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Chander S, Kumari R, Wang HY, Mohammed YN, Parkash O, Lohana S, Sorath F, Lohana AC, Sadarat F, Shiwlani S. Effect of low vs. high vancomycin trough level on the clinical outcomes of adult patients with sepsis or gram-positive bacterial infections: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:1114. [PMID: 39375599 DOI: 10.1186/s12879-024-09927-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 09/13/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND & OBJECTIVE The Infectious Disease Society of America guidelines recommend vancomycin trough levels of 15-20 mg/L for severe methicillin-resistant Staphylococcus aureus. However, recent consensus guidelines of four infectious disease organizations no longer recommend vancomycin dosing using minimum serum trough concentrations. Therefore, this study aimed to evaluate the impact of low (< 15 mg/L) vs. high (≥ 15 mg/L) vancomycin trough levels on clinical outcomes in adult patients with sepsis or gram-positive bacterial infections. METHOD A systematic literature review from inception to December 2022 was conducted using four online databases, followed by a meta-analysis. The outcomes of interest included clinical response/efficacy, microbial clearance, length of ICU stay, treatment failure, nephrotoxicity, and mortality. RESULTS Fourteen cohort studies met the inclusion criteria from which vancomycin trough concentration data were available for 5,228 participants. Our analysis found no association between vancomycin trough levels and clinical response [OR = 1.06 (95%CI 0.41-2.72], p = 0.91], microbial clearance [OR = 0.47 (95% CI 0.23-0.96), p = 0.04], ICU length of stay [MD=-1.01 (95%CI -5.73-3.71), p = 0.68], or nephrotoxicity [OR = 0.57 (95% CI 0.31-1.06), p = 0.07]. However, low trough levels were associated with a non-significant trend towards a lower risk of treatment failure [OR = 0.89 (95% CI 0.73-1.10), p = 0.28] and were significantly associated with reduced risk of all-cause mortality [OR = 0.74 (95% CI 0.62-0.90), p = 0.002]. CONCLUSION Except for a lower risk of treatment failure and all-cause mortality at low vancomycin trough levels, this meta-analysis found no significant association between vancomycin trough levels and clinical outcomes in adult patients with sepsis or gram-positive bacterial infections.
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Affiliation(s)
- Subhash Chander
- Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA.
- Mount Sinai Beth Israel Hospital, 281 1st Ave, New York, NY, 10003, USA.
| | - Roopa Kumari
- Department of Pathology, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Hong Yu Wang
- Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | | | - Om Parkash
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sindhu Lohana
- Department of Medicine, AGA khan University Hospital, Karachi, Pakistan
| | - Fnu Sorath
- Department of Medicine, Dow University Health Sciences, Karachi, Pakistan
| | - Abhi Chand Lohana
- Department of Medicine, Western Michigan University, Kalamazoo, WV, USA
| | - Fnu Sadarat
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Sheena Shiwlani
- Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA
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Escrihuela-Vidal F, Chico C, Borjabad González B, Vázquez Sánchez D, Lérida A, De Blas Escudero E, Sanmartí M, Linares González L, Simonetti AF, Conde AC, Muelas-Fernandez M, Diaz-Brito V, Quintana SGH, Oriol I, Berbel D, Càmara J, Grillo S, Pujol M, Cuervo G, Carratalà J. Effect of a bundle intervention on adherence to quality-of-care indicators and on clinical outcomes in patients with Staphylococcus aureus bacteraemia hospitalized in non-referral community hospitals. J Antimicrob Chemother 2024:dkae298. [PMID: 39212166 DOI: 10.1093/jac/dkae298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 08/09/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Although a significant number of cases of Staphylococcus aureus bacteraemia (SAB) are managed at non-referral community hospitals, the impact of a bundle-of-care intervention in this setting has not yet been explored. METHODS We performed a quasi-experimental before-after study with the implementation of a bundle of care for the management of SAB at five non-referral community hospitals and a tertiary care university hospital. Structured recommendations for the five indicators selected to assess quality of care were provided to investigators before the implementation of the bundle and monthly thereafter. Primary endpoints were adherence to the bundle intervention and treatment failure, defined as death or relapse at 90 days of follow-up. RESULTS One hundred and seventy patients were included in the pre-intervention period and 103 in the intervention period. Patient characteristics were similar in both periods. Multivariate analysis controlling for potential confounders showed that performance of echocardiography was the only factor associated with improved adherence to the bundle in the intervention period (adjusted OR 2.13; 95% CI 1.13-4.02). Adherence to the bundle, performance of follow-up blood cultures, and adequate duration of antibiotic therapy for complicated SAB presented non-significant improvements. The intervention was not associated with a lower rate of 90 day treatment failure (OR 1.11; 95% CI 0.70-1.77). CONCLUSIONS A bundle-of-care intervention for the management of SAB at non-referral community hospitals increased adherence to quality indicators, but did not significantly reduce rates of 90 day mortality or relapse.
