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Kim J, Keum H, Albadawi H, Zhang Z, Graf EH, Cevik E, Oklu R. Multi-Functional Biomaterial for the Treatment and Prevention of Central Line-Associated Bloodstream Infections. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024:e2405805. [PMID: 39148150 DOI: 10.1002/adma.202405805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/01/2024] [Indexed: 08/17/2024]
Abstract
Central venous catheters are among the most used medical devices in hospitals today. Despite advances in modern medicine, catheter infections remain prevalent, causing significant morbidity and mortality worldwide. Here, SteriGel is reported, which is a multifunctional hydrogel engineered to prevent and treat central line-associated bloodstream infections (CLABSI). The mechanical properties of SteriGel are optimized to ensure appropriate gelation kinetics, bio-adhesiveness, stretchability, and recoverability to promote durability upon application and to provide persistent protection against infection. In vitro assays demonstrated that SteriGel exhibits long-term antimicrobial efficacy and has bactericidal effects against highly resistant patient-derived pathogens known to be frequently associated with CLABSI. SteriGel outperformed Biopatch, which is a clinically used device for CLABSI, in ex vivo cadaver studies that simulate clinical scenarios. Furthermore, SteriGel has biocompatible, pro-healing, and anti-inflammatory properties in vitro and in a rat subcutaneous injection model, suggesting a potential synergistic effect in the prevention and treatment of CLABSI. SteriGel is a multifunctional adherent biomaterial with potent antimicrobial effects for sustained sterility while promoting healing of the catheter incision site to protect against infection.
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Affiliation(s)
- Jinjoo Kim
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Hyeongseop Keum
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Hassan Albadawi
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Zefu Zhang
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Erin H Graf
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Enes Cevik
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Rahmi Oklu
- The Laboratory for Patient-Inspired Engineering, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA
- Division of Vascular & Interventional Radiology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Park KH, Jung YJ, Lee HJ, Kim HJ, Maeng CH, Baek SK, Han JJ, Jeon W, Kim DY, Lee YM, Lee MS. Impact of multidrug resistance on outcomes in hematologic cancer patients with bacterial bloodstream infections. Sci Rep 2024; 14:15622. [PMID: 38972913 PMCID: PMC11228017 DOI: 10.1038/s41598-024-66524-w] [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: 04/15/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024] Open
Abstract
Despite the improved outcomes in patients with hematological malignancies, infections caused by multidrug-resistant organisms (MDROs) pose a new threat to these patients. We retrospectively reviewed the patients with hematological cancer and bacterial bloodstream infections (BSIs) at a tertiary hospital between 2003 and 2022 to assess the impact of MDROs on outcomes. Among 328 BSIs, 81 (24.7%) were caused by MDROs. MDRO rates increased from 10.3% (2003-2007) to 39.7% (2018-2022) (P < 0.001). The 30-day mortality rate was 25.0%, which was significantly higher in MDRO-infected patients than in non-MDRO-infected patients (48.1 vs. 17.4%; P < 0.001). The observed trend was more pronounced in patients with newly diagnosed diseases and relapsed/refractory disease but less prominent in patients in complete remission. Among MDROs, carbapenem-resistant Gram-negative bacteria exhibited the highest mortality, followed by vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and extended-spectrum β-lactamase-producing Enterobacteriaceae. Multivariate analysis identified independent risk factors for 30-day mortality as age ≥ 65 years, newly diagnosed disease, relapsed/refractory disease, MDROs, polymicrobial infection, CRP ≥ 20 mg/L, and inappropriate initial antibiotic therapy. In conclusion, MDROs contribute to adverse outcomes in patients with hematological cancer and bacterial BSIs, with effects varying based on the underlying disease status and causative pathogens. Appropriate initial antibiotic therapy may improve patient outcomes.
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Affiliation(s)
- Ki-Ho Park
- Department of Infectious Diseases, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Ye Ji Jung
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Hyun Jung Lee
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Hong Jun Kim
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Chi Hoon Maeng
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Sun Kyung Baek
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea
| | - Jae Joon Han
- Department of Hematology and Medical Oncology, Kyung Hee University College of Medicine, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea.
| | - Woojae Jeon
- Department of Infectious Diseases, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Dong Youn Kim
- Department of Infectious Diseases, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Lee
- Department of Infectious Diseases, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Mi Suk Lee
- Department of Infectious Diseases, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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Premkumar M, Karvellas CJ, Kulkarni AV, Bhujade H, Reddy KR. Role of point-of-care ultrasound (POCUS) in clinical hepatology. Hepatology 2024:01515467-990000000-00946. [PMID: 38954829 DOI: 10.1097/hep.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
Hospitalized patients with cirrhosis frequently require critical care management for sepsis, HE, respiratory failure, acute variceal bleeding, acute kidney injury (AKI), shock, and optimization for liver transplantation, while outpatients have unique care considerations. Point-of-care ultrasonography (POCUS) enhances bedside examination of the hepatobiliary system and relevant extrahepatic sites. POCUS includes cardiac US and is used to assess volume status and hemodynamic parameters like cardiac output, systemic vascular resistance, cardiac contractility, and pulmonary artery pressure, which aid in the early and accurate diagnosis of heart failure, cirrhotic cardiomyopathy, porto-pulmonary hypertension, hepatopulmonary syndrome, arrhythmia, and pulmonary embolism. This also helps in fluid management and vasopressor use in the resuscitation of patients with cirrhosis. Lung ultrasound (LUS) can help in differentiating pneumonia, effusion, and edema. Further, US guides interventions such as line placement, drainage of abdominal collections/abscesses, relief of tension pneumothorax, drainage of pleural and pericardial effusions, and biliary drainage in cholangitis. Additionally, its role is essential to assess liver masses foci of sepsis, for appropriate sites for paracentesis, and to assess for vascular disorders such as portal vein or hepatic vein thrombosis. Renal US can identify renal and postrenal causes of AKI and aid in diagnosis of prerenal AKI through volume assessment. In this review, we address the principles and methods of POCUS in hospitalized patients and in outpatients with cirrhosis and discuss the application of this diverse modality in clinical hepatology.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Constantine J Karvellas
- Department of Critical Care Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Harish Bhujade
- Department of Radiodiagnosis and Interventional Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA
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Canale V, Skiba-Kurek I, Klesiewicz K, Papież M, Ropek M, Pomierny B, Piska K, Koczurkiewicz-Adamczyk P, Empel J, Karczewska E, Zajdel P. Improving Activity of New Arylurea Agents against Multidrug-Resistant and Biofilm-Producing Staphylococcus epidermidis. ACS Med Chem Lett 2024; 15:369-375. [PMID: 38505856 PMCID: PMC10945555 DOI: 10.1021/acsmedchemlett.3c00536] [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: 11/28/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 03/21/2024] Open
Abstract
Multidrug-resistant (MDR) strains of Staphylococcus epidermidis (S. epidermidis), prevalent in hospital environments, contribute to increased morbidity and mortality, especially among newborns, posing a critical concern for neonatal sepsis. In response to the pressing demand for novel antibacterial therapies, we present findings from synthetic chemistry and structure-activity relationship studies focused on arylsulfonamide/arylurea derivatives of aryloxy[1-(thien-2-yl)propyl]piperidines. Through bioisosteric replacement of the sulfonamide fragment with a urea moiety, compound 25 was identified, demonstrating potent bacteriostatic activity against clinical multidrug-resistant S. epidermidis strains (MIC50 and MIC90 = 1.6 and 3.125 μg/mL). Importantly, it showed activity against linezolid-resistant strains and exhibited selectivity over mammalian cells. Compound 25 displayed antibiofilm-forming properties against clinical S. epidermidis strains and demonstrated the capacity to eliminate existing biofilm layers. Additionally, it induced complete depolarization of the bacterial membrane in clinical S. epidermidis strains. In light of these findings, targeting bacterial cell membranes with compound 25 emerges as a promising strategy in the fight against multidrug-resistant S. epidermidis strains.
