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Freiberg JA, Reyes Ruiz VM, Gimza BD, Murdoch CC, Green ER, Curry JM, Cassat JE, Skaar EP. Restriction of arginine induces antibiotic tolerance in Staphylococcus aureus. Nat Commun 2024; 15:6734. [PMID: 39112491 PMCID: PMC11306626 DOI: 10.1038/s41467-024-51144-9] [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: 11/14/2023] [Accepted: 07/31/2024] [Indexed: 08/10/2024] Open
Abstract
Staphylococcus aureus is responsible for a substantial number of invasive infections globally each year. These infections are problematic because they are frequently recalcitrant to antibiotic treatment. Antibiotic tolerance, the ability of bacteria to persist despite normally lethal doses of antibiotics, contributes to antibiotic treatment failure in S. aureus infections. To understand how antibiotic tolerance is induced, S. aureus biofilms exposed to multiple anti-staphylococcal antibiotics are examined using both quantitative proteomics and transposon sequencing. These screens indicate that arginine metabolism is involved in antibiotic tolerance within a biofilm and support the hypothesis that depletion of arginine within S. aureus communities can induce antibiotic tolerance. Consistent with this hypothesis, inactivation of argH, the final gene in the arginine synthesis pathway, induces antibiotic tolerance. Arginine restriction induces antibiotic tolerance via inhibition of protein synthesis. In murine skin and bone infection models, an argH mutant has enhanced ability to survive antibiotic treatment with vancomycin, highlighting the relationship between arginine metabolism and antibiotic tolerance during S. aureus infection. Uncovering this link between arginine metabolism and antibiotic tolerance has the potential to open new therapeutic avenues targeting previously recalcitrant S. aureus infections.
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Affiliation(s)
- Jeffrey A Freiberg
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Valeria M Reyes Ruiz
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brittney D Gimza
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caitlin C Murdoch
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin R Green
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Microbiology, University of Chicago, Chicago, IL, USA
| | - Jacob M Curry
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James E Cassat
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Eric P Skaar
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Shah S, Clarke LG, Ludwig J, Burgdorf S, Arbulu Guerra RD, Shields RK. Carbapenem combination therapy versus standard of care for persistent methicillin-susceptible Staphylococcus aureus bacteraemia. J Antimicrob Chemother 2024; 79:1990-1997. [PMID: 38946294 DOI: 10.1093/jac/dkae198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/26/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Successful use of carbapenems in combination with cefazolin or oxacillin for treatment of MSSA bacteraemia has been described; however, comparative data to standard treatment approaches are lacking. METHODS This was a multicentre, retrospective study of adult patients with MSSA bacteraemia for >48 h. Standard treatment was considered monotherapy with cefazolin, oxacillin or nafcillin. Combination therapy was defined as the addition of ertapenem or meropenem to standard treatment for at least 24 h. The primary outcome was duration of bacteraemia defined as time from administration of an antibiotic with in vitro activity to first negative blood culture. Time to blood culture sterilization was compared through risk-set matching with aid of a propensity score. RESULTS Overall, 238 patients were included; 66% (157/238) received standard treatment and 34% (81/238) received combination therapy. The median (IQR) time to carbapenem initiation was 4.7 (3.63-6.5) days. Patients who received combination therapy were younger (P = 0.012), more likely to have endocarditis (P = 0.034) and had longer median duration of bacteraemia (P < 0.001). After applying risk-set matching, patients who received combination therapy experienced faster time to blood culture sterilization compared with control patients [HR = 1.618 (95% CI; 1.119-2.339) P = 0.011]. Using a paired hazard model, 90 day mortality rates were not statistically different among patients who received combination therapy versus matched controls [HR = 1.267 (95% CI; 0.610-2.678), P = 0.608]. DISCUSSION Carbapenem combination therapy resulted in faster time to blood culture sterilization, but no differences in overall mortality rates. Randomized trials are critical to determine the utility of carbapenem combination therapy.
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Affiliation(s)
- Sunish Shah
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lloyd G Clarke
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Justin Ludwig
- Office of Quality and Clinical Research Innovation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sarah Burgdorf
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Ryan K Shields
- Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Hendriks MMC, Schweren KSA, Kleij A, Berrevoets MAH, de Jong E, van Wijngaarden P, Ammerlaan HSM, Vos A, van Assen S, Slieker K, Gisolf JH, Netea MG, ten Oever J, Kouijzer IJE. Low-Risk Staphylococcus aureus Bacteremia Patients Do Not Require Routine Diagnostic Imaging: A Multicenter, Retrospective, Cohort Study. Clin Infect Dis 2024; 79:43-51. [PMID: 38576380 PMCID: PMC11259217 DOI: 10.1093/cid/ciae187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/21/2024] [Accepted: 04/02/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Stratification to categorize patients with Staphylococcus aureus bacteremia (SAB) as low or high risk for metastatic infection may direct diagnostic evaluation and enable personalized management. We investigated the frequency of metastatic infections in low-risk SAB patients, their clinical relevance, and whether omission of routine imaging is associated with worse outcomes. METHODS We performed a retrospective cohort study at 7 Dutch hospitals among adult patients with low-risk SAB, defined as hospital-acquired infection without treatment delay, absence of prosthetic material, short duration of bacteremia, and rapid defervescence. Primary outcome was the proportion of patients whose treatment plan changed due to detected metastatic infections, as evaluated by both actual therapy administered and by linking a adjudicated diagnosis to guideline-recommended treatment. Secondary outcomes were 90-day relapse-free survival and factors associated with the performance of diagnostic imaging. RESULTS Of 377 patients included, 298 (79%) underwent diagnostic imaging. In 15 of these 298 patients (5.0%), imaging findings during patient admission had been interpreted as metastatic infections that should extend treatment. Using the final adjudicated diagnosis, 4 patients (1.3%) had clinically relevant metastatic infection. In a multilevel multivariable logistic regression analysis, 90-day relapse-free survival was similar between patients without imaging and those who underwent imaging (81.0% versus 83.6%; adjusted odds ratio, 0.749; 95% confidence interval, .373-1.504). CONCLUSIONS Our study advocates risk stratification for the management of SAB patients. Prerequisites are follow-up blood cultures, bedside infectious diseases consultation, and a critical review of disease evolution. Using this approach, routine imaging could be omitted in low-risk patients.
