1
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Fisher M, Komarow L, Kahn J, Patel G, Revolinski S, Huskins WC, van Duin D, Banerjee R, Fries BC. Carbapenem-resistant Enterobacterales in Children at 18 US Health Care System Study Sites: Clinical and Molecular Epidemiology From a Prospective Multicenter Cohort Study. Open Forum Infect Dis 2024; 11:ofad688. [PMID: 38390459 PMCID: PMC10883725 DOI: 10.1093/ofid/ofad688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 02/24/2024] Open
Abstract
Background Carbapenem-resistant Enterobacterales (CRE) are an urgent public health threat in the United States. Objective Describe the clinical and molecular epidemiology of CRE in a multicenter pediatric cohort. Methods CRACKLE-1 and CRACKLE-2 are prospective cohort studies with consecutive enrollment of hospitalized patients with CRE infection or colonization between 24 December 2011 and 31 August 2017. Patients younger than age 18 years and enrolled in the CRACKLE studies were included in this analysis. Clinical data were obtained from the electronic health record. Carbapenemase genes were detected using polymerase chain reaction and whole-genome sequencing. Results Fifty-one children were identified at 18 healthcare system study sites representing all U.S. census regions. The median age was 8 months, with 67% younger than age 2 years. Median number of days from admission to culture collection was 11. Seventy-three percent of patients had required intensive care and 41% had a history of mechanical ventilation. More than half of children had no documented comorbidities (Q1, Q3 0, 2). Sixty-seven percent previously received antibiotics during their hospitalization. The most common species isolated were Enterobacter species (41%), Klebsiella pneumoniae (27%), and Escherichia coli (20%). Carbapenemase genes were detected in 29% of isolates tested, which was lower than previously described in adults from this cohort (61%). Thirty-four patients were empirically treated on the date of culture collection, but only 6 received an antibiotic to which the CRE isolate was confirmed susceptible in vitro. Thirty-day mortality was 13.7%. Conclusions CRE infection or colonization in U.S. children was geographically widespread, predominantly affected children younger than age 2 years, associated with significant mortality, and less commonly caused by carbapenemase-producing strains than in adults.
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Affiliation(s)
- Matthew Fisher
- Department of Medicine, Division of Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
- Department of Pediatrics, Division of Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
| | - Lauren Komarow
- The Biostatistics Center, The George Washington University, Rockville, Maryland, USA
| | - Jordan Kahn
- The Biostatistics Center, The George Washington University, Rockville, Maryland, USA
| | - Gopi Patel
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara Revolinski
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - W Charles Huskins
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David van Duin
- Department of Medicine, Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ritu Banerjee
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bettina C Fries
- Department of Medicine, Division of Infectious Diseases, Stony Brook University, Stony Brook, New York, USA
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2
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Heydarian N, Wouters CL, Neel A, Ferrell M, Panlilio H, Haight T, Gu T, Rice CV. Eradicating Biofilms of Carbapenem-Resistant Enterobacteriaceae by Simultaneously Dispersing the Biomass and Killing Planktonic Bacteria with PEGylated Branched Polyethyleneimine. ChemMedChem 2023; 18:e202200428. [PMID: 36542457 PMCID: PMC9899318 DOI: 10.1002/cmdc.202200428] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/21/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are emerging pathogens that cause variety of severe infections. CRE evade antibiotic treatments because these bacteria produce enzymes that degrade a wide range of antibiotics including carbapenems and β-lactams. The formation of biofilms aggravates CRE infections, especially in a wound environment. These difficulties lead to persistent infection and non-healing wounds. This creates the need for new compounds to overcome CRE antimicrobial resistance and disrupt biofilms. Recent studies in our lab show that 600 Da branched polyethyleneimine (BPEI) and its derivative PEG350-BPEI can overcome antimicrobial resistance and eradicate biofilms in methicillin-resistant S. aureus, methicillin-resistant S. epidermidis, P. aeruginosa, and E. coli. In this study, the ability of 600 Da BPEI and PEG350-BPEI to eradicate carbapenem-resistant Enterobacteriaceae bacteria and their biofilms is demonstrated. We show that both BPEI and PEG350-BPEI have anti-biofilm efficacy against CRE strains expressing Klebsiella pneumoniae carbapenemases (KPCs) and metallo-β-lactamases (MBLs), such as New Delhi MBL (NDM-1). Furthermore, our results illustrate that BPEI affects planktonic CRE bacteria by increasing bacterial length and width from the inability to proceed with normal cell division processes. These data demonstrate the multi-functional properties of 600 Da BPEI and PEG350-BPEI to reduce biofilm formation and mitigate virulence in carbapenem-resistant Enterobacteriaceae.