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Affiliation(s)
- Vittorio Canale
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Iwona Skiba-Kurek
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Karolina Klesiewicz
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Monika Papież
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Marlena Ropek
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Bartosz Pomierny
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Kamil Piska
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | | | - Joanna Empel
- Department
of Epidemiology and Clinical Microbiology, National Medicines Institute, 30/34 Chełmska Street, 00-725 Warsaw, Poland
| | - Elżbieta Karczewska
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
| | - Paweł Zajdel
- Faculty
of Pharmacy Jagiellonian University Medical College, 9 Medyczna Str., 30-688 Kraków, Poland
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Witt LS, Sexton ME, Smith G, Farley M, Jacob JT. Evaluating indwelling devices and other risk factors for mortality in invasive Carbapenem-resistant Enterobacterales infections in Georgia, 2012-2019. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 3:e254. [PMID: 38178877 PMCID: PMC10762638 DOI: 10.1017/ash.2023.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024]
Abstract
Objective Carbapenem-resistant Enterobacterales (CRE) infections are a public health threat due to the risk of transmission between patients and high associated mortality. We sought to identify risk factors for mortality in patients with invasive CRE infections and to specifically evaluate whether there was an association between indwelling medical devices and 90-day mortality. Design Retrospective observational cohort study of patients infected with CRE in the eight-county metropolitan Atlanta area between 2012 and 2019. Methods Patients with invasive CRE infections were identified via the Georgia Emerging Infections Program's active, population- and laboratory-based surveillance system and linked with the Georgia Vital Statistics database. We used bivariate analysis to identify risk factors for mortality and completed log binomial multivariable regression to estimate risk ratios (RR) for the association between indwelling devices and mortality. Results In total, 154 invasive CRE infections were identified, with indwelling devices present in most patients (87.7%) around the time of infection. Admission to an intensive care unit was found to be associated with 90-day mortality (adjusted RR [aRR] 1.55, 95% CI 1.07, 2.24); however, the presence of any indwelling device was not associated with increased risk of 90-day mortality in multivariable analysis (aRR 1.22, 95% CI 0.55, 2.73). Having at least two indwelling devices was associated with increased mortality (aRR 1.79, 95% CI 1.05, 3.05). Conclusions Indwelling devices were prevalent in our cohort but were not consistently associated with an increased risk of mortality. Further studies are needed to examine this relationship and the role of device removal.
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Affiliation(s)
- Lucy S. Witt
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Gillian Smith
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Monica Farley
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Jesse T. Jacob
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Emerging Infections Program, Atlanta, GA, USA
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Uchida M, Terada N, Saito K, Ishikawa H, Funayama Y, Oishi T, Shinohara H, Ebihara T, Kurihara Y, Hitomi S. Clinical and Microbiological Characteristics of Bacteremia Caused by Carbapenemase-producing Enterobacterales in Minami Ibaraki Area, Japan. JOURNAL OF MICROORGANISM CONTROL 2024; 29:81-89. [PMID: 38880620 DOI: 10.4265/jmc.29.2_81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Although recent propagation of carbapenemase-producing Enterobacterales (CPE) has become a problem worldwide, the picture of CPE infection in Japan has not fully been elucidated. In this study, we examined clinical and microbiological characteristics of invasive CPE infection occurring at 8 hospitals in Minami Ibaraki Area between July 2001 to June 2017. Of 7294 Enterobacterales strains isolated from independent cases of bacteremia and/or meningitis, 10 (0.14%) were CPE (8 Enterobacter cloacae-complex, 1 Escherichia coli, and 1 Edwardsiella tarda), all of which had the blaIMP-1 gene and susceptible to gentamicin and trimethoprim/sulfamethoxazole. These strains were isolated from 7 adult and 2 infant bacteremia (1 infant patient developed CPE bacteremia twice) after 2007. The most common portal of entry was intravenous catheters. All of the adult patients were recovered, while the infant patients eventually died. Genomic analyses showed that the 8 E. cloacae-complex strains were classified into 5 groups, each of which was exclusively detected in specific facilities at intervals of up to 3 years, suggesting persistent colonization in the facilities. This study showed that invasive CPE infection in the area was rare, caused by IMP-1-type CPE having susceptibility to various antibiotics, and nonfatal among adult patients.
