CRE infections and to focus on the current evidence on antimicrobial regimens for CRE infections, particularly from the perspective of mortality. METHODS A systematic literature review was performed by searching the databases of EMBASE, PubMed, and the Cochrane Library to identify studies that evaluated mortality-related risk factors and antimicrobial regimens for CRE infections published from 2012 to 2022. RESULTS In total, 33 and 28 studies were included to analyze risk factors and antibiotic treatment, respectively. The risk factors most frequently reported as significantly associated with CRE mortality were antibiotic use (92.9%; 26/28 studies), comorbidities (88.7%; 23/26 studies), and hospital-related factors (82.8%; 24/29 studies). In 10 studies that did not contain ceftazidime/avibactam (CAZ-AVI) therapy, seven demonstrated significantly lower mortality in combination therapy than in monotherapy. However, 5 of 6 studies identified no substantial difference between CAZ-AVI monotherapy and CAZ-AVI combination therapy. Six studies reported substantially lower mortality in CAZ-AVI regimens than in other regimens. CONCLUSION Several risk factors, particularly antibiotic use and patients' comorbidities, are strong risk factors for CRE mortality. The optimal regimen for CRE infections remains controversial. Combination therapy should be considered when carbapenems, colistin, tigecycline, or aminoglycosides are administered. CAZ-AVI appears to be a promising antibiotic for CRE infections. Most importantly, treatment should be individualized according to the source and severity of the disease or other highly related risk factors.
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Affiliation(s)
- Qin Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Hospital Institute Administration, Central South University, Changsha, People’s Republic of China
- Xiangya Health Development Research Center, Changsha, People’s Republic of China
| | - Jinglan Chen
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, People’s Republic of China
| | - Shusen Sun
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Western New England University, Springfeld, MA, USA
| | - Sheng Deng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Institute for Rational and Safe Medication Practices, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- The Hunan Institute of Pharmacy Practice and Clinical Research, Changsha, People’s Republic of China
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31
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Arjun R, Niyas VKM, John KE, Nair A, Hussain F. Impact of Adding Rapid Polymerase Chain Reaction-based Blood Culture Identification Panel to Antimicrobial Stewardship Program: Initial Experience. Indian J Crit Care Med 2022; 26:1155-1157. [PMID: 36876210 PMCID: PMC9983680 DOI: 10.5005/jp-journals-10071-24329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/20/2022] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Arjun R, Niyas VKM, John KE, Nair A, Hussain F. Impact of Adding Rapid Polymerase Chain Reaction-based Blood Culture Identification Panel to Antimicrobial Stewardship Program: Initial Experience. Indian J Crit Care Med 2022;26(10):1155-1157.
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Affiliation(s)
- Rajalakshmi Arjun
- Department of Infectious Diseases, KIMSHEALTH, Thiruvananthapuram, Kerala, India
| | | | | | - Ashalatha Nair
- Department of Laboratory Medicine, KIMSHEALTH, Thiruvananthapuram, Kerala, India
| | - Febeena Hussain
- Department of Infectious Diseases, KIMSHEALTH, Thiruvananthapuram, Kerala, India
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32
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Swaminathan S, Routray A, Mane A. Early and Appropriate Use of Ceftazidime-Avibactam in the Management of Multidrug-Resistant Gram-Negative Bacterial Infections in the Indian Scenario. Cureus 2022; 14:e28283. [PMID: 36072213 PMCID: PMC9440350 DOI: 10.7759/cureus.28283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
The increasing prevalence of antibiotic-resistant pathogens exerts a substantial burden on the healthcare infrastructure worldwide. The World Health Organization (WHO) has declared that multidrug-resistant (MDR) Gram-negative pathogens, especially, carbapenem-resistant Enterobacterales (CRE), Acinetobacter baumannii, and Pseudomonas aeruginosa as the topmost priority while developing newer antimicrobials. The increasing prevalence of infectious diseases caused by MDR Gram-negative bacteria also poses a challenge when choosing the empiric antimicrobial therapy for seriously ill hospitalized patients. The infections caused by MDR Gram-negative organisms ultimately result in increased mortality, morbidity, prolonged hospital stay, and increased cost of management. To tackle these challenges, newer antimicrobials like ceftazidime-avibactam were explored. The article also discusses the in vitro activity and therapeutic efficacy of ceftazidime-avibactam along with its pharmacokinetic properties and the role it will play in the management of MDR Gram-negative organisms in the Indian setting. Several studies have highlighted the role of early and appropriate antibiotic use in the reduction of mortality in patients with Gram-negative infections. Timely initiation of appropriate antibiotic therapy for serious infections leads to favorable clinical outcomes. Early and appropriate use of ceftazidime-avibactam while treating MDR Gram-negative infections has been associated with improved clinical outcomes. The aim of this review is to highlight the efficacy of ceftazidime-avibactam in the treatment of MDR Gram-negative infections. We have also summarized the information on outcomes achieved by early and appropriate use of ceftazidime-avibactam.