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Affiliation(s)
- Marianne M C Hendriks
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kris S A Schweren
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ayden Kleij
- Department of Internal Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Marvin A H Berrevoets
- Department of Internal Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Emma de Jong
- Department of Internal Medicine, Amphia Hospital, Breda, The Netherlands
| | | | - Heidi S M Ammerlaan
- Department of Internal Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Anja Vos
- Department of Internal Medicine, Treant, Emmen, The Netherlands
| | | | - Kitty Slieker
- Department of Internal Medicine, Bernhoven Hospital, Uden, The Netherlands
| | - Jet H Gisolf
- Department of Intenal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Jaap ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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Shaikh S, Saleem AN, Ymele-Leki P. Simulation and Modeling of the Adhesion of Staphylococcus aureus onto Inert Surfaces under Fluid Shear Stress. Pathogens 2024; 13:551. [PMID: 39057778 PMCID: PMC11280353 DOI: 10.3390/pathogens13070551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
Bacterial adhesion to biotic and abiotic surfaces under fluid shear stress plays a major role in the pathogenesis of infections linked to medical implants and tissues. This study employed an automated BioFlux 200 microfluidic system and video microscopy to conduct real-time adhesion assays, examining the influence of shear stress on adhesion kinetics and spatial distribution of Staphylococcus aureus on glass surfaces. The adhesion rate exhibited a non-linear relationship with shear stress, with notable variations at intermediate levels. Empirical adhesion events were simulated with COMSOL Multiphysics® and Python. Overall, COMSOL accurately predicted the experimental trend of higher rates of bacterial adhesion with decreasing shear stress but poorly characterized the plateauing phenomena observed over time. Python provided a robust mathematical representation of the non-linear relationship between cell concentration, shear stress, and time but its polynomial regression approach was not grounded on theoretical physical concepts. These insights, combined with advancements in AI and machine learning, underscore the potential for synergistic computational techniques to enhance our understanding of bacterial adhesion to surfaces, offering a promising avenue for developing novel therapeutic strategies.
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Affiliation(s)
- Sarees Shaikh
- Department of Chemical Engineering, Howard University, Washington, DC 20059, USA;
| | - Abdul Nafay Saleem
- Department of Electrical Engineering and Computer Science, Howard University, Washington, DC 20059, USA;
| | - Patrick Ymele-Leki
- Department of Chemical Engineering, Howard University, Washington, DC 20059, USA;
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5
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Buis DTP, van der Vaart TW, Mohan A, Prins JM, van der Meer JTM, Bonten MJM, Jakulj L, van Werkhoven CH, Sigaloff KCE. Acute kidney injury in Staphylococcus aureus bacteraemia: a recurrent events analysis. Clin Microbiol Infect 2024:S1198-743X(24)00297-0. [PMID: 38925460 DOI: 10.1016/j.cmi.2024.06.017] [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: 02/27/2024] [Revised: 05/09/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES To estimate risk factors for acute kidney injury (AKI) and the effect of AKI on mortality in Staphylococcus aureus bacteraemia, while taking into account recurrent AKI episodes, competing risks, time-varying variables, and time-varying effects. METHODS We performed an unplanned analysis using data from a multicentre cohort study of patients with Staphylococcus aureus bacteraemia (SAB). The primary outcome was cumulative incidence of AKI, according to Kidney Disease Improving Global Outcomes definitions. RESULTS We included 453 patients in this study of whom 194 (43%) patients experienced one or more AKI episodes. Age (hazard ratio (HR) 1.013, 95% CI 1.001-1.024), Charlson comorbidity index (HR 1.07, 95% CI 1.01-1.14), prior chronic kidney disease (HR 1.76, 95% CI 1.28-2.42), septic shock (HR 3.28, 95% CI 2.31-4.66), persistent bacteraemia (HR 1.53, 95% CI 1.08-2.17), and vancomycin therapy (HR 1.80, 95% CI 1.05-3.09) were independently associated with AKI, but flucloxacillin, cefazolin, rifampicin, and aminoglycoside therapy were not. After adjustment for confounders and immortal time bias, AKI was associated with an increased risk of 90-day mortality (HR 4.26, 95% CI 2.91-6.23). DISCUSSION The incidence of AKI in SAB is high and a substantial proportion of patients develop recurrent episodes of AKI after recovery. AKI is specifically linked to the use of vancomycin and not to anti-staphylococcal penicillins. The clinical outcome of patients with SAB complicated by AKI is worse than previously estimated.
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Affiliation(s)
- David T P Buis
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
| | - Thomas W van der Vaart
- Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam UMC Location Universiteit van Amsterdam, Amsterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Asna Mohan
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jan T M van der Meer
- Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands; Department of Internal Medicine, Amsterdam UMC Location Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, the Netherlands; European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
| | - Lily Jakulj
- Department of Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Dianet Dialysis Center Amsterdam, the Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
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Souza EG, do Nascimento CDD, Aguzzoli C, Santillán ESB, Cuevas-Suárez CE, Nascente PDS, Piva E, Lund RG. Enhanced Antibacterial Properties of Titanium Surfaces through Diversified Ion Plating with Silver Atom Deposition. J Funct Biomater 2024; 15:164. [PMID: 38921537 PMCID: PMC11204396 DOI: 10.3390/jfb15060164] [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: 05/03/2024] [Revised: 06/06/2024] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
In this study, we investigate the antibacterial effect of silver atoms implanted into a thin surface layer of titanium at low energies using an alternative ion plating technology called Diversified Ion Plating. Silver atoms were incorporated into titanium samples using reactive low-voltage ion plating at 2 keV and 4 keV. Surface modifications and morphology were evaluated using wettability, profilometry measurements, and energy-dispersive spectroscopy. For a precise determination of the quantity and depth of implanted silver atoms on titanium surfaces, a combination of experimental techniques such as Rutherford Backscattering Spectrometry along with Monte Carlo simulations were utilized. To assess the antibacterial effects of the silver atoms incorporated into pure titanium surfaces, bacterial suspension immersion tests were performed with a standard strain of Staphylococcus aureus (ATCC 12600). The outcomes indicate that titanium surfaces implanted with silver atoms were more effective in inhibiting the growth of Staphylococcus aureus than pure titanium surfaces. Better results were found when the deposition was performed at 4 keV, indicating that a deeper implantation of silver, spanning a few nanometers, can result in a longer and more effective release of silver atoms. These findings suggest the potential for the development of new, cost-effective biomaterials, paving the way for improved implant materials in various health-related applications.