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Affiliation(s)
- Michie Uchida
- Department of Pharmacy, Tokyo Sakura Hospital, Japan
- Doctoral Program in Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba,Japan
| | - Norihiko Terada
- Department of Infectious Diseases, University of Tsukuba Hospital, Japan
| | - Kazuhito Saito
- Department of Respiratory Diseases, Tsuchiura Kyodo General Hospital, Japan
| | - Hiroichi Ishikawa
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Japan
| | | | - Tsuyoshi Oishi
- Department of Infectious Diseases, Tokyo Medical University Ibaraki Medical Center, Japan
| | | | - Tsugio Ebihara
- Department of Gastroenterology and Hepatology, Ryugasaki Saiseikai Hospital, Japan
| | - Yoko Kurihara
- Department of Infectious Diseases, University of Tsukuba Hospital, Japan
| | - Shigemi Hitomi
- Department of Infectious Diseases, University of Tsukuba Hospital, Japan
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Pitiriga V, Bakalis J, Theodoridou K, Dimitroulia E, Saroglou G, Tsakris A. Comparison of microbial colonization rates between central venous catheters and peripherally inserted central catheters. Antimicrob Resist Infect Control 2023; 12:74. [PMID: 37550791 PMCID: PMC10405474 DOI: 10.1186/s13756-023-01285-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Central venous catheters (CVCs) and peripherally inserted central catheters (PICCs), have been widely used as intravascular devices in critically ill patients. However, they might evoke complications, such as catheter colonization that has been considered as predisposing factor for central line-associated bloodstream infections (CLABSIs). Although numerous studies have compared the risk of bloodstream infections between PICCs and CVCs, comparative studies on their colonization rates are limited. OBJECTIVES The episodes of catheter colonization in critically ill patients with CVCs or PICCs were retrospectively analysed during a two-year period in a Greek tertiary care hospital and colonization rates, microbial profiles and antimicrobial susceptibility patterns were compared. METHODS Clinical and laboratory data of consecutive hospitalized critically-ill patients who underwent PICC and CVC placement between May 2017-May 2019 were analysed. All catheters were examined by the semiquantitative culture technique for bacterial pathogens, either as a routine process after catheter removal or after suspicion of infection. Species identification and antimicrobial resistance patterns were determined by the Vitek2 automated system. RESULTS During the survey period a total of 122/1187 (10.28%) catheter colonization cases were identified among CVCs and 19/639 (2.97%) cases among PICCs (p = 0.001). The colonization rate was 12.48/1000 catheter-days for the CVC group and 1.71/1000 catheter-days for the PICC group (p < 0.001). The colonization rate per 1000 catheter-days due to multidrug-resistant organisms (MDROs) was 3.85 in all study cases, 7.26 (71/122) in the CVC group and 0.63 (7/19) in the PICC group (p < 0.001). Within the CVC group, the most common microorganism isolated was MDR Acinetobacter baumannii (n = 38, 31.1%) followed by MDR Klebsiella pneumoniae (n = 20, 16.4%). In the PICC group, the predominant microorganism isolated was Candida spp. (n = 5, 23.8%) followed by MDR K. pneumoniae and MDR A. baumannii in equal numbers (n = 3, 14.2%). CONCLUSION PICC lines were associated with significantly lower colonization rates comparing to the CVC ones. In addition, patterns of microbial colonization revealed a trend over the predominance of MDR gram-negatives in CVCs suggesting that PICCs might be a safer alternative for prolonged inpatient intravascular access. Prevention programs directed by local microbial ecology may diminish catheter colonization rates and CLABSIs.
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Affiliation(s)
- Vassiliki Pitiriga
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527, Athens, Greece
| | - John Bakalis
- Department of Internal Medicine, Metropolitan Hospital, 9 Ethnarchou Makariou Street, 18547, Athens, Greece
| | - Kalliopi Theodoridou
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527, Athens, Greece
| | - Evangelia Dimitroulia
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527, Athens, Greece
| | - George Saroglou
- Department of Internal Medicine, Metropolitan Hospital, 9 Ethnarchou Makariou Street, 18547, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527, Athens, Greece.
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Ture Z, Güner R, Alp E. Antimicrobial stewardship in the intensive care unit. JOURNAL OF INTENSIVE MEDICINE 2023; 3:244-253. [PMID: 37533805 PMCID: PMC10391567 DOI: 10.1016/j.jointm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 08/04/2023]
Abstract
High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.
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Affiliation(s)
- Zeynep Ture
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri 38039,Turkey
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
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Shields RK, Paterson DL, Tamma PD. Navigating Available Treatment Options for Carbapenem-Resistant Acinetobacter baumannii-calcoaceticus Complex Infections. Clin Infect Dis 2023; 76:S179-S193. [PMID: 37125467 PMCID: PMC10150276 DOI: 10.1093/cid/ciad094] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Carbapenem-resistant Acinetobacter baumannii-calcoaceticus complex (CRAB) is one of the top-priority pathogens for new antibiotic development. Unlike other antibiotic-resistant threats, none of the available therapies have been shown to consistently reduce mortality or improve patient outcomes in clinical trials. Antibiotic combination therapy is routinely used in clinical practice; however, the preferred combination has not been defined. This narrative review focuses on evidence-based solutions for the treatment of invasive CRAB infections. We dissect the promise and perils of traditional agents used in combination, such as colistin, sulbactam, and the tetracyclines, and offer clinical pearls based on our interpretation of the available data. Next, we investigate the merits of newly developed β-lactam agents like cefiderocol and sulbactam-durlobactam, which have demonstrated contrasting results in recent randomized clinical trials. The review concludes with the authors' perspective on the evolving treatment landscape for CRAB infections, which is complicated by limited clinical data, imperfect treatment options, and a need for future clinical trials. We propose that effective treatment for CRAB infections requires a personalized approach that incorporates host factors, the site of infection, pharmacokinetic-pharmacodynamic principles, local molecular epidemiology of CRAB isolates, and careful interpretation of antibiotic susceptibility testing results. In most clinical scenarios, a dose-optimized, sulbactam-based regimen is recommended with the addition of at least one other in vitro active agent. Should sulbactam-durlobactam receive regulatory approval, recommendations will need to be re-evaluated with the most recent evidence.
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Affiliation(s)
- Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David L Paterson
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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10
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Ten Years of KPC-Kp Bloodstream Infections Experience: Impact of Early Appropriate Empirical Therapy on Mortality. Biomedicines 2022; 10:biomedicines10123268. [PMID: 36552024 PMCID: PMC9776375 DOI: 10.3390/biomedicines10123268] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Background. In K. pneumoniae KPC (KPC-Kp) bloodstream infections (BSI), INCREMENT CPE score >7, Charlson Comorbidity Index (CCI) ≥3 and septic shock are recognized predictors of mortality, with a possible beneficial effect of combination therapy in seriously ill patients. Materials and Methods. We conducted a ten-year retrospective study including all KPC-Kp BSI in patients ≥18 years of age with the aim to evaluate the characteristics and impact of appropriate empirical therapy, either monotherapy or combination therapy, and targeted therapy on mortality. Appropriate therapy was defined as at least one active antimicrobial agent with in vitro activity against KPC-kp demonstrated by susceptibility testing, administered within 48 h from blood culture collection. Results. The median age of the 435 analyzed patients was 66.09 years (IQR 54.87−73.98). The median CCI was 4. KPC-Kp colonization was present in 324 patients (74.48%). The probable origin of the KPC-Kp BSI was not identified in 136 patients (31.26%), whereas in 120 (27.59%) patients, it was CVC-related, and in 118 (27.13%), it was respiratory. Source control was achieved in 87 patients (72.5%) with CVC-related KPC-Kp BSI. The twenty-eight-day survival was 70.45% for empirical monotherapy, 63.88% for empirical combination therapy and 57.05% for targeted therapy (p = 0.0399). A probable source of KPC-Kp BSI other than urinary, CVC or abdominal [aHR 1.64 (IC 1.15−2.34) p = 0.006] and deferred targeted therapy [HR 1.67 (IC 1.12−2.51), p= 0.013] emerged as predictors of mortality, whereas source control [HR 0.62 (IC 0.44−0.86), p = 0.005] and ceftazidime/avibactam administration in empirical therapy [aHR 0.37 (IC 0.20−0.68) p = 0.002] appeared as protective factors. Discussion. These data underline the importance of source control together with timing appropriateness in the early start of empirical therapy over the choice of monotherapy or combination therapy and the use of ceftazidime/avibactam against KPC-Kp BSI.