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Affiliation(s)
- Neda Heydarian
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Cassandra L. Wouters
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Andrew Neel
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Maya Ferrell
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Hannah Panlilio
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Tristan Haight
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
| | - Tingting Gu
- Department of Biology, 730 Van Vleet Oval, Room 314, University of Oklahoma, Norman, OK 73019, USA
| | - Charles V. Rice
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, OK 73019
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3
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Panlilio H, Neel A, Heydarian N, Best W, Atkins I, Boris A, Bui M, Dick C, Ferrell M, Gu T, Haight T, Roedl CC, Rice CV. Antibiofilm Activity of PEGylated Branched Polyethylenimine. ACS OMEGA 2022; 7:44825-44835. [PMID: 36530285 PMCID: PMC9753512 DOI: 10.1021/acsomega.2c04911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
Biofilm formation is an adaptive resistance mechanism that pathogens employ to survive in the presence of antimicrobials. Pseudomonas aeruginosa is an infectious Gram-negative bacterium whose biofilm allows it to withstand antimicrobial attack and threaten human health. Chronic wound healing is often impeded by P. aeruginosa infections and the associated biofilms. Previous findings demonstrate that 600 Da branched polyethylenimine (BPEI) can restore β-lactam potency against P. aeruginosa and disrupt its biofilms. Toxicity concerns of 600 Da BPEI are mitigated by covalent linkage with low-molecular-weight polyethylene glycol (PEG), and, in this study, PEGylated BPEI (PEG350-BPEI) was found exhibit superior antibiofilm activity against P. aeruginosa. The antibiofilm activity of both 600 Da BPEI and its PEG derivative was characterized with fluorescence studies and microscopy imaging. We also describe a variation of the colony biofilm model that was employed to evaluate the biofilm disruption activity of BPEI and PEG-BPEI.
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Affiliation(s)
- Hannah Panlilio
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Andrew Neel
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Neda Heydarian
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - William Best
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Isaac Atkins
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Andrew Boris
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Maggie Bui
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Catherine Dick
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Maya Ferrell
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Tingting Gu
- Department
of Biology, University of Oklahoma, 730 Van Vleet Oval, Room 314, Norman, Oklahoma 73019, United States
| | - Tristan Haight
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Chase C. Roedl
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
| | - Charles V. Rice
- Department
of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73069, United States
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4
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Abstract
PURPOSE OF REVIEW Skin and soft tissue infections (SSTIs) are a leading cause of morbidity, emergency department visits and hospitalization. In recent years, the spread of carbapenem-resistant gram-negative bacteria (GNB) is also increasing in SSTIs. However, the armamentarium of available drugs is recently expanding as well. In this review, we reported the most recent data and about management and treatment of SSTIs caused by GNB, mainly for the treatment of carbapenem-resistant Enterobacterales (CRE), Pseudomonas spp and Acinetobacter spp. RECENT FINDINGS The increasing incidence of carbapenem-resistant GNB is challenging for management and treatment, considering the high rate of inappropriate empiric and targeted antimicrobial treatments. The role of new antibiotics, mainly licensed for the treatment of other infections, is an object of continuous debate. As a matter of fact, no specific clinical trials on SSTIs have been performed for new drugs; however, recent data about the use in real life of new compounds in clinical practice are available. SUMMARY Some recently approved drugs are actually considered the backbone of targeted therapy in patients with severe infections caused by susceptible carbapenem-resistant GNB strains. Prompt diagnosis of cSSTIs is crucial and, when necessary, surgical debridement for source control of infection is the milestone of the treatment. The physicians should be confident to identify patients at high risk for multidrug-resistant pathogens to minimize inappropriate empiric therapy.