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Affiliation(s)
- Everton Granemann Souza
- Graduate Program in Electronic and Computer Engineering, Catholic University of Pelotas, Pelotas 96015-560, Brazil;
| | | | - Cesar Aguzzoli
- Graduate Program in Materials Science and Engineering, University of Caxias do Sul, Caxias 95070-560, Brazil;
| | - Elena Sarai Baena Santillán
- Academic Area of Dentistry, Autonomous University of Hidalgo, Pachuca de Soto 42080, Mexico; (E.S.B.S.); (C.E.C.-S.)
| | - Carlos Enrique Cuevas-Suárez
- Academic Area of Dentistry, Autonomous University of Hidalgo, Pachuca de Soto 42080, Mexico; (E.S.B.S.); (C.E.C.-S.)
| | | | - Evandro Piva
- Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas 96010-610, Brazil; (E.P.); (R.G.L.)
- Graduate Program in Materials Science and Engineering, Technology Development Center, Federal University of Pelotas, Pelotas 96010-610, Brazil
| | - Rafael Guerra Lund
- Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas 96010-610, Brazil; (E.P.); (R.G.L.)
- Graduate Program in Materials Science and Engineering, Technology Development Center, Federal University of Pelotas, Pelotas 96010-610, Brazil
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O'Toole HJ, Lowe N, Arun V, Kolesov AV, Palmieri TL, Tran NK, Carney RP. Plasma-derived Extracellular Vesicles (EVs) as Biomarkers of Sepsis in Burn Patients via Label-free Raman Spectroscopy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.14.593634. [PMID: 38798662 PMCID: PMC11118394 DOI: 10.1101/2024.05.14.593634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Sepsis following burn trauma is a global complication with high mortality, with ~60% of burn patient deaths resulting from infectious complications. Sepsis diagnosis is complicated by confounding clinical manifestations of the burn injury, and current biomarkers markers lack the sensitivity and specificity required for prompt treatment. Circulating extracellular vesicles (EVs) from patient liquid biopsy as biomarkers of sepsis due to their release by pathogens from bacterial biofilms and roles in subsequent immune response. This study applies Raman spectroscopy to patient plasma derived EVs for rapid, sensitive, and specific detection of sepsis in burn patients, achieving 97.5% sensitivity and 90.0% specificity. Furthermore, spectral differences between septic and non-septic burn patient EVs could be traced to specific glycoconjugates of bacterial strains associated with sepsis morbidity. This work illustrates the potential application of EVs as biomarkers in clinical burn trauma care, and establishes Raman analysis as a fast, label-free method to specifically identify features of bacterial EVs relevant to infection amongst the host background.
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Affiliation(s)
- Hannah J O'Toole
- Department of Biomedical Engineering, University of California, Davis, 1 Shields Ave, Davis., CA 95616, USA
| | - Neona Lowe
- Department of Biomedical Engineering, University of California, Davis, 1 Shields Ave., Davis, CA 95616, USA
| | - Vishalakshi Arun
- Department of Neurobiology, Physiology, and Behavior, University of California, Davis, 1 Shields Ave., Davis, CA 95616, USA
| | - Anna V Kolesov
- Department of Biomedical Engineering, University of California, Davis, 1 Shields Ave., Davis, CA 95616, USA
| | - Tina L Palmieri
- Division of Burn Surgery & Reconstruction, Department of Surgery, University of California, Davis Health, Firefighters Burn Institute Regional Burn Center, 2315 X Street, Sacramento, CA 95616, USA; Shriners Hospitals for Children Northern California, 2425 Stockton Blvd., Sacramento, CA 95817, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 4400 V. St., Sacramento, CA 95817, USA
| | - Randy P Carney
- Department of Biomedical Engineering, University of California, Davis, 1 Shields Ave, Davis, CA 95616, USA
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van der Vaart TW, Prins JM, Goorhuis A, Lemkes BA, Sigaloff KCE, Spoorenberg V, Stijnis C, Bonten MJM, van der Meer JTM. The Utility of Risk Factors to Define Complicated Staphylococcus aureus Bacteremia in a Setting With Low Methicillin-Resistant S. aureus Prevalence. Clin Infect Dis 2024; 78:846-854. [PMID: 38157401 PMCID: PMC11006106 DOI: 10.1093/cid/ciad784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/06/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION Recommended duration of antibiotic treatment of Staphylococcus aureus bacteremia (SAB) is frequently based on distinguishing uncomplicated and complicated SAB, and several risk factors at the onset of infection have been proposed to define complicated SAB. Predictive values of risk factors for complicated SAB have not been validated, and consequences of their use on antibiotic prescriptions are unknown. METHODS In a prospective cohort, patients with SAB were categorized as complicated or uncomplicated through adjudication (reference definition). Associations and predictive values of 9 risk factors were determined, compared with the reference definition, as was accuracy of Infectious Diseases Society of America (IDSA) criteria that include 4 risk factors, and the projected consequences of applying IDSA criteria on antibiotic use. RESULTS Among 490 patients, 296 (60%) had complicated SAB. In multivariable analysis, persistent bacteremia (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.9-12.0), community acquisition of SAB (OR, 2.9; 95% CI, 1.9-4.7) and presence of prosthetic material (OR, 2.3; 95% CI, 1.5-3.6) were associated with complicated SAB. Presence of any of the 4 risk factors in the IDSA definition of complicated SAB had a positive predictive value of 70.9% (95% CI, 65.5-75.9) and a negative predictive value of 57.5% (95% CI, 49.1-64.8). Compared with the reference, IDSA criteria yielded 24 (5%) false-negative and 90 (18%) false-positive classifications of complicated SAB. Median duration of antibiotic treatment of these 90 patients was 16 days (interquartile range, 14-19), all with favorable clinical outcome. CONCLUSIONS Risk factors have low to moderate predictive value to identify complicated SAB and their use may lead to unnecessary prolonged antibiotic use.