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Iachkine J, Buetti N, de Grooth HJ, Briant AR, Mimoz O, Mégarbane B, Mira JP, Ruckly S, Souweine B, du Cheyron D, Mermel LA, Timsit JF, Parienti JJ. Development and validation of a multivariable prediction model of central venous catheter-tip colonization in a cohort of five randomized trials. Crit Care 2022; 26:205. [PMID: 35799302 PMCID: PMC9261073 DOI: 10.1186/s13054-022-04078-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The majority of central venous catheters (CVC) removed in the ICU are not colonized, including when a catheter-related infection (CRI) is suspected. We developed and validated a predictive score to reduce unnecessary CVC removal.
Methods
We conducted a retrospective cohort study from five multicenter randomized controlled trials with systematic catheter-tip culture of consecutive CVCs. Colonization was defined as growth of ≥103 colony-forming units per mL. Risk factors for colonization were identified in the training cohort (CATHEDIA and 3SITES trials; 3899 CVCs of which 575 (15%) were colonized) through multivariable analyses. After internal validation in 500 bootstrapped samples, the CVC-OUT score was computed by attaching points to the robust (> 50% of the bootstraps) risk factors. External validation was performed in the testing cohort (CLEAN, DRESSING2 and ELVIS trials; 6848 CVCs, of which 588 (9%) were colonized).
Results
In the training cohort, obesity (1 point), diabetes (1 point), type of CVC (dialysis catheter, 1 point), anatomical insertion site (jugular, 4 points; femoral 5 points), rank of the catheter (second or subsequent, 1 point) and catheterization duration (≥ 5 days, 2 points) were significantly and independently associated with colonization . Area under the ROC curve (AUC) for the CVC-OUT score was 0.69, 95% confidence interval (CI) [0.67–0.72]. In the testing cohort, AUC for the CVC-OUT score was 0.60, 95% CI [0.58–0.62]. Among 1,469 CVCs removed for suspected CRI in the overall population, 1200 (82%) were not colonized. The negative predictive value (NPV) of a CVC-OUT score < 6 points was 94%, 95% CI [93%–95%].
Conclusion
The CVC-OUT score had a moderate ability to discriminate catheter-tip colonization, but the high NPV may contribute to reduce unnecessary CVCs removal. Preference of the subclavian site is the strongest and only modifiable risk factor that reduces the likelihood of catheter-tip colonization and consequently the risk of CRI.
Clinical Trials Registration: NCT00277888, NCT01479153, NCT01629550, NCT01189682, NCT00875069.
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12
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Sheu RK, Pardeshi MS. A Survey on Medical Explainable AI (XAI): Recent Progress, Explainability Approach, Human Interaction and Scoring System. SENSORS (BASEL, SWITZERLAND) 2022; 22:8068. [PMID: 36298417 PMCID: PMC9609212 DOI: 10.3390/s22208068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
The emerging field of eXplainable AI (XAI) in the medical domain is considered to be of utmost importance. Meanwhile, incorporating explanations in the medical domain with respect to legal and ethical AI is necessary to understand detailed decisions, results, and current status of the patient's conditions. Successively, we will be presenting a detailed survey for the medical XAI with the model enhancements, evaluation methods, significant overview of case studies with open box architecture, medical open datasets, and future improvements. Potential differences in AI and XAI methods are provided with the recent XAI methods stated as (i) local and global methods for preprocessing, (ii) knowledge base and distillation algorithms, and (iii) interpretable machine learning. XAI characteristics details with future healthcare explainability is included prominently, whereas the pre-requisite provides insights for the brainstorming sessions before beginning a medical XAI project. Practical case study determines the recent XAI progress leading to the advance developments within the medical field. Ultimately, this survey proposes critical ideas surrounding a user-in-the-loop approach, with an emphasis on human-machine collaboration, to better produce explainable solutions. The surrounding details of the XAI feedback system for human rating-based evaluation provides intelligible insights into a constructive method to produce human enforced explanation feedback. For a long time, XAI limitations of the ratings, scores and grading are present. Therefore, a novel XAI recommendation system and XAI scoring system are designed and approached from this work. Additionally, this paper encourages the importance of implementing explainable solutions into the high impact medical field.
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Affiliation(s)
- Ruey-Kai Sheu
- Department of Computer Science, Tunghai University, No. 1727, Section 4, Taiwan Blvd, Xitun District, Taichung 407224, Taiwan
| | - Mayuresh Sunil Pardeshi
- AI Center, Tunghai University, No. 1727, Section 4, Taiwan Blvd, Xitun District, Taichung 407224, Taiwan
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13
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Catheter management across patients with hematologic malignancies and catheter-related blood stream infections: a systematic review. Ann Hematol 2022; 101:2515-2524. [DOI: 10.1007/s00277-022-04969-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/23/2022] [Indexed: 11/01/2022]
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14
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Johns J, Wahlrab L, Elefritz JL. Acutely ill hematology/oncology patients with central-line associated bloodstream infections and the impact of timing of catheter removal on outcomes. Am J Infect Control 2022; 50:749-754. [PMID: 34774897 DOI: 10.1016/j.ajic.2021.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hematology/oncology patients are at risk for central line-associated bloodstream infections (CLABSI). The purpose was to determine if infection-related mortality, persistent bacteremia, and recurrent bacteremia were decreased with early central venous catheter (CVC) removal. METHODS A case-matched, retrospective cohort study was conducted comparing patients with early catheter removal (≤12 hours) to late catheter removal (>12 hours) in hematology/oncology patients with CLABSI from June 1, 2015 to May 31, 2018. Patients were case-matched based on intensive care unit admission and presence of shock to control for severity of illness. RESULTS/DISCUSSION Of 148 patients meeting study inclusion, 128 (86.5%), had their CVC removed during hospitalization (median 11.8 hours). The majority had a hematologic malignancy (90.5%). Following case-matching, 48 patients remained in each group. The primary outcome of infection-related mortality, persistent bacteremia, or recurrent bacteremia occurred more frequently in the late catheter removal group compared to the early catheter removal group although this was not statistically significant (18.8% vs 8.3%, P = .136). CONCLUSIONS A lower incidence of infection-related mortality, persistent bacteremia, and recurrent bacteremia was found in patients early catheter removal; however the sample size was not adequate to detect statistical differences. Investigators should continue to evaluate if early catheter removal confers a benefit in a larger patient population.