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5
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Current international and national guidelines for managing skin and soft tissue infections. Curr Opin Infect Dis 2022; 35:61-71. [PMID: 35067522 DOI: 10.1097/qco.0000000000000814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Skin and soft tissue infections account for a significant percentage of both community and nosocomial infections. Several nosological entities are included in this concept. However, there is a very scarce body of doctrine for their treatment based on randomised trials. Therefore, we considered it necessary to review current treatment guidelines to bring new recommendations and improvements to our colleagues. In this review of recent literature, we identified updated guidelines in this area by searching the databases PubMed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip and Sumsearch using the terms: soft tissue infection, therapy, guideline. RECENT FINDINGS Developments focus on using new antimicrobials and on the prescription of shorter antibiotic treatment courses. SUMMARY With the development of new drugs and the current evidence of their use, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life, which allows weekly administration, can reduce hospital admission and length of stay with fewer healthcare resources. Shorter courses of antibiotics are recommended. The role of stewardship programmes will continue to expand. The surgical indication and its value are evident in many patients. Therefore, management should rely on a collaborative group with experience in this disease.
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6
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Panlilio H, Lam AK, Heydarian N, Haight T, Wouters CL, Moen EL, Rice CV. Dual-Function Potentiation by PEG-BPEI Restores Activity of Carbapenems and Penicillins against Carbapenem-Resistant Enterobacteriaceae. ACS Infect Dis 2021; 7:1657-1665. [PMID: 33945257 PMCID: PMC8689638 DOI: 10.1021/acsinfecdis.0c00863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The rise of life-threatening carbapenem-resistant Enterobacteriaceae (CRE) infections has become a critical medical threat. Some of the most dangerous CRE bacteria can produce enzymes that degrade a wide range of antibiotics, including carbapenems and β-lactams. Infections by CRE have a high mortality rate, and survivors can have severe morbidity from treatment with toxic last-resort antibiotics. CRE have mobile genetic elements that transfer resistance genes to other species. These bacteria also circulate throughout the healthcare system. The mobility and spread of CRE need to be curtailed, but these goals are impeded by having few agents that target a limited range of pathogenic CRE species. Against CRE possessing the metallo-β-lactamase NDM-1, Klebsiella pneumoniae ATCC BAA-2146 and Escherichia coli ATCC BAA-2452, the potentiation of meropenem and imipenem is possible with low-molecular weight branched polyethylenimine (600 Da BPEI) and its poly(ethylene glycol) (PEG)ylated derivative (PEG-BPEI) that has a low in vivo toxicity. The mechanism of action is elucidated with fluorescence assays of drug influx and isothermal calorimetry data showing the chelation of essential Zn2+ ions. These results suggested that 600 Da BPEI and PEG-BPEI may also improve the uptake of antibiotics and β-lactamase inhibitors. Indeed, the CRE E. coli strain is rendered susceptible to the combination of piperacillin and tazobactam. These results expand the possible utility of 600 Da BPEI potentiators, where previously we have demonstrated the ability to improve antibiotic efficacy against antibiotic resistant clinical isolates of Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis.
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Affiliation(s)
- Hannah Panlilio
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Anh K Lam
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Neda Heydarian
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Tristan Haight
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Cassandra L Wouters
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Erika L Moen
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
| | - Charles V Rice
- Department of Chemistry and Biochemistry, Stephenson Life Sciences Research Center, University of Oklahoma, 101 Stephenson Parkway, Norman, Oklahoma 73019, United States
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7
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A γ-lactam siderophore antibiotic effective against multidrug-resistant Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter spp. Eur J Med Chem 2021; 220:113436. [PMID: 33933754 DOI: 10.1016/j.ejmech.2021.113436] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
Serious infections caused by multidrug-resistant (MDR) organisms (Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii) present a critical need for innovative drug development. Herein, we describe the preclinical evaluation of YU253911, 2, a novel γ-lactam siderophore antibiotic with potent antimicrobial activity against MDR Gram-negative pathogens. Penicillin-binding protein (PBP) 3 was shown to be a target of 2 using a binding assay with purified P. aeruginosa PBP3. The specific binding interactions with P. aeruginosa were further characterized with a high-resolution (2.0 Å) X-ray structure of the compound's acylation product in P. aeruginosa PBP3. Compound 2 was shown to have a concentration >1 μg/ml at the 6 h time point when administered intravenously or subcutaneously in mice. Employing a meropenem resistant strain of P. aeruginosa, 2 was shown to have dose-dependent efficacy at 50 and 100 mg/kg q6h dosing in a mouse thigh infection model. Lastly, we showed that a novel γ-lactam and β-lactamase inhibitor (BLI) combination can effectively lower minimum inhibitory concentrations (MICs) against carbapenem resistant Acinetobacter spp. that demonstrated decreased susceptibility to 2 alone.
