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Hojat LS, Wilson BM, Satlin MJ, Perez F, Mojica MF, Singer ME, Bonomo RA, Epstein LH. 14-Year Epidemiologic study of Pseudomonas aeruginosa bloodstream infection incidence and resistance in the Veterans Health Administration system, 2009-2022. JAC Antimicrob Resist 2024; 6:dlae031. [PMID: 38449517 PMCID: PMC10914452 DOI: 10.1093/jacamr/dlae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Multidrug resistant Pseudomonas aeruginosa (PA) represents a serious threat to hospitalized patients. Characterizing the incidence of PA infection and degree of resistance can inform empiric treatment and preventative measures. Objectives We sought to describe trends in incidence and resistance characteristics of PA bloodstream infections (BSI) observed within the Veterans Health Administration (VHA) system and identify factors contributing to higher observed mortality within this population. Methods We characterized demographic and clinical features of unique patients among the VHA population presenting with their first episode of PA-BSI between 2009 and 2022 and summarized trends related to mortality and resistance phenotype based on year and geographical location. We additionally used logistic regression analysis to identify predictors of 30-day mortality among this cohort. Results We identified 8039 PA-BSIs during the study period, 32.7% of which were hospital onset. Annual PA-BSI cases decreased by 35.8%, and resistance among all antimicrobial classes decreased during the study period, while the proportion of patients receiving early active treatment based on susceptibility testing results increased. Average 30-day mortality rate was 23.3%. Higher Charlson Comorbidity Index, higher mAPACHE score, VHA facility complexity 1b and hospital-onset cases were associated with higher mortality, and early active treatment was associated with lower mortality. Conclusions PA-BSI resistance decreased across the VHA system during the study period. Further investigation of antimicrobial stewardship measures possibly contributing to the observed decreased resistance in this cohort and identification of measures to improve on the high mortality associated with PA-BSI in the VHA population is warranted.
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Affiliation(s)
- Leila S Hojat
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brigid M Wilson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Michael J Satlin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Federico Perez
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, OH, USA
| | - Maria F Mojica
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
| | - Mendel E Singer
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Robert A Bonomo
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
- Geriatric Research Education and Clinical Center (GRECC), The VA Northeast Ohio Healthcare System, Cleveland, OH, USA
- Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, OH, USA
- Research Service, VA Northeast Ohio Healthcare System, Cleveland, OH, USA
| | - Lauren H Epstein
- US Department of Veterans Affairs Medical Center, Emory University, Atlanta, Georgia, USA
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Guillamet CV, Kollef MH. Is Zero Ventilator-Associated Pneumonia Achievable? Updated Practical Approaches to Ventilator-Associated Pneumonia Prevention. Infect Dis Clin North Am 2024; 38:65-86. [PMID: 38040518 DOI: 10.1016/j.idc.2023.11.001] [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] [Indexed: 12/03/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a significant clinical entity with reported incidence rates of 7% to 15%. Given the considerable adverse consequences associated with this infection, VAP prevention became a core measure required in most US hospitals. Many institutions took pride in implementing effective VAP prevention bundles that combined at least head of bed elevation, hand hygiene, chlorhexidine oral care, and subglottic drainage. Spontaneous breathing and awakening trials have also consistently been shown to shorten the duration of mechanical ventilation and secondarily reduce the occurrence of VAP.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Martin-Loeches I, Bruno CJ, DeRyke CA. Perspectives on the use of ceftolozane/tazobactam: a review of clinical trial data and real-world evidence. Future Microbiol 2024; 19:465-480. [PMID: 38252038 PMCID: PMC11216532 DOI: 10.2217/fmb-2023-0197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/06/2023] [Indexed: 01/23/2024] Open
Abstract
Hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are common healthcare-associated infections linked to high morbidity and mortality. Gram-negative pathogens, such as Pseudomonas aeruginosa, exhibit multidrug resistance and are recognized as major public health concerns, particularly among critically ill patients with HABP/VABP. Ceftolozane/tazobactam is a novel combination antibacterial agent comprising ceftolozane (a potent antipseudomonal cephalosporin) and tazobactam (a β-lactamase inhibitor). Phase III trials have demonstrated non-inferiority of ceftolozane/tazobactam to comparators, leading to the approval of ceftolozane/tazobactam for the treatment of complicated urinary tract infections, complicated intra-abdominal infections, and nosocomial pneumonia. In this article, we review the clinical trial evidence and key real-world effectiveness data of ceftolozane/tazobactam for the treatment of serious healthcare-associated Gram-negative infections, focusing on patients with HABP/VABP.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, D08 NHY1, Ireland