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15
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Abdul-Mutakabbir JC, Griffith NC, Shields RK, Tverdek FP, Escobar ZK. Contemporary Perspective on the Treatment of Acinetobacter baumannii Infections: Insights from the Society of Infectious Diseases Pharmacists. Infect Dis Ther 2021; 10:2177-2202. [PMID: 34648177 PMCID: PMC8514811 DOI: 10.1007/s40121-021-00541-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/23/2021] [Indexed: 01/10/2023] Open
Abstract
The purpose of this narrative review is to bring together the most recent epidemiologic, preclinical, and clinical findings to offer our perspective on best practices for managing patients with A. baumannii infections with an emphasis on carbapenem-resistant A. baumannii (CRAB). To date, the preferred treatment for CRAB infections has not been defined. Traditional agents with retained in vitro activity (aminoglycosides, polymyxins, and tetracyclines) are limited by suboptimal pharmacokinetic characteristics, emergence of resistance, and/or toxicity. Recently developed and US Food and Drug Administration (FDA)-approved β-lactam/β-lactamase inhibitor agents do not provide enhanced activity against CRAB. On balance, cefiderocol and eravacycline demonstrate potent in vitro activity and are well tolerated, but clinical data for patients with CRAB infections do not yet support widespread use. Given that CRAB has the capacity to infect vulnerable patients and preferred regimens have not been identified, we advocate for combination therapy. Our preferred regimen for critically ill patients infected, or considered to be at high risk for CRAB, includes meropenem, polymyxin B, and ampicillin/sulbactam. Importantly, site of infection, severity of illness, and local epidemiology are essential factors to be considered in selecting combination therapies. Molecular mechanisms of resistance may unveil preferred combinations at individual centers; however, such data are often unavailable to treating clinicians and have not been linked to improved clinical outcomes. Combination strategies may also pose an increased risk for antibiotic toxicity and Clostridioides difficile infection, and should therefore be balanced by understanding patient goals of care and underlying health conditions. Promising therapies that are in clinical development and/or under investigation include durlobactam-sulbactam, cefiderocol combination regimens, and bacteriophage therapy, which may over time eliminate the need for the continued use of polymyxins. Future goals for CRAB management include pathogen-focused treatment paradigms that are based on molecular mechanisms of resistance, local susceptibility rates, and the availability of well-tolerated, effective treatment options.
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Affiliation(s)
- Jacinda C Abdul-Mutakabbir
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.
- Department of Basic Sciences, Loma Linda University School of Medicine, Loma Linda, CA, USA.
| | - Nicole C Griffith
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Frank P Tverdek
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Zahra Kassamali Escobar
- University of Washington Medicine, Valley Medical Center, University of Washington School of Pharmacy, Renton, WA, USA
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16
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Reducing Central Line Associated Bloodstream Infections (CLABSIs) by Reducing Central Line Days. Curr Infect Dis Rep 2021; 23:23. [PMID: 34744517 PMCID: PMC8562022 DOI: 10.1007/s11908-021-00767-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/27/2022]
Abstract
Purpose of Review While reducing unnecessary days present of central venous catheters (CVCs) is part of central line associated bloodstream infection (CLABSI) best practices, there is limited information regarding compliance with this recommendation as well as addressing barriers to compliance. Recent Findings Significant work has been directed towards daily audits of necessity and improving communication between members of the medical team. Other critical interventions include utilization of the electronic health record (EHR), leadership support of CLABSI reduction goals, and avoiding CVC placement over more appropriate vascular access. Summary Institutions have varied approaches to addressing the issue of removing idle CVCs, and more standardized approaches in checklists as well as communication, particularly on multidisciplinary rounds, will be key to CVC removal. Utilization of the EHR for reminders or appropriate documentation of necessity is a factor. Avoidance of placing a CVC or appropriateness of the CVC is also important to consider.
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Mitchell E, Pearce M, Roberts A, Newton J. Predictive factors of in-hospital mortality in patients with laboratory-confirmed Escherichia coli, Klebsiella species or Pseudomonas aeruginosa bloodstream infections. PLoS One 2021; 16:e0259305. [PMID: 34727130 PMCID: PMC8562814 DOI: 10.1371/journal.pone.0259305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
Gram-negative bloodstream infections (GNBSI) are confirmed by the presence of gram-negative bacteria in the bloodstream and pose a significant healthcare issue as they increase the risk of sepsis and mortality. In England, the aim is to reduce GNBSI cases and further deterioration through enhanced population surveillance of patients with a laboratory-confirmed GNBSI to inform on healthcare policies. The objective of this study was to evaluate the factors associated with in-hospital mortality in patients with a laboratory-confirmed Escherichia coli, Klebsiella or Pseudomonas aeruginosa GNBSIs, with data obtained from the enhanced data capture for the surveillance of GNBSIs. All patients with a laboratory-confirmed GNBSI at a single centre, admitted between April 2017 and March 2019, were included in this retrospective observational study. Demographic and recent exposure to healthcare risk factors were collected and assessed for the association with in-hospital mortality. In 1113 patients with laboratory-confirmed GNBSIs, the in-hospital mortality rate was 13%. Multivariable analysis confirmed that patients with respiratory (OR = 3.73, 95%CI = 2.05-6.76), gastrointestinal (2.61; 1.22-5.58) or skin (3.61; 1.24-10.54) infection primary focus had a greater risk of in-hospital mortality, compared to upper urinary tract infections. Increased risk of in-hospital mortality was also observed in patients with hospital-onset GNBSIs (OR = 1.87; 1.17-2.97) compared with community-onset healthcare acquired GNBSIs, or who were on dialysis at the time of the GNBSI (3.28; 1.01-10.14), as well as in patients who had recently been discharged from hospital (1.55; 1.01-2.38), or had a vascular device recently manipulated (2.41; 1.01-5.74). Results confirm that the data obtained from the enhanced data capture for GNBSIs in England can predict in-hospital mortality in patients with a GNBSI. Several factors associated with an increased risk of in-hospital mortality have been identified. Results should be reported back to clinicians in order to identify patients at a greater risk of dying in-hospital who may benefit from further monitoring.