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8
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Interplay between ESKAPE Pathogens and Immunity in Skin Infections: An Overview of the Major Determinants of Virulence and Antibiotic Resistance. Pathogens 2021; 10:pathogens10020148. [PMID: 33540588 PMCID: PMC7912840 DOI: 10.3390/pathogens10020148] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The skin is the largest organ in the human body, acting as a physical and immunological barrier against pathogenic microorganisms. The cutaneous lesions constitute a gateway for microbial contamination that can lead to chronic wounds and other invasive infections. Chronic wounds are considered as serious public health problems due the related social, psychological and economic consequences. The group of bacteria known as ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter sp.) are among the most prevalent bacteria in cutaneous infections. These pathogens have a high level of incidence in hospital environments and several strains present phenotypes of multidrug resistance. In this review, we discuss some important aspects of skin immunology and the involvement of ESKAPE in wound infections. First, we introduce some fundamental aspects of skin physiology and immunology related to cutaneous infections. Following this, the major virulence factors involved in colonization and tissue damage are highlighted, as well as the most frequently detected antimicrobial resistance genes. ESKAPE pathogens express several virulence determinants that overcome the skin's physical and immunological barriers, enabling them to cause severe wound infections. The high ability these bacteria to acquire resistance is alarming, particularly in the hospital settings where immunocompromised individuals are exposed to these pathogens. Knowledge about the virulence and resistance markers of these species is important in order to develop new strategies to detect and treat their associated infections.
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9
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Abstract
Skin and soft tissue infections (SSTIs) frequently are encountered in clinical practice, and gram-negative bacilli (GNB) constitute an underrated portion of their etiology. The rate of GNB-causing SSTIs is increasing, especially with the rise in antimicrobial resistance. Although the diagnosis of SSTIs mostly is clinical, rapid diagnostic modalities can shorten the time to initiating proper therapy and improving outcomes. Novel antibiotics are active against GNB SSTIs and can be of great value in the management. This review provides an overview of the role of GNB in SSTIs and summarizes their epidemiology, risk factors, outcome, and clinical management.
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Affiliation(s)
- Jean-Francois Jabbour
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon.
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10
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Puzniak L, DePestel DD, Yu K, Ye G, Gupta V. Epidemiology and regional variation of nonsusceptible and multidrug-resistant Pseudomonas aeruginosa isolates from intensive versus non-intensive care units across multiple centers in the United States. Diagn Microbiol Infect Dis 2020; 99:115172. [PMID: 33130502 DOI: 10.1016/j.diagmicrobio.2020.115172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
Nonsusceptible (NS) and multidrug-resistant (MDR) Pseudomonas aeruginosa (PsA) infections are associated with considerable mortality. This retrospective study assessed NS PsA and MDR PsA prevalence in US intensive care unit (ICU) and non-ICU settings. We evaluated nonduplicate PsA isolates collected in 2017. Data were classified by hospital admission setting. PsA isolates were evaluated for NS to each of 4 drug classes and MDR. Significantly higher rates of NS PsA and MDR PsA were found in ICU versus non-ICU settings (P < .001), except for respiratory isolates, which had high rates regardless of setting; rates also correlated with source, hospital size, urban/rural status, and geographic region. NS PsA isolates for each antibacterial category (except fluoroquinolones) and MDR PsA were significantly more likely to be classified as hospital-onset than admission-onset (P < .001). These data are consistent with previous reports and emphasize the importance of testing for resistant infection upon admission and when treating hospital-acquired infections.