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Sophonsri A, Lou M, Ny P, Minejima E, Nieberg P, Wong-Beringer A. Machine learning to identify risk factors associated with the development of ventilated hospital-acquired pneumonia and mortality: implications for antibiotic therapy selection. Front Med (Lausanne) 2023; 10:1268488. [PMID: 38170135 PMCID: PMC10759933 DOI: 10.3389/fmed.2023.1268488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background Among patients with nosocomial bacterial pneumonia, those who decompensated to requiring mechanical ventilation (vHABP) faced the highest mortality followed by ventilator-associated pneumonia (VABP) and non-ventilated hospital-acquired pneumonia (nvHABP). The objectives of this study were to identify risk factors associated with the development and mortality of vHABP and to evaluate antibiotic management. Methods A multicenter retrospective cohort study of adult inpatients with nosocomial pneumonia during 2014-2019 was performed. Groups were stratified by vHABP, nvHABP, and VABP and compared on demographics, clinical characteristics, treatment, and outcomes. Multivariable models were generated via machine learning to identify risk factors for progression to vHABP as well as pneumonia-associated mortality for each cohort. Results 457 patients (32% nvHABP, 37% vHABP, and 31% VABP) were evaluated. The vHABP and nvHABP groups were similar in age (median age 66.4 years) with 77% having multiple comorbidities but more vHABP patients had liver disease (18.2% vs. 7.7% p = 0.005), alcohol use disorder (27% vs. 7.1%, p < 0.0001), and were hospitalized within the past 30 days (30.4% vs. 19.5%, p = 0.02). An immediate need for ventilatory support occurred in 70% of vHABP patients on the day of diagnosis. Mortality was the highest in vHABP followed by VABP and nvHABP groups (44.6% vs. 36% vs. 14.3%, p < 0.0001). Nearly all (96%) vHABP patients had positive cultures, with Gram-negative pathogens accounting for 58.8% whereby 33.0% were resistant to extended-spectrum β-lactams (ESBLs), ceftriaxone (17.5%), fluoroquinolones (20.6%), and carbapenems (12.4%). Up to half of the vHABP patients with ESBL-Enterobacterales or P. aeruginosa did not receive an effective empiric regimen; over 50% increase in mortality rate was observed among patients whom effective therapy was initiated past the day of pneumonia diagnosis. Risk factors associated with vHABP development were alcohol use disorder, APACHE II score, vasopressor therapy prior to infection, and culture positive for ESBL-Enterobacterales whereas history of hospitalization in the past 30 days, active malignancy, isolation of ceftriaxone-resistant pathogens or Pseudomonas aeruginosa, and vasopressor therapy were risk factors for vHABP-associated mortality. Conclusion Patients with vHABP experienced an acute and severe decompensation upon diagnosis. The risk factors identified in this study could provide actionable data for clinicians to identify those at risk for vHABP at the onset of pneumonia and to target antimicrobial stewardship efforts to improve treatment success.
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Affiliation(s)
- Anthony Sophonsri
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
| | - Mimi Lou
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
| | - Pamela Ny
- Department of Pharmacy, Huntington Hospital, Pasadena, CA, United States
| | - Emi Minejima
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
- Department of Pharmacy, Los Angeles General Medical Center, Los Angeles, CA, United States
| | - Paul Nieberg
- Department of Medicine – Infectious Diseases, Huntington Hospital, Pasadena, CA, United States
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
- Department of Pharmacy, Huntington Hospital, Pasadena, CA, United States
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Adrover-Jaume C, Clemente A, Rodríguez-Urretavizcaya B, Vilaplana L, Marco MP, Rojo-Molinero E, Oliver A, de la Rica R. A paper biosensor for overcoming matrix effects interfering with the detection of sputum pyocyanin with competitive immunoassays. Mikrochim Acta 2023; 190:441. [PMID: 37845505 PMCID: PMC10579119 DOI: 10.1007/s00604-023-06017-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
Detecting sputum pyocyanin (PYO) with a competitive immunoassay is a promising approach for diagnosing Pseudomonas aeruginosa respiratory infections. However, it is not possible to perform a negative control to evaluate matrix-effects in competitive immunoassays, and the highly complex sputum matrix often interferes with target detection. Here, we show that these issues are alleviated by performing competitive immunoassays with a paper biosensor. The biosensing platform consists of a paper reservoir, which contains antibody-coated gold nanoparticles, and a substrate containing a competing recognition element, which is a piece of paper modified with an albumin-antigen conjugate. Detection of PYO with a limit of detection of 4.7·10-3 µM and a dynamic range between 4.7·10-1 µM and 47.6 µM is accomplished by adding the sample to the substrate with the competing element and pressing the reservoir against it for 5 min. When tested with patient samples, the biosensor was able to qualitatively differentiate spiked from non-spiked samples, whereas ELISA did not show a clear cut-off between them. Furthermore, the relative standard deviation was lower when determining sputum with the paper-based biosensor. These features, along with a mild liquefaction step that circumvents the use of harsh chemicals or instruments, make our biosensor a good candidate for diagnosing Pseudomonas infections at the bedside through the detection of sputum PYO.
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Affiliation(s)
- Cristina Adrover-Jaume
- Multidisciplinary Sepsis Group, Hospital Universitario Son Espases, Health Research Institute of Balearic Islands (IdISBa), Palma, Spain
- Department of Chemistry, University of the Balearic Islands, Palma, Spain
| | - Antonio Clemente
- Multidisciplinary Sepsis Group, Hospital Universitario Son Espases, Health Research Institute of Balearic Islands (IdISBa), Palma, Spain.
- Department of Chemistry, University of the Balearic Islands, Palma, Spain.
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Bárbara Rodríguez-Urretavizcaya
- Nanobiotechnology for Diagnostics (Nb4D), Department of Surfactants and Nanobiotechnology, Institute for Advanced Chemistry of Catalonia (IQAC), Barcelona, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - Lluïsa Vilaplana
- Nanobiotechnology for Diagnostics (Nb4D), Department of Surfactants and Nanobiotechnology, Institute for Advanced Chemistry of Catalonia (IQAC), Barcelona, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - M Pilar Marco
- Nanobiotechnology for Diagnostics (Nb4D), Department of Surfactants and Nanobiotechnology, Institute for Advanced Chemistry of Catalonia (IQAC), Barcelona, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Barcelona, Spain
| | - Estrella Rojo-Molinero
- Microbiology Department, Hospital Universitario Son Espases, Health Research Institute of Balearic Islands (IdISBa), Palma, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Oliver
- Microbiology Department, Hospital Universitario Son Espases, Health Research Institute of Balearic Islands (IdISBa), Palma, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Roberto de la Rica
- Multidisciplinary Sepsis Group, Hospital Universitario Son Espases, Health Research Institute of Balearic Islands (IdISBa), Palma, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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