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Affiliation(s)
- Eleanor Mitchell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mark Pearce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anthony Roberts
- Academic Health Science Network – North East & North Cumbria, Newcastle upon Tyne, United Kingdom
- North East Quality Observatory Service (NEQOS), Newcastle upon Tyne, United Kingdom
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Julia Newton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Academic Health Science Network – North East & North Cumbria, Newcastle upon Tyne, United Kingdom
- North East Quality Observatory Service (NEQOS), Newcastle upon Tyne, United Kingdom
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18
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Gompelman M, Paus C, Bond A, Akkermans RP, Bleeker-Rovers CP, Lal S, Wanten GJA. Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis. Am J Clin Nutr 2021; 114:1173-1188. [PMID: 34038951 PMCID: PMC8408872 DOI: 10.1093/ajcn/nqab164] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/23/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Catheter-related bloodstream infection (CRBSI) is a life-threatening complication of parenteral nutrition. Therefore, optimal management, ideally with catheter salvage, is required to maintain long-term venous access. OBJECTIVES We aimed to evaluate successful catheter salvage rates in patients on home parenteral nutrition (HPN). METHODS Studies were retrieved from medical databases, conference proceedings, and article reference lists. Data were collected relating to clinical outcomes of 3 treatments: systemic antibiotics, antimicrobial lock therapy (ALT), and catheter exchange. ORs and 95% CIs were calculated from a mixed logistic effects model. RESULTS From 10,036 identified publications, 28 met the inclusion criteria (22 cohort studies, 5 case-control studies, and 1 randomized clinical trial), resulting in a total of 4911 CRBSIs. To achieve successful catheter salvage, the addition of an antimicrobial lock solution was superior to systemic antibiotics alone (OR: 1.75; 95% CI: 1.21, 2.53; P = 0.003). Recurrence of infection was less common in studies that used ALT than in those that used systemic antibiotics alone (OR: 0.26; 95% CI: 0.11, 0.61; P = 0.002). The catheter exchange group was excluded from multilevel regression analysis because only 1 included study applied this treatment. Successful salvage rates were highest for coagulase-negative staphylococci, followed by Gram-negative rods and Staphylococcus aureus . CONCLUSIONS The addition of an antimicrobial lock solution seems beneficial for successful catheter salvage in HPN-dependent patients with a CRBSI. Future prospective randomized studies should identify the most effective and pathogen-specific strategy.This review was registered at www.crd.york.ac.uk/PROSPERO as CRD42018102959.
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Affiliation(s)
- Michelle Gompelman
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Carmen Paus
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ashley Bond
- Intestinal Failure Unit, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Reinier P Akkermans
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Chantal P Bleeker-Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Geert J A Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
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Srisuwananukorn A, Han J, Raslan R, Gowhari M, Hussain F, Njoku F, Molokie RE, Gordeuk VR, Saraf SL. Antimicrobial resistance is a risk factor for mortality in adults with sickle cell disease. Haematologica 2021; 106:1745-1748. [PMID: 33121239 PMCID: PMC8168496 DOI: 10.3324/haematol.2020.267872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Andrew Srisuwananukorn
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612
| | - Jin Han
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612; Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612
| | - Rasha Raslan
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA, 23219
| | - Michel Gowhari
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612
| | - Faiz Hussain
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612
| | - Franklin Njoku
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612
| | - Robert E Molokie
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612; Department of Medicine; Jesse Brown VA Medical Center, Chicago IL 60612
| | - Victor R Gordeuk
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612
| | - Santosh L Saraf
- Sickle Cell Center; Department of Medicine; University of Illinois at Chicago, Chicago IL 60612.
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20
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Lara HH, Lopez-Ribot JL. Inhibition of Mixed Biofilms of Candida albicans and Methicillin-Resistant Staphylococcus aureus by Positively Charged Silver Nanoparticles and Functionalized Silicone Elastomers. Pathogens 2020; 9:E784. [PMID: 32992727 PMCID: PMC7600790 DOI: 10.3390/pathogens9100784] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/16/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022] Open
Abstract
Both bacterial and fungal organisms display the ability to form biofilms; however, mixed bacterial/fungal biofilms are particularly difficult to control and eradicate. The opportunistic microbial pathogens Candida albicans and Staphylococcus aureus are among the most frequent causative agents of healthcare-acquired infections, and are often co-isolated forming mixed biofilms, especially from contaminated catheters. These mixed species biofilms display a high level of antibiotic resistance; thus, these infections are challenging to treat resulting in excess morbidity and mortality. In the absence of effective conventional antibiotic treatments, nanotechnology-based approaches represent a promising alternative for the treatment of highly recalcitrant polymicrobial biofilm infections. Our group has previously reported on the activity of pure positively charged silver nanoparticles synthesized by a novel microwave technique against single-species biofilms of C. albicans and S. aureus. Here, we have expanded our observations to demonstrate that that silver nanoparticles display dose-dependent activity against dual-species C. albicans/S. aureus biofilms. Moreover, the same nanoparticles were used to functionalize catheter materials, leading to the effective inhibition of the mixed fungal/bacterial biofilms. Overall, our results indicate the potent activity of silver nanoparticles against these cross-kingdom biofilms. More studies are warranted to examine the ability of functionalized catheters in the prevention of catheter-related bloodstream infections.
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Affiliation(s)
- Humberto H. Lara
- Department of Biology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Jose L. Lopez-Ribot
- Department of Biology and South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249, USA
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21
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Timsit JF, Baleine J, Bernard L, Calvino-Gunther S, Darmon M, Dellamonica J, Desruennes E, Leone M, Lepape A, Leroy O, Lucet JC, Merchaoui Z, Mimoz O, Misset B, Parienti JJ, Quenot JP, Roch A, Schmidt M, Slama M, Souweine B, Zahar JR, Zingg W, Bodet-Contentin L, Maxime V. Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit. Ann Intensive Care 2020; 10:118. [PMID: 32894389 PMCID: PMC7477021 DOI: 10.1186/s13613-020-00713-4] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheter-related infections’ prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2− adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed definitions, and therapeutic strategies.