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Affiliation(s)
- Laura Puzniak
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA.
| | - Daryl D DePestel
- Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ 07033, USA.
| | - Kalvin Yu
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ 07417, USA.
| | - Gang Ye
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ 07417, USA.
| | - Vikas Gupta
- Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ 07417, USA.
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11
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Goldberg JA, Nguyen H, Kumar V, Spencer EJ, Hoyer D, Marshall EK, Cmolik A, O'Shea M, Marshall SH, Hujer AM, Hujer KM, Rudin SD, Domitrovic TN, Bethel CR, Papp-Wallace KM, Logan LK, Perez F, Jacobs MR, van Duin D, Kreiswirth BM, Bonomo RA, Plummer MS, van den Akker F. A γ-Lactam Siderophore Antibiotic Effective against Multidrug-Resistant Gram-Negative Bacilli. J Med Chem 2020; 63:5990-6002. [PMID: 32420736 DOI: 10.1021/acs.jmedchem.0c00255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Treatment of multidrug-resistant Gram-negative bacterial pathogens represents a critical clinical need. Here, we report a novel γ-lactam pyrazolidinone that targets penicillin-binding proteins (PBPs) and incorporates a siderophore moiety to facilitate uptake into the periplasm. The MIC values of γ-lactam YU253434, 1, are reported along with the finding that 1 is resistant to hydrolysis by all four classes of β-lactamases. The druglike characteristics and mouse PK data are described along with the X-ray crystal structure of 1 binding to its target PBP3.
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Affiliation(s)
- Joel A Goldberg
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Ha Nguyen
- Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Vijay Kumar
- Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Elizabeth J Spencer
- Yale Center for Molecular Discovery, West Haven, Connecticut 06516, United States
| | - Denton Hoyer
- Yale Center for Molecular Discovery, West Haven, Connecticut 06516, United States
| | - Emma K Marshall
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Anna Cmolik
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Margaret O'Shea
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Steven H Marshall
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Andrea M Hujer
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Kristine M Hujer
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Susan D Rudin
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - T Nicholas Domitrovic
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Christopher R Bethel
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Latania K Logan
- Department of Pediatrics, Rush University Medical Center, Rush Medical College, Chicago, Illinois 60612, United States.,Cook County Health and Hospital Systems, Chicago, Illinois 60612, United States
| | - Federico Perez
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States.,Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States
| | - Michael R Jacobs
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States.,Department of Pathology, University Hospitals Cleveland Medical Center, Division of Clinical Microbiology, Cleveland, Ohio 44106, United States
| | - David van Duin
- University of North Carolina School of Medicine, Chapel Hill, North Carolina 27514, United States
| | - Barry M Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey 07601, United States
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio 44106, United States.,Department of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States.,Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, United States.,Departments of Pharmacology, Molecular Biology & Microbiology, and Proteomics & Bioinformatics, Case Western Reserve University, Cleveland, Ohio 44106, United States.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio 44106, United States
| | - Mark S Plummer
- Yale Center for Molecular Discovery, West Haven, Connecticut 06516, United States
| | - Focco van den Akker
- Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio 44106, United States
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12
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Abstract
PURPOSE OF REVIEW Skin and soft tissue infections (SSTIs) are among the most common infections in outpatients and the most frequent infectious cause of referrals to emergency departments in developed world, contributing to significant morbidity and healthcare expenditures. We sought to review recent literature covering epidemiology of SSTIs. RECENT FINDINGS Staphylococcus aureus and streptococci predominate and methicillin-resistant S. aureus (MRSA) poses additional challenges; community-acquired-MRSA in some areas is superseding methicillin-susceptible S. aureus and multidrug resistance is evolving. Incidence data of SSTIs from United States show a decreasing trend, whereas trends of hospitalization rates were increasing. Despite low mortality associated with SSTIs, high rates of treatment failure and relapses are of concern. Diagnosis and management decisions in the emergency department (ED) lack validated tools for prediction of clinical response particularly among elderly, immunocompromised, obese, and patients with comorbidities. A variety of modifiable and nonmodifiable risk factors of the host and data from local epidemiology should be considered to prevent recurrence and treatment failure. SUMMARY An evolving epidemiology of SSTIs make microbiologic documentation and surveillance of local data imperative. New assessment algorithms with potential use in the ED are a priority. The universal applicability of international guidelines is questioned in this setting.