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Affiliation(s)
- Thomas W van der Vaart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bregtje A Lemkes
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Veroniek Spoorenberg
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis Stijnis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan T M van der Meer
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Bouiller K, Jacko NF, Shumaker MJ, Talbot BM, Read TD, David MZ. Factors associated with foreign body infection in methicillin-resistant Staphylococcus aureus bacteremia. Front Immunol 2024; 15:1335867. [PMID: 38433826 PMCID: PMC10904584 DOI: 10.3389/fimmu.2024.1335867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Background We aimed to compare patient characteristics, MRSA sequence types, and biofilm production of MRSA strains that did and did not cause a foreign body infection in patients with MRSA bloodstream infections (BSI). Methods All adult patients with MRSA BSI hospitalized in two hospitals were identified by clinical microbiology laboratory surveillance. Only patients who had at least one implanted foreign body during the episode of BSI were included. Results In July 2018 - March 2022, of 423 patients identified with MRSA BSI, 118 (28%) had ≥1 foreign body. Among them, 51 (43%) had one or more foreign body infections. In multivariable analysis, factors associated with foreign body infection were history of MRSA infection in the last year (OR=4.7 [1.4-15.5], p=0.012) community-associated BSI (OR=68.1 [4.2-1114.3], p=0.003); surgical site infection as source of infection (OR=11.8 [2-70.4], p=0.007); presence of more than one foreign body (OR=3.4 [1.1-10.7], p=0.033); interval between foreign body implantation and infection <18 months (OR=3.3 [1.1-10], p=0.031); and positive blood culture ≥48h (OR=16.7 [4.3-65.7], p<0.001). The most prevalent sequence type was ST8 (39%), followed by ST5 (29%), and ST105 (20%) with no significant difference between patients with or without foreign body infection. Only 39% of MRSA isolates formed a moderate/strong biofilm. No significant difference was observed between patients with foreign body infection and those without foreign body infection. In multivariable analysis, subjects infected with a MRSA isolate producing moderate/strong in vitro biofilm were more likely to have a history of MRSA infection in the last year (OR=3.41 [1.23-9.43]), interval between foreign body implantation and MRSA BSI <18 months (OR=3.1 [1.05-9.2]) and ST8 (OR=10.64 [2-57.3]). Conclusion Most factors associated with foreign body infection in MRSA BSI were also characteristic of persistent infections. Biofilm-forming isolates were not associated with a higher risk of foreign-body infection but appeared to be associated with MRSA genetic lineage, especially ST8.
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Affiliation(s)
- Kevin Bouiller
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Université de Franche-Comté, CHU Besançon, UMR-CNRS 6249 Chrono-environnement, Department of Infectious and Tropical Diseases, Besançon, France
| | - Natasia F Jacko
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Margot J Shumaker
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Brooke M Talbot
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Timothy D Read
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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10
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Quiñonez-Flores A, Martinez-Guerra BA, Román-Montes CM, Tamez-Torres KM, González-Lara MF, Ponce-de-León A, Rajme-López S. Cephalotin Versus Dicloxacillin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteraemia: A Retrospective Cohort Study. Antibiotics (Basel) 2024; 13:176. [PMID: 38391562 PMCID: PMC10885996 DOI: 10.3390/antibiotics13020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/30/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND First-line treatments for methicillin-susceptible S. aureus (MSSA) bacteraemia are nafcillin, oxacillin, or cefazolin. Regional shortages of these antibiotics force clinicians to use other options like dicloxacillin and cephalotin. This study aims to describe and compare the safety and efficacy of cephalotin and dicloxacillin for the treatment of MSSA bacteraemia. METHODS This retrospective study was conducted in a referral centre in Mexico City. We identified MSSA isolates in blood cultures from 1 January 2012 to 31 December 2022. Patients ≥ 18 years of age, with a first episode of MSSA bacteraemia, who received cephalotin or dicloxacillin as the definitive antibiotic treatment, were included. The primary outcome was in-hospital all-cause mortality. RESULTS We included 202 patients, of which 48% (97/202) received cephalotin as the definitive therapy and 52% (105/202) received dicloxacillin. In-hospital all-cause mortality was 20.7% (42/202). There were no differences in all-cause in-hospital mortality between patients receiving cephalotin or dicloxacillin (20% vs. 21%, p = 0.43), nor in 30-day all-cause mortality (14% vs. 18%, p = 0.57) or 90-day all-cause mortality (24% vs. 22%, p = 0.82). No severe adverse reactions were associated with either antibiotic. CONCLUSIONS Cephalotin and dicloxacillin were equally effective for treating MSSA bacteraemia, and both showed an adequate safety profile.
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Affiliation(s)
- Alejandro Quiñonez-Flores
- Internal Medicine Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Bernardo A Martinez-Guerra
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Carla M Román-Montes
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Karla M Tamez-Torres
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - María F González-Lara
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Alfredo Ponce-de-León
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Sandra Rajme-López
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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11
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Abdollahi A, Nojomi M, Karimi Y, Ranjbar M. Mortality patterns in patients with Staphylococcus aureus bacteremia during the COVID-19 pandemic: Predictors and insights. Heliyon 2024; 10:e24511. [PMID: 38312595 PMCID: PMC10835178 DOI: 10.1016/j.heliyon.2024.e24511] [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: 10/14/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
Objectives This paper aims to determine the Staphylococcus aureus bacteremia (SAB) in-hospital mortality rate and its associated risk factors during the COVID-19 pandemic. Methods A total of 167 SAB samples were collected between March 2020 and March 2022 at a teaching hospital in Tehran, Iran. The patient's baseline data and antibiograms were collected. The outcome of the study was in-hospital mortality. Results The overall in-hospital mortality rate was 41.9 %, with higher mortality observed in patients over 60 years old (P = 0.032), those with community-acquired Staphylococcus aureus bacteremia (P = 0.010), and those admitted to the ICU (P = 0.016). Antibiotic resistance profiles indicated a higher mortality in resistant S.aureus strains but only significant for ciprofloxacin (P = 0.001), methicillin (P = 0.047), and sulfamethoxazole (P = 0.023). Multivariate analysis identified age, sex, ICU admission, and the source of bacteremia as independent predictors of mortality, while COVID-19 coinfection and resistance to antibiotics were not found to be significant predictors. Conclusion SAB remains a challenging infection that is amplified by the pandemic. Older age and ICU admission are significant mortality predictors. In settings with a high prevalence of MRSA, factors like age, sex, and quality of care outweigh pathogen-related factors such as antibiotic resistance.