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Affiliation(s)
- Jean-François Timsit
- APHP/Hopital Bichat-Medical and Infectious Diseases ICU (MI2), 46 rue Henri Huchard, 75018, Paris, France.,UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases, Control and Care Inserm/Université de Paris, Sorbonne Paris Cité, 75018, Paris, France
| | - Julien Baleine
- Department of Neonatal Medicine and Pediatric Intensive Care, Arnaud de Villeneuve University Hospital, 371 Avenue Doyen G Giraud, 34295, Montpellier Cedex 5, France
| | - Louis Bernard
- Infectious Diseases Unit, University Hospital Tours, Nîmes 2 Boulevard, 37000, Tours, France
| | - Silvia Calvino-Gunther
- CHU Grenoble Alpes, Réanimation Médicale Pôle Urgences Médecine Aiguë, 38000, Grenoble, France
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Jean Dellamonica
- Centre Hospitalier Universitaire de Nice, Médecine Intensive Réanimation, Archet 1, UR2CA Unité de Recherche Clinique Côte d'Azur, Université Cote d'Azur, Nice, France
| | - Eric Desruennes
- Clinique d'anesthésie pédiatrique, Hôpital Jeanne-de-Flandre, avenue Eugène-Avinée, CHU Lille, 59000, Lille, France.,Unité accès vasculaire, Centre Oscar Lambret, 3 rue Frédéric Combemale, 59000, Lille, France
| | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, 13015, Marseille, France
| | - Alain Lepape
- Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, Lyon, France.,UMR CNRS 5308, Inserm U1111, Laboratoire des Pathogènes Émergents, Centre International de Recherche en Infectiologie, Lyon, France
| | - Olivier Leroy
- Medical ICU, Chatilliez Hospital, Tourcoing, France.,U934/UMR3215, Institut Curie, PSL Research University, 75005, Paris, France
| | - Jean-Christophe Lucet
- AP-HP, Infection Control Unit, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,INSERM IAME, U1137, Team DesCID, University of Paris, Paris, France
| | - Zied Merchaoui
- Pediatric Intensive Care, Paris South University Hospitals AP-HP, Le Kremlin Bicêtre, France
| | - Olivier Mimoz
- Services des Urgences Adultes and SAMU 86, Centre Hospitalier Universitaire de Poitiers, 86021, Poitiers, France.,Université de Poitiers, Poitiers, France.,Inserm U1070, Poitiers, France
| | - Benoit Misset
- Department of Intensive Care, Sart-Tilman University Hospital, and University of Liège, Liège, Belgium
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research and Department of Infectious Diseases, Caen University Hospital, 14000, Caen, France.,EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) UNICAEN, CHU Caen Medical School Université Caen Normandie, Caen, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Antoine Roch
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Service des Urgences, 13015, Marseille, France.,Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Faculté de médecine, Aix-Marseille Université, 13005, Marseille, France
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris (APHP), Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris, France.,INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Sorbonne Universités, 75651, Paris Cedex 13, France
| | - Michel Slama
- Medical Intensive Care Unit, CHU Sud Amiens, Amiens, France
| | - Bertrand Souweine
- Medical ICU, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France.,Service de Microbiologie Clinique et Unité de Contrôle et de Prévention Du Risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 Rue de Stalingrad, 93000, Bobigny, France
| | - Walter Zingg
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Laetitia Bodet-Contentin
- Medical Intensive Care Unit, INSERM CIC 1415, CRICS-TriGGERSep Network, CHRU de Tours and Université de Tours, Tours, France
| | - Virginie Maxime
- Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France.
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22
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Hu Y, Guo Y, Wang X, Li Y, Sun D, Cui D. Effects of the Incidence Density of Fever (IDF) on Patients Resuscitated From In-Hospital Cardiac Arrest: A Mediation Analysis. Front Med (Lausanne) 2020; 7:86. [PMID: 32269996 PMCID: PMC7109405 DOI: 10.3389/fmed.2020.00086] [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: 11/19/2019] [Accepted: 03/02/2020] [Indexed: 12/05/2022] Open
Abstract
Objective: The aim of this research was to study the factors contributing to the survival rate of in-hospital cardiac arrest (IHCA) and to determine whether the incidence density of fever (IDF) acts as a mediator. Methods: Data from patients with IHCA who survived more than 48 h were collected from 2011 to 2017. IDF was defined as the fever duration divided by the hospitalization duration, prolonged fever was defined as fever lasting for more than 5 days, and early fever was defined as an initial onset within the first 2 days of IHCA. Possible clinical variables associated with IDF were examined by linear regression, and possible clinical variables associated with survival rate were examined by univariate and multivariate analyses. IDF was investigated as a mediator of the indirect effects of the risk factors on survival. Results: In our retrospective study, the median IDF was 0, with an interquartile range from 0 to 0.42. Prolonged fever was noted in 16% (97/605) of the total, and early fever was noted in 17.2% (104/605) of the total. Linear regression results showed that positive chest X-ray, central venous catheter and Glasgow Coma Score (GCS) ≤ 8 were related to IDF. The IDF (OR: 0.36, 95% CI, 0.13–0.97, P = 0.04), prolonged fever (adjusted OR = 0.13, 95% CI, 0.06–0.29, P < 0.001), positive chest X-ray (OR: 0.67, 95% CI, 0.46–0.98, P = 0.04), central venous catheter placement (OR: 0.54, 95% CI, 0.34–0.89, P = 0.01), and endotracheal intubation (OR: 0.47, 95% CI, 0.33–0.69, P < 0.001) were also related to the negative outcome of hospital discharge after adjustment. Additionally, positive chest X-ray had a 19% effect on survival outcome through IDF as a mediator, and the indirect effect of central venous catheter mediated by IDF accounted for 10% of the total. Conclusions: A higher IDF, prolonged fever, a positive chest X-ray, the use of a central venous catheter and endotracheal intubation reduced the survival rate of these patients, and the detrimental impacts of a positive chest X-ray and the use of a central venous catheter on survival outcomes were partially mediated by IDF.
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Affiliation(s)
- Yue Hu
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yong Guo
- Department of Critical Care Medicine, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xintao Wang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yi Li
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Dawei Sun
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
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23
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Téoule P, Birgin E, Mertens C, Schwarzbach M, Post S, Rahbari NN, Reißfelder C, Ronellenfitsch U. Clinical Pathways for Oncological Gastrectomy: Are They a Suitable Instrument for Process Standardization to Improve Process and Outcome Quality for Patients Undergoing Gastrectomy? A Retrospective Cohort Study. Cancers (Basel) 2020; 12:E434. [PMID: 32069805 PMCID: PMC7073178 DOI: 10.3390/cancers12020434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 12/24/2022] Open
Abstract
(1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before (n = 64) or after (n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.