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13
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The role of carbapenem-resistant pathogens in cSSTI and how to manage them. Curr Opin Infect Dis 2019; 32:113-122. [DOI: 10.1097/qco.0000000000000528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Giannella M, Pascale R, Gutiérrez-Gutiérrez B, Cano A, Viale P. The use of predictive scores in the management of patients with carbapenem-resistant Klebsiella pneumoniae infection. Expert Rev Anti Infect Ther 2019; 17:265-273. [PMID: 30876375 DOI: 10.1080/14787210.2019.1595590] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections are associated with high morbidity and mortality rates. A therapeutic approach based on the patient risk stratification could improve outcome and avoid antibiotic misuse. Areas covered: English literature search, from 2008 to 2018, was done using PubMed database. Risk factors for developing CR-KP infection in several settings were reviewed. Since, rectal carriage was a main risk factor for developing infection, we revised in deep clinical score to predict infection among colonized patients. Furthermore, we investigated overall and treatment-related risk factors for poor outcome in patients with CR-KP infection, in particular the carbapenem producing Enterobacteriacieae (CPE)-INCREMENT score. Finally, an algorithm, based on such scores, for the therapeutic management of patients with CR-KP colonization was commented. Expert opinion: The therapeutic approach analyzed in this review could help physicians to avoid antibiotic overuse as well as to start promptly with the most appropriate antibiotic regimen. However, it has to be validated in further studies, mainly among special population such as immunocompromised patients. The availability of new drugs, fast microbiology, and analysis of gut microbiome could significantly improve the management of CR-KP colonized and/or infected patients.
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Affiliation(s)
- Maddalena Giannella
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Renato Pascale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Belén Gutiérrez-Gutiérrez
- b Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS) and Department of Medicine , Universidad de Sevilla , Sevilla , Spain
| | - Angela Cano
- c Infectious Diseases Unit , Hospital Univesritario Reina Sofia-Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC)-Unversidad de Cordoba , Cordoba , Spain
| | - Pierluigi Viale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
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Bazzi AM, Rabaan AA, Al-Tawfiq JA, Shannak BM. Comparison of Effectiveness of Germania Honey Compared to Manuka Honey in Methicillin-Resistant Staphylococcus aureus (MRSA) Killing. Open Microbiol J 2019. [DOI: 10.2174/1874285801913010021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Purpose:
Manuka honey is currently used in medical-grade sterile wound treatment products and has been shown to be effective in methicillin-resistant Staphylococcus aureus (MRSA) killing in vitro and in wound healing in a number of case studies and series. Locally produced honey in Pakistan and Chile have been proposed to be as effective as Manuka honey in bacterial killing in vitro, presenting potentially more accessible and affordable alternatives. In this study, we compared the effectiveness of a local Germania honey from Saudi Arabia to Manuka honey MGO 550 for in vitro killing of MRSA.
Methodology:
Overnight Muller Hinton broth cultures of 50 wound culture isolates of MRSA from 50 patients were incubated with a series of dilutions of Manuka honey MGO 550 and corresponding Germania honey dilutions for 24 h. Turbidity was assessed to determine whether bacterial growth had occurred, and no growth was confirmed by a further 24 h sub-culture on blood agar.
Results/Key findings:
Manuka honey MGO 550 was significantly more effective than Germania honey at MRSA killing at 100% v/v, 50% v/v and 25% v/v (p=0.025, 0.000265, and 0.000112 respectively)
Conclusion:
Manuka honey MGO 550 is significantly more effective in killing MRSA in vitro than Germania honey. Germania honey does not appear to be a promising locally produced alternative to Manuka honey for the development of honey-based wound dressings. Further experiments could determine if Germania honey is effective against other bacterial species.