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33
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Tiseo G, Brigante G, Giacobbe DR, Maraolo AE, Gona F, Falcone M, Giannella M, Grossi P, Pea F, Rossolini GM, Sanguinetti M, Sarti M, Scarparo C, Tumbarello M, Venditti M, Viale P, Bassetti M, Luzzaro F, Menichetti F, Stefani S, Tinelli M. Diagnosis and management of infections caused by multidrug-resistant bacteria: guideline endorsed by the Italian Society of Infection and Tropical Diseases (SIMIT), the Italian Society of Anti-Infective Therapy (SITA), the Italian Group for Antimicrobial Stewardship (GISA), the Italian Association of Clinical Microbiologists (AMCLI) and the Italian Society of Microbiology (SIM). Int J Antimicrob Agents 2022; 60:106611. [PMID: 35697179 DOI: 10.1016/j.ijantimicag.2022.106611] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/12/2022] [Accepted: 05/29/2022] [Indexed: 02/08/2023]
Abstract
Management of patients with infections caused by multidrug-resistant organisms is challenging and requires a multidisciplinary approach to achieve successful clinical outcomes. The aim of this paper is to provide recommendations for the diagnosis and optimal management of these infections, with a focus on targeted antibiotic therapy. The document was produced by a panel of experts nominated by the five endorsing Italian societies, namely the Italian Association of Clinical Microbiologists (AMCLI), the Italian Group for Antimicrobial Stewardship (GISA), the Italian Society of Microbiology (SIM), the Italian Society of Infectious and Tropical Diseases (SIMIT) and the Italian Society of Anti-Infective Therapy (SITA). Population, Intervention, Comparison and Outcomes (PICO) questions about microbiological diagnosis, pharmacological strategies and targeted antibiotic therapy were addressed for the following pathogens: carbapenem-resistant Enterobacterales; carbapenem-resistant Pseudomonas aeruginosa; carbapenem-resistant Acinetobacter baumannii; and methicillin-resistant Staphylococcus aureus. A systematic review of the literature published from January 2011 to November 2020 was guided by the PICO strategy. As data from randomised controlled trials (RCTs) were expected to be limited, observational studies were also reviewed. The certainty of evidence was classified using the GRADE approach. Recommendations were classified as strong or conditional. Detailed recommendations were formulated for each pathogen. The majority of available RCTs have serious risk of bias, and many observational studies have several limitations, including small sample size, retrospective design and presence of confounders. Thus, some recommendations are based on low or very-low certainty of evidence. Importantly, these recommendations should be continually updated to reflect emerging evidence from clinical studies and real-world experience.
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Affiliation(s)
- Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Gioconda Brigante
- Clinical Pathology Laboratory, ASST Valle Olona, Busto Arsizio, Italy
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Floriana Gona
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy, and Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Maurizio Sanguinetti
- Microbiology Unit, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Largo 'A. Gemelli', Rome, Italy
| | - Mario Sarti
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, Modena, Italy
| | - Claudio Scarparo
- Clinical Microbiology Laboratory, Angel's Hospital, AULSS3 Serenissima, Mestre, Venice, Italy
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Mario Venditti
- Policlinico 'Umberto I', Department of Public Health and Infectious Diseases, 'Sapienza' University of Rome, Rome, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Luzzaro
- Clinical Microbiology and Virology Unit, A. Manzoni Hospital, Lecco, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy.
| | - Stefania Stefani
- Medical Molecular Microbiology and Antibiotic Resistance Laboratory (MMARLab), Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Marco Tinelli
- Infectious Diseases Consultation Service, IRCCS Istituto Auxologico Italiano, Milan, Italy
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