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Affiliation(s)
- Arash Abdollahi
- Medical Doctor, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Nojomi
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Yeganeh Karimi
- Medical Doctor, Iran University of Medical Sciences, Tehran, Iran
| | - Mitra Ranjbar
- Department of Infectious Diseases, School of Medicine, Firoozgar General Hospital, Iran University of Medical Sciences, Tehran, Iran
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12
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El-Dalati S, Alnabelsi T, Gurley J, Cremeans K, Reda H, London-Bounds T, Ogburn E, Sekela M. Acute drug-use-related native tricuspid valve infective endocarditis: a non-surgical disease. Ther Adv Infect Dis 2024; 11:20499361241267124. [PMID: 39132095 PMCID: PMC11311191 DOI: 10.1177/20499361241267124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/21/2024] [Indexed: 08/13/2024] Open
Abstract
As a result of the ongoing opioid epidemic, physicians have encountered increasing rates of drug-use-related native tricuspid valve infective endocarditis (DU-TVIE), a complex multi-faceted disease that is best managed by interdisciplinary teams. Despite the large number of patients with DU-TVIE, there is little data to support the optimal treatment strategy with respect to medical and surgical therapy. The recent introduction of percutaneous mechanical aspiration of tricuspid valve vegetations has added another treatment modality that is also of uncertain benefit. Here we review the literature on the management of DU-TVIE and highlight the multi-step treatment approach developed by the multidisciplinary endocarditis team at the University of Kentucky.
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Affiliation(s)
- Sami El-Dalati
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky Medical Center, 3101 Beaumont Centre Circle, Lexington, KY 40513, USA
| | - Talal Alnabelsi
- Gill Heart and Vascular Institute, University of Kentucky Medical Center, Lexington, KY, USA
| | - John Gurley
- Gill Heart and Vascular Institute, University of Kentucky Medical Center, Lexington, KY, USA
| | - Kelli Cremeans
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Hassan Reda
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Tessa London-Bounds
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Erinn Ogburn
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky Medical Center, Lexington, KY, USA
| | - Michael Sekela
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky Medical Center, Lexington, KY, USA
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13
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Hackemann VCJ, Hagel S, Jandt KD, Rödel J, Löffler B, Tuchscherr L. The Controversial Effect of Antibiotics on Methicillin-Sensitive S. aureus: A Comparative In Vitro Study. Int J Mol Sci 2023; 24:16308. [PMID: 38003500 PMCID: PMC10671744 DOI: 10.3390/ijms242216308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Methicillin-sensitive Staphylococcus (S.) aureus (MSSA) bacteremia remains a global challenge, despite the availability of antibiotics. Primary treatments include β-lactam agents such as cefazolin and flucloxacillin. Ongoing discussions have focused on the potential synergistic effects of combining these agents with rifampicin or fosfomycin to combat infections associated with biofilm formation. Managing staphylococcal infections is challenging due to antibacterial resistance, biofilms, and S. aureus's ability to invade and replicate within host cells. Intracellular invasion shields the bacteria from antibacterial agents and the immune system, often leading to incomplete bacterial clearance and chronic infections. Additionally, S. aureus can assume a dormant phenotype, known as the small colony variant (SCV), further complicating eradication and promoting persistence. This study investigated the impact of antibiotic combinations on the persistence of S. aureus 6850 and its stable small colony variant (SCV strain JB1) focusing on intracellular survival and biofilm formation. The results from the wild-type strain 6850 demonstrate that β-lactams combined with RIF effectively eliminated biofilms and intracellular bacteria but tend to select for SCVs in planktonic culture and host cells. Higher antibiotic concentrations were associated with an increase in the zeta potential of S. aureus, suggesting reduced membrane permeability to antimicrobials. When using the stable SCV mutant strain JB1, antibiotic combinations with rifampicin successfully cleared planktonic bacteria and biofilms but failed to eradicate intracellular bacteria. Given these findings, it is reasonable to report that β-lactams combined with rifampicin represent the optimal treatment for MSSA bacteremia. However, caution is warranted when employing this treatment over an extended period, as it may elevate the risk of selecting for small colony variants (SCVs) and, consequently, promoting bacterial persistence.