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Jacobs MR, Abdelhamed AM, Good CE, Rhoads DD, Hujer KM, Hujer AM, Domitrovic TN, Rudin SD, Richter SS, van Duin D, Kreiswirth BN, Greco C, Fouts DE, Bonomo RA. ARGONAUT-I: Activity of Cefiderocol (S-649266), a Siderophore Cephalosporin, against Gram-Negative Bacteria, Including Carbapenem-Resistant Nonfermenters and Enterobacteriaceae with Defined Extended-Spectrum β-Lactamases and Carbapenemases. Antimicrob Agents Chemother 2019; 63:e01801-18. [PMID: 30323050 PMCID: PMC6325197 DOI: 10.1128/aac.01801-18] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/06/2018] [Indexed: 01/06/2023] Open
Abstract
The activity of the siderophore cephalosporin cefiderocol is targeted against carbapenem-resistant Gram-negative bacteria. In this study, the activity of cefiderocol against characterized carbapenem-resistant Acinetobacter baumannii complex, Stenotrophomonas maltophilia, Pseudomonas aeruginosa, and Enterobacteriaceae strains was determined by microdilution in iron-depleted Mueller-Hinton broth. The MIC90s against A. baumannii, S. maltophilia, and P. aeruginosa were 1, 0.25, and 0.5 mg/liter, respectively. Against Enterobacteriaceae, the MIC90 was 1 mg/liter for the group harboring OXA-48-like, 2 mg/liter for the group harboring KPC-3, and 8 mg/liter for the group harboring TEM/SHV ESBL, NDM, and KPC-2.
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Affiliation(s)
- Michael R Jacobs
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ayman M Abdelhamed
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Caryn E Good
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniel D Rhoads
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Kristine M Hujer
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Andrea M Hujer
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - T Nicholas Domitrovic
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Susan D Rudin
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Sandra S Richter
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - David van Duin
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Barry N Kreiswirth
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Chris Greco
- J. Craig Venter Institute, Rockville, Maryland, USA
| | | | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Pharmacology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio, USA
- Center for Proteomics and Bioinformatics, Case Western Reserve University, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case Virginia, USA CARES), Cleveland, Ohio, USA
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Esposito S, Ascione T, Pagliano P. Management of bacterial skin and skin structure infections with polymicrobial etiology. Expert Rev Anti Infect Ther 2018; 17:17-25. [PMID: 30518267 DOI: 10.1080/14787210.2019.1552518] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Skin and Soft Tissue Infections (SSTIs) are some of the most commonly occurring bacterial infections, with a wide range of possible etiological pathogens and a considerable variety of clinical presentations and severity; from mild to severe life-threatening infections. Several classifications have been proposed based on a specific variable, such as anatomical localization, skin extension, progression rate, clinical presentation, severity, and etiological agent. Areas covered: The last criteria allows the differentiation of SSTIs as monomicrobial and polymicrobial. Among them, especially those infections with a long lasting or chronic course can be sustained by multiple microbial etiology. Most polymicrobial SSTIs can be included in the following: diabetes foot infections (DFIs), pressure ulcers infection, burn infection, and infected chronic ulcers. Expert commentary: The medical management of these infections comprises the administration of wide a spectrum antibiotic, taking into consideration the frequent occurrence of multidrug resistant microorganisms as responsible agents. An appropriate deep tissue specimen for microbiological examination is a very important issue, especially for polymicrobial infections, sometimes permitting the distinction between real pathogens and contaminants avoiding more complex antibiotic treatments. This aspect must be strongly emphasized, as frequently superficial swabs remain the specimen of choice because they are easy to obtain.