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Affiliation(s)
- Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Christina Mertens
- Department of General and Visceral Surgery, Städtisches Klinikum Karlsruhe, Moltkestr.90, 76133 Karlsruhe, Germany;
| | - Matthias Schwarzbach
- Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt, Germany;
| | - Stefan Post
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Nuh N. Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Christoph Reißfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; (P.T.); (E.B.); (S.P.); (N.N.R.); (C.R.)
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Ernst-Grube-Str.40, 06120 Halle (Saale), Germany
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24
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Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020; 46:266-284. [PMID: 32047941 PMCID: PMC7223992 DOI: 10.1007/s00134-020-05950-6] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary—that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5–8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-to-date expert statements.
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Affiliation(s)
- Jean-François Timsit
- AP-HP, Hôpital Bichat, Medical and Infectious Diseases ICU, 75018, Paris, France. .,Université de Paris, IAME, INSERM, 75018, Paris, France.
| | - Etienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Hôpital Bichat, Bacteriology Laboratory, 75018, Paris, France
| | | | - Alexis Tabah
- ICU, Redcliffe Hospital, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino-IRCCS, Genoa, Italy
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25
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Dunne CP, Ryan P, Connolly R, Dunne SS, Kaballo MA, Powell J, Woulfe B, O'Connell NH, Gupta RK. Management of Staphylococcus aureus bacteraemia (SAB) in the oncology patient: Further evidence supports prompt removal of central venous catheters and shorter duration of intravenous antimicrobial therapy. Infect Prev Pract 2020; 2:100037. [PMID: 34368689 PMCID: PMC8335915 DOI: 10.1016/j.infpip.2020.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Staphylococcus aureus bacteraemia (SAB) is associated with relatively high risk of complications and high levels of mortality. Internationally, SAB management guidelines lack consensus and especially so regarding oncology patients. This is likely a reflection of insufficient randomised control trials (RCT) and the diversity of SAB patient populations. However, there are 2011 guidelines recommending a minimum of 14 days of appropriate IV antibiotic therapy for SAB. Objective We wished to determine whether our practice of shortened duration of intravenous antimicrobial therapy in favour of oral administration proved as effective as recommended guidelines in a mixed oncology patient cohort. Methods Retrospective review of patient records that included any SAB episode among oncology patients from January 2002 to December 2015. Medical chart reviews were undertaken to determine patient demographics, clinical management & antimicrobial therapy, duration of stay, presence of a central venous catheter (CVC) and outcome. Results Our CVC removal rate was just 73% in SAB where CVC was the identified source of infection, with an attributable mortality rate (<4%) far lower than would be expected. Antimicrobial therapy durations were considerably lower (10 days) than current recommendations of 14 days IV therapy. The recurrence rate of 15% was also significantly lower than has been reported previously. Conclusions Our observations contribute new insights concerning the management of SAB in oncology patients. Our findings suggest that therapeutic approaches should perhaps remain individualised and reflective of patient characteristics taking into consideration the complex nature of oncology patients.
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Affiliation(s)
- Colum P Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Phelim Ryan
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Roisin Connolly
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Suzanne S Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Mohammed A Kaballo
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - James Powell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Bernie Woulfe
- Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.,Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Rajnish K Gupta
- Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
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26
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Influence of Clinical pathways on treatment and outcome quality for patients undergoing pancreatoduodenectomy? A retrospective cohort study. Asian J Surg 2019; 43:799-809. [PMID: 31732412 DOI: 10.1016/j.asjsur.2019.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/25/2019] [Accepted: 10/06/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pancreatic surgery demands complex multidisciplinary management. Clinical pathways (CPs) are a tool to facilitate this task, but evidence for their utility in pancreatic surgery is scarce. This study evaluated the effect of CPs on quality of care for pancreatoduodenectomy. METHODS Data of all consecutive patients who underwent pancreatoduodenectomy before (n = 147) or after (n = 148) CP introduction were evaluated regarding catheter and drain management, postoperative mobilization, pancreatic enzyme substitution, resumption of diet and length of stay. Outcome quality was assessed using glycaemia management, morbidity, mortality, reoperation and readmission rates. RESULTS Catheters and abdominal drainages were removed significantly earlier in patients treated with CP (p < 0.0001). First intake of liquids, nutritional supplement and solids was significantly earlier in the CP group (p < 0.0001). Exocrine insufficiency was significantly less common after CP implementation (47.3% vs. 69.7%, p < 0.0001). The number of patients receiving intraoperative transfusion dropped significantly after CP implementation (p = 0.0005) and transfusion rate was more frequent in the pre-CP group (p = 0.05). The median number of days with maximum pain level >3 was significantly higher in the CP group (p < 0.0001). There was no significant difference in mortality, morbidity, reoperation and readmission rates. CONCLUSIONS Following implementation of a CP for pancreatoduodenectomy, several indicators of process and outcome quality improved, while others such as mortality and reoperation rates remained unchanged. CPs are a promising tool to improve quality of care in pancreatic surgery.
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27
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Jiménez-Aguilar P, López-Cortés LE, Rodríguez-Baño J. Impact of infectious diseases consultation on the outcome of patients with bacteraemia. Ther Adv Infect Dis 2019; 6:2049936119893576. [PMID: 31839942 PMCID: PMC6900613 DOI: 10.1177/2049936119893576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022] Open
Abstract
Bacteraemia or bloodstream infections (BSI) are associated with much morbidity and mortality. Management of patients with bacteraemia is complex, and the increase in immunosuppressed patients and multidrug-resistant organisms poses additional challenges. The objective of this review is to assess the available published information about the impact of different aspects of management on the outcome of patients with BSI, and, specifically, the importance of infectious diseases specialists (IDS) consultation. The impact of management by IDS on different aspects, including interpretation of newer rapid techniques, early evaluation and treatment, and follow up, are reviewed. Overall, the available data suggest that IDS intervention improves the management and outcome of patients with BSI, either through consultation or structured unsolicited interventions in the context of multidisciplinary bacteraemia programmes.
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Affiliation(s)
- Patricia Jiménez-Aguilar
- Unidad Clínica de Enfermedades Infecciosas,
Hospital Universitario Puerto Real, Puerto Real, Cádiz, Spain
- Instituto de Investigación e Innovación
Biomédica de Cádiz (INiBICA), Cádiz, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
- Departamento de Medicina, Universidad de
Sevilla, Sevilla, Spain
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