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Affiliation(s)
| | - Stefan Hagel
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany
| | - Klaus D Jandt
- Otto Schott Institute of Materials Research (OSIM), Friedrich Schiller University Jena, 07743 Jena, Germany
- Jena School for Microbial Communication (JSMC), 07743 Jena, Germany
| | - Jürgen Rödel
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
| | - Bettina Löffler
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
| | - Lorena Tuchscherr
- Institute for Medical Microbiology, Jena University Hospital, 07747 Jena, Germany
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14
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Freiberg JA, Ruiz VMR, Green ER, Skaar EP. Restriction of Arginine Induces Antibiotic Tolerance in Staphylococcus aureus. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.10.12.561972. [PMID: 37873095 PMCID: PMC10592767 DOI: 10.1101/2023.10.12.561972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Staphylococcus aureus is responsible for a substantial number of invasive infections globally each year. These infections are problematic because they are frequently recalcitrant to antibiotic treatment, particularly when they are caused by Methicillin-Resistant Staphylococcus aureus (MRSA). Antibiotic tolerance, the ability for bacteria to persist despite normally lethal doses of antibiotics, is responsible for most antibiotic treatment failure in MRSA infections. To understand how antibiotic tolerance is induced, S. aureus biofilms exposed to multiple anti-MRSA antibiotics (vancomycin, ceftaroline, delafloxacin, and linezolid) were examined using both quantitative proteomics and transposon sequencing. These screens indicated that arginine metabolism is involved in antibiotic tolerance within a biofilm and led to the hypothesis that depletion of arginine within S. aureus communities can induce antibiotic tolerance. Consistent with this hypothesis, inactivation of argH, the final gene in the arginine synthesis pathway, induces antibiotic tolerance under conditions in which the parental strain is susceptible to antibiotics. Arginine restriction was found to induce antibiotic tolerance via inhibition of protein synthesis. Finally, although S. aureus fitness in a mouse skin infection model is decreased in an argH mutant, its ability to survive in vivo during antibiotic treatment with vancomycin is enhanced, highlighting the relationship between arginine metabolism and antibiotic tolerance during S. aureus infection. Uncovering this link between arginine metabolism and antibiotic tolerance has the potential to open new therapeutic avenues targeting previously recalcitrant S. aureus infections.
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Affiliation(s)
- Jeffrey A. Freiberg
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Valeria M. Reyes Ruiz
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN 37232
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Erin R. Green
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN 37232
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232
- Department of Microbiology, University of Chicago, Chicago, IL 60637
| | - Eric P. Skaar
- Vanderbilt Institute for Infection, Immunology, and Inflammation, Vanderbilt University Medical Center, Nashville, TN 37232
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232
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15
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Grillo S, Pujol M, Miró JM, López-Contreras J, Euba G, Gasch O, Boix-Palop L, Garcia-País MJ, Pérez-Rodríguez MT, Gomez-Zorrilla S, Oriol I, López-Cortés LE, Pedro-Botet ML, San-Juan R, Aguado JM, Gioia F, Iftimie S, Morata L, Jover-Sáenz A, García-Pardo G, Loeches B, Izquierdo-Cárdenas Á, Goikoetxea AJ, Gomila-Grange A, Dietl B, Berbel D, Videla S, Hereu P, Padullés A, Pallarès N, Tebé C, Cuervo G, Carratalà J. Cloxacillin plus fosfomycin versus cloxacillin alone for methicillin-susceptible Staphylococcus aureus bacteremia: a randomized trial. Nat Med 2023; 29:2518-2525. [PMID: 37783969 PMCID: PMC10579052 DOI: 10.1038/s41591-023-02569-0] [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: 08/25/2023] [Indexed: 10/04/2023]
Abstract
Treatment failure occurs in about 25% of patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia. We assessed whether cloxacillin plus fosfomycin achieves better treatment success than cloxacillin alone in hospitalized adults with MSSA bacteremia. We conducted a multicenter, open-label, phase III-IV superiority randomized clinical trial. We randomly assigned patients (1:1) to receive 2 g of intravenous cloxacillin alone every 4 h or with 3 g of intravenous fosfomycin every 6 h for the initial 7 days. The primary endpoint was treatment success at day 7, a composite endpoint with the following criteria: patient alive, stable or with improved quick Sequential Organ Failure Assessment score, afebrile and with negative blood cultures for MSSA, adjudicated by an independent committee blinded to treatment allocation. We randomized 215 patients, of whom 105 received cloxacillin plus fosfomycin and 110 received cloxacillin alone. We analyzed the primary endpoint with the intention-to-treat approach in 214 patients who received at least 1 day of treatment. Treatment success at day 7 after randomization was achieved in 83 (79.8%) of 104 patients receiving combination treatment versus 82 (74.5%) of 110 patients receiving monotherapy (risk difference 5.3%; 95% confidence interval (CI), -5.95-16.48). Secondary endpoints, including mortality and adverse events, were similar in the two groups except for persistent bacteremia at day 3, which was less common in the combination arm. In a prespecified interim analysis, the independent committee recommended stopping recruitment for futility prior to meeting the planned randomization of 366 patients. Cloxacillin plus fosfomycin did not achieve better treatment success at day 7 of therapy than cloxacillin alone in MSSA bacteremia. Further trials should consider the intrinsic heterogeneity of the infection by using a more personalized approach. ClinicalTrials.gov registration: NCT03959345 .
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Grants
- Funding by Spanish Ministry of Health (grant PI17/01116), Instituto de Salud Carlos III, Madrid, Spain, and Laboratorios ERN, Barcelona, Spain (grant 19PNJ145). Spanish Clinical Research Network (SCReN), Instituto de Salud Carlos II, for its support through the projects PT17/0017/0010 and PT20/000008, integrated into the “Plan Estatal de I+D+I” 2013-2016 and co-financed by the European Regional Development Fund (FEDER).
- José María Miró received a personal 80:20 research grant from Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, during 2017–24. Oriol Gasch received a research grant from the “Pla estratègic de recerca i innovació en salut (PERIS) 2019-2021” (Departament de Salut. Generalitat de Catalunya).
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Affiliation(s)
- Sara Grillo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain
| | - Miquel Pujol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
- Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain.