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Affiliation(s)
- Silvano Esposito
- a Departement of Infectious Diseases , University of Salerno , Salerno , Italy
| | - Tiziana Ascione
- b Department of Infectious Diseases , AORN dei Colli , Naples , Italy
| | - Pasquale Pagliano
- b Department of Infectious Diseases , AORN dei Colli , Naples , Italy
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McCann E, Srinivasan A, DeRyke CA, Ye G, DePestel DD, Murray J, Gupta V. Carbapenem-Nonsusceptible Gram-Negative Pathogens in ICU and Non-ICU Settings in US Hospitals in 2017: A Multicenter Study. Open Forum Infect Dis 2018; 5:ofy241. [PMID: 30364442 PMCID: PMC6194421 DOI: 10.1093/ofid/ofy241] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/18/2018] [Indexed: 11/16/2022] Open
Abstract
Background Infections caused by Gram-negative pathogens resistant to carbapenems have limited treatment options and are associated with increased morbidity and mortality. We evaluated the rates, infection sources, and pathogen types associated with carbapenem-nonsusceptible (Carb-NS) Gram-negative isolates in intensive care unit (ICU) and non-ICU settings in a large US hospital database. Methods We conducted a retrospective cross-sectional analysis of carbapenem susceptibility of all nonduplicate isolates of Gram-negative pathogens collected from January 1, 2017, to December 31, 2017, at 358 US hospitals in the BD Insights Research Database. Carb-NS isolates included all pathogens reported at the institutional level as intermediate or resistant. Results Of 312 075 nonduplicate Gram-negative isolates, 10 698 (3.4%) were Carb-NS. Respiratory samples were the most frequent source of Carb-NS isolates (35.2%); skin/wound accounted for 23.6%. Pseudomonas aeruginosa was the most common Carb-NS pathogen (58.5% of isolates), and about 30% were Enterobacteriaceae. The highest rates of Carb-NS were found in Acinetobacter spp. (35.6%) and P. aeruginosa (14.6%). The rate of Carb-NS was significantly higher in ICU (5.4%) vs non-ICU settings (2.7%; P < .0001 in univariate analysis). This difference remained significant in multivariable analysis after adjusting for infection and hospital characteristics (odds ratio, 1.35; 95% confidence interval, 1.17–1.56; P < .0001). Conclusions Infections caused by Carb-NS isolates pose a significant clinical problem across different sources of infection, species of pathogen, and hospital settings. Widespread infection prevention and antimicrobial stewardship initiatives, in combination with new treatment options, may be required to reduce the burden of carbapenem resistance in health care settings.
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Affiliation(s)
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Gang Ye
- Becton, Dickinson and Company, Franklin Lakes, New Jersey
| | | | - John Murray
- Becton, Dickinson and Company, Franklin Lakes, New Jersey
| | - Vikas Gupta
- Becton, Dickinson and Company, Franklin Lakes, New Jersey
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19
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Ioannou P, Tsagkaraki E, Athanasaki A, Tsioutis C, Gikas A. Gram-negative bacteria as emerging pathogens affecting mortality in skin and soft tissue infections. Hippokratia 2018; 22:23-28. [PMID: 31213754 PMCID: PMC6528699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Skin and soft tissue infections (SSTIs) are commonly encountered in clinical practice and mainly caused by gram-positive cocci such as S.aureus and β-hemolytic streptococci. Complicated SSTIs involving deeper tissues often necessitate surgical intervention and occur in patients with significant comorbidities such as diabetes or immunocompromising conditions. METHODS In this study, we retrospectively reviewed the epidemiology, clinical characteristics, microbiology, and treatment of patients admitted with SSTI during a five-year period in the Internal Medicine Department of a tertiary hospital. RESULTS During the study period, 317 patients were recorded, with a mean age of 72.1 years. The most common underlying medical conditions were diabetes mellitus, chronic kidney disease, and heart failure. Cultures were positive in 23.3 % of cases, 62.2 % of which were polymicrobial. The most frequently isolated microorganisms were Enterococci, Escherichia coli, and Pseudomonas aeruginosa. Significant antimicrobial resistance rates were noted, in particular for gram-negative microorganisms. Mortality was higher than described in the literature and associated with age, comorbidities, and infection by gram-negative microorganisms. CONCLUSION This study denotes the role of gram-negative bacteria in SSTI epidemiology. Therapeutic protocols regarding the empiric treatment of SSTIs should necessarily take into account the local epidemiology of isolated pathogens and antimicrobial resistance. HIPPOKRATIA 2018, 22(1): 23-28.
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Affiliation(s)
- P Ioannou
- Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
| | - E Tsagkaraki
- Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
| | - A Athanasaki
- Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
| | - C Tsioutis
- Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - A Gikas
- Internal Medicine & Infectious Diseases Department, University Hospital of Heraklion, Heraklion, Greece
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