| | - Josep M Miró
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- University of Barcelona, Barcelona, Spain
- Department of Infectious Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Joaquín López-Contreras
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Gorane Euba
- Department of Infectious Diseases, Hospital Universitario Cruces, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Oriol Gasch
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Lucia Boix-Palop
- Department of Infectious Diseases, Hospital Universitari Mútua Terrassa, Terrassa, Spain
| | - Maria José Garcia-País
- Department of Internal Medicine, Hospital Universitario Lucus Augusti, Lugo, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Teresa Pérez-Rodríguez
- Infectious Diseases Unit, Internal Medicine Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
- Galicia Sur Health Research Institute, Vigo, Spain
| | - Silvia Gomez-Zorrilla
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobial Research Group (IPAR), Barcelona, Spain
| | - Isabel Oriol
- Department of Internal Medicine, Hospital de Sant Joan Despi Moises Broggi, Sant Joan Despi, Spain
| | - Luis Eduardo López-Cortés
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena, Seville, Spain
- Department of Medicine, School of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS)/CSIC, Seville, Spain
| | - Maria Luisa Pedro-Botet
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Rafael San-Juan
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francesca Gioia
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramon y Cajal de Investigacion Sanitaria, Madrid, Spain
| | - Simona Iftimie
- Institut d'Investigació Sanitària Pere Virgili, Department of Medicine and Surgery, Universitat Rovira i Virgili, Reus, Spain
- Department of Internal Medicine, Hospital Universitari de Sant Joan, Reus, Spain
| | - Laura Morata
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- University of Barcelona, Barcelona, Spain
- Department of Infectious Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial y Política Antibiòtica (UTIN), Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Graciano García-Pardo
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- IISPV, Universitat Rovira i Virgili, Tarragona, Spain
- Grup de control de la Infecció, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Belén Loeches
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitario La Paz, Madrid, Spain
| | - Álvaro Izquierdo-Cárdenas
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Ane Josune Goikoetxea
- Department of Infectious Diseases, Hospital Universitario Cruces, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Aina Gomila-Grange
- Department of Infectious Diseases, Hospital Universitari Parc Taulí, Sabadell, Spain
- Institut d'Investigació i Innovació Parc Taulí (I3PT), Sabadell, Spain
| | - Beatriz Dietl
- Department of Infectious Diseases, Hospital Universitari Mútua Terrassa, Terrassa, Spain
| | - Damaris Berbel
- Department of Microbiology and Parasitology, Hospital Universitari de Bellvitge (IDIBELL), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sebastian Videla
- University of Barcelona, Barcelona, Spain
- Spanish Clinical Research Network (SCReN), Hospital Universitari de Bellvitge (IDIBELL), Barcelona, Spain
- Department of Clinical Pharmacology, Clinical Research and Clinical Trials Unit, Barcelona, Spain
| | - Pilar Hereu
- University of Barcelona, Barcelona, Spain
- Spanish Clinical Research Network (SCReN), Hospital Universitari de Bellvitge (IDIBELL), Barcelona, Spain
- Department of Clinical Pharmacology, Clinical Research and Clinical Trials Unit, Barcelona, Spain
| | - Ariadna Padullés
- Department of Pharmacy, Hospital Universitari de Bellvitge (IDIBELL), Barcelona, Spain
| | | | | | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
- Bellvitge Institute for Biomedical Research (IDIBELL), Barcelona, Spain.
- University of Barcelona, Barcelona, Spain.
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16
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Kim SH, Jeon M, Jang S, Mun SJ. Factors for mortality in patients with persistent Staphylococcus aureus bacteremia: The importance of treatment response rather than bacteremia duration. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:1007-1015. [PMID: 37580183 DOI: 10.1016/j.jmii.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/06/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The criteria for antibiotic failure in persistent Staphylococcus aureus bacteremia (SAB) are unclear, but treatment response and bacteremia duration are commonly used indicators of antibiotic failure. We evaluated the effects of treatment response and bacteremia duration on mortality in persistent SAB. METHODS We retrospectively identified patients with persistent SAB in four university-affiliated hospitals between 2017 and 2021. Bacteremia duration was calculated from the first day of active antibiotic therapy, and persistent SAB was defined as bacteremia lasting for 2 or more days. Defervescence and Pitt bacteremia score (PBS) were used to evaluate treatment response at treatment day 4. The primary outcome was 30-day in-hospital mortality. Time-dependent multivariable Cox regression analysis and subgroup analysis according to methicillin resistance were performed. RESULTS A total of 221 patients was included in the study, and the 30-day in-hospital mortality was 28.5%. There was no significant difference in bacteremia duration between survived and deceased patients. Independent factors for mortality included age, Charlson comorbidity index, initial PBS, pneumonia, and removal of the eradicable focus. PBS at treatment day 4 ≥ 3 was the strongest risk factor (adjusted hazard ratio [HR] = 4.260), but defervescence was not. Bacteremia duration was not an independent factor except for 13 days or more of methicillin-resistant SAB (adjusted HR = 1.064). CONCLUSIONS In patients with persistent SAB, PBS at treatment day 4 was associated with 30-day in-hospital mortality rather than defervescence and bacteremia duration. The results of this study could help determine early intensified treatment strategies in persistent SAB patients.
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Affiliation(s)
- Si-Ho Kim
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Minji Jeon
- Division of Infectious Diseases, Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
| | - Sukbin Jang
- Division of Infectious Diseases, Department of Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Seok Jun Mun
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Paik Institute for Clinical Research, Inje University College of Medicine, Busan, Republic of Korea.
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17
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Ariëns RAS, Cassat JE. Surviving a sticky situation: therapeutic administration of fibrinogen variant γ' improves outcomes of Staphylococcus aureus septicemia. J Thromb Haemost 2023; 21:2048-2050. [PMID: 37468174 PMCID: PMC10947783 DOI: 10.1016/j.jtha.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - James E Cassat
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute for Infection, Immunology, and Inflammation (VI4), Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Center for Bone Biology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Ioannou P, Zacharioudaki M, Spentzouri D, Koutoulakou A, Kitsos-Kalyvianakis K, Chontos C, Karakonstantis S, Maraki S, Samonis G, Kofteridis DP. A Retrospective Study of Staphylococcus aureus Bacteremia in a Tertiary Hospital and Factors Associated with Mortality. Diagnostics (Basel) 2023; 13:diagnostics13111975. [PMID: 37296829 DOI: 10.3390/diagnostics13111975] [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: 04/18/2023] [Revised: 05/17/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023] Open
Abstract
Staphylococcus aureus bacteremia (SAB) is a severe infection frequently associated with significant morbidity and mortality. Recent studies have shown that SAB mortality has decreased during the last decades. However, about 25% of patients suffering from the disease will ultimately die. Hence, there is an urgent need for more timely and efficient treatment of patients with SAB. The aim of the present study was to retrospectively evaluate a cohort of SAB patients hospitalized in a tertiary hospital and to identify factors independently associated with mortality. All 256 SAB patients hospitalized from January 2005 to December 2021 in the University Hospital of Heraklion, Greece, were evaluated. Their median age was 72 years, while 101 (39.5%) were female. Most SAB patients were cared for in medical wards (80.5%). The infection was community-acquired in 49.5%. Among all strains 37.9% were methicillin-resistant S. aureus (MRSA), however, definite treatment with an antistaphylococcal penicillin was given only in 22% of patients. Only 14.4% of patients had a repeat blood culture after the initiation of antimicrobial treatment. Infective endocarditis was present in 8%. In-hospital mortality has reached 15.9%. Female gender, older age, higher McCabe score, previous antimicrobial use, presence of a central venous catheter, neutropenia, severe sepsis, septic shock, and MRSA SAB were positively associated with in-hospital mortality, while monomicrobial bacteremia was negatively associated. The multivariate logistic regression model identified only severe sepsis (p = 0.05, odds ratio = 12.294) and septic shock (p = 0.007, odds ratio 57.18) to be independently positively associated with in-hospital mortality. The evaluation revealed high rates of inappropriate empirical antimicrobial treatment and non-adherence to guidelines, as shown, by the lack of repeat blood cultures. These data underline the urgent need for interventions with antimicrobial stewardship, increased involvement of infectious diseases physicians, educational sessions, and creation and implementation of local guidelines for improvement of the necessary steps for timely and efficient SAB treatment. Optimization of diagnostic techniques is needed to overcome challenges such as heteroresistance that may affect treatment. Clinicians should be aware of the factors associated with mortality in patients with SAB to identify those who are at a higher risk and optimize medical management.
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Affiliation(s)
- Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece
- Internal Medicine Department, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Maria Zacharioudaki
- Pediatrics Department, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Despoina Spentzouri
- Internal Medicine Department, University Hospital of Heraklion, 71110 Heraklion, Greece
| | | | | | - Christoforos Chontos
- Internal Medicine Department, University Hospital of Heraklion, 71110 Heraklion, Greece
| | | | - Sofia Maraki
- Department of Clinical Microbiology, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - George Samonis
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Diamantis P Kofteridis
- School of Medicine, University of Crete, 71003 Heraklion, Greece
- Internal Medicine Department, University Hospital of Heraklion, 71110 Heraklion, Greece
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19
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Buis D, van Werkhoven CH, van Agtmael MA, Bax HI, Berrevoets M, de Boer M, Bonten M, Bosmans JE, Branger J, Douiyeb S, Gelinck L, Jong E, Lammers A, Van der Meer J, Oosterheert JJ, Sieswerda E, Soetekouw R, Stalenhoef JE, Van der Vaart TW, Bij de Vaate EA, Verkaik NJ, Van Vonderen M, De Vries PJ, Prins JM, Sigaloff K. Safe shortening of antibiotic treatment duration for complicated Staphylococcus aureus bacteraemia (SAFE trial): protocol for a randomised, controlled, open-label, non-inferiority trial comparing 4 and 6 weeks of antibiotic treatment. BMJ Open 2023; 13:e068295. [PMID: 37085305 PMCID: PMC10124302 DOI: 10.1136/bmjopen-2022-068295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION A major knowledge gap in the treatment of complicated Staphylococcus aureus bacteraemia (SAB) is the optimal duration of antibiotic therapy. Safe shortening of antibiotic therapy has the potential to reduce adverse drug events, length of hospital stay and costs. The objective of the SAFE trial is to evaluate whether 4 weeks of antibiotic therapy is non-inferior to 6 weeks in patients with complicated SAB. METHODS AND ANALYSIS The SAFE-trial is a multicentre, non-inferiority, open-label, parallel group, randomised controlled trial evaluating 4 versus 6 weeks of antibiotic therapy for complicated SAB. The study is performed in 15 university hospitals and general hospitals in the Netherlands. Eligible patients are adults with methicillin-susceptible SAB with evidence of deep-seated or metastatic infection and/or predictors of complicated SAB. Only patients with a satisfactory clinical response to initial antibiotic treatment are included. Patients with infected prosthetic material or an undrained abscess of 5 cm or more at day 14 of adequate antibiotic treatment are excluded. Primary outcome is success of therapy after 180 days, a combined endpoint of survival without evidence of microbiologically confirmed disease relapse. Assuming a primary endpoint occurrence of 90% in the 6 weeks group, a non-inferiority margin of 7.5% is used. Enrolment of 396 patients in total is required to demonstrate non-inferiority of shorter antibiotic therapy with a power of 80%. Currently, 152 patients are enrolled in the study. ETHICS AND DISSEMINATION This is the first randomised controlled trial evaluating duration of antibiotic therapy for complicated SAB. Non-inferiority of 4 weeks of treatment would allow shortening of treatment duration in selected patients with complicated SAB. This study is approved by the Medical Ethics Committee VUmc (Amsterdam, the Netherlands) and registered under NL8347 (the Netherlands Trial Register). Results of the study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NL8347 (the Netherlands Trial Register).
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Affiliation(s)
- Dtp Buis
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - M A van Agtmael
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - H I Bax
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - M Berrevoets
- Department of Internal Medicine, Elisabeth twee-steden Hospital, Tilburg, The Netherlands
| | - Mgj de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Mjm Bonten
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - J E Bosmans
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health research institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - J Branger
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | - S Douiyeb
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Lbs Gelinck
- Department of Internal Medicine, Haaglanden Medisch Centrum, Den Haag, The Netherlands
| | - E Jong
- Department of Internal Medicine, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Ajj Lammers
- Department of Internal medicine & Infectious Diseases, Isala Zwolle, Zwolle, The Netherlands
| | - Jtm Van der Meer
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - J J Oosterheert
- Department of Internal Medicine, Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - E Sieswerda
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - R Soetekouw
- Department of Internal Medicine, Spaarne Gasthuis, Haarlem/Hoofddorp, The Netherlands
| | - J E Stalenhoef
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
| | - T W Van der Vaart
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - E A Bij de Vaate
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N J Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | | | - P J De Vries
- Department of Internal Medicine, Tergooi Hospital, Hilversum, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Kce Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
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