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Affiliation(s)
- Francesc Escrihuela-Vidal
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristina Chico
- Department of Internal Medicine, Hospital Residència Sant Camil, Sant Pere de Ribes, Barcelona, Spain
| | - Beatriz Borjabad González
- Department of Internal Medicine, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | - Daniel Vázquez Sánchez
- Department of Microbiology, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ana Lérida
- Department of Internal Medicine, Hospital de Viladecans-Institut Català de la Salut (Àrea Metropolitana Sud), Viladecans, Barcelona, Spain
| | - Elisa De Blas Escudero
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Montserrat Sanmartí
- Department of Infectious Diseases, Parc Sanitari Sant Joan de Déu, Sant Boi, Barcelona, Spain
| | - Laura Linares González
- Department of Internal Medicine, Hospital Comarcal de l'Alt Penedès, Vilafranca del Penedès, Barcelona, Spain
| | | | - Ana Coloma Conde
- Department of Internal Medicine, Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | - Magdalena Muelas-Fernandez
- Department of Internal Medicine, Hospital de Viladecans-Institut Català de la Salut (Àrea Metropolitana Sud), Viladecans, Barcelona, Spain
| | - Vicens Diaz-Brito
- Department of Infectious Diseases, Parc Sanitari Sant Joan de Déu, Sant Boi, Barcelona, Spain
| | - Sara Gertrudis Horna Quintana
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Isabel Oriol
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Damaris Berbel
- Department of Microbiology, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Càmara
- Department of Microbiology, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Grillo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Miquel Pujol
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Guillermo Cuervo
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Lee SI, Bae S, Kim YS, Lee S. Complete genome sequencing of three methicillin-resistant Staphylococcus aureus isolated from the blood of patients with persistent bacteremia. Microbiol Resour Announc 2024; 13:e0117723. [PMID: 38990024 PMCID: PMC11323899 DOI: 10.1128/mra.01177-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 06/28/2024] [Indexed: 07/12/2024] Open
Abstract
We report the complete genome sequences of three molecular types of methicillin-resistant Staphylococcus aureus (MRSA) clinical strains isolated from the blood of three patients diagnosed with persistent MRSA bacteremia: KNIH_5618 (ST5-t5076-SCCmecII), KNIH_5844 (ST72-t664-SCCmecIV), and KNIH_6268 (ST89-t375-SCCmecII). These genome sequences contribute to an enhanced understanding of the underlying causes of persistent MRSA infection.
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Affiliation(s)
- Soo In Lee
- Department of Bacterial Disease Research, National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Seongman Bae
- Division of Infectious Diseases, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sungkyoung Lee
- Department of Bacterial Disease Research, National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
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Yang E, Cho YG, Kim E, Chang E, Bae S, Jung J, Kim MJ, Chong YP, Kim SH, Choi SH, Lee SO, Chung YS, Kim YS. Clinical and microbiological characteristics of persistent Staphylococcus aureus bacteremia, risk factors for mortality, and the role of CD4 + T cells. Sci Rep 2024; 14:15472. [PMID: 38969796 PMCID: PMC11226624 DOI: 10.1038/s41598-024-66520-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/02/2024] [Indexed: 07/07/2024] Open
Abstract
This study evaluated the determinants of mortality and the T cell immune response in patients with persistent Staphylococcus aureus bacteremia (SAB). This was a prospective cohort study and patients with confirmed SAB were enrolled from 2008 to 2020. We compared clinical, microbiological, and genotypic features between surviving and deceased patients with persistent SAB. The concentrations of cytokines and the proportions of IFN-γ secreting CD4+ T cells were measured serially during the bacteremia period. Of the 1760 patients, 242 had persistent bacteremia (PB), and 49 PB patients died within 30 days. In the multivariate analysis, the APACHE II score and female sex were independently associated with 30 days mortality. The level of IL-10 was significantly increased in the plasma of patients with a high Pitt bacteremia score and those who died within 12 weeks from the index day. The proportion of IFN-γ-secreting CD4+ T cells were the highest just before the positive-to-negative conversion of blood cultures in patients with a low Pitt bacteremia score and those who survived for 12 weeks. The level of IL-10 is correlated with clinical outcomes in PB patients. IFN-γ secreting CD4+ T cells might play a pivotal role in SAB PB.
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Affiliation(s)
- Eunmi Yang
- Division of Infectious Diseases, Seoul Medical Center, Seoul, South Korea
| | - Yeong Geon Cho
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, South Korea
- Asan Institute for Life Science, Asan Medical Center, Seoul, South Korea
| | - Eunsil Kim
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, South Korea
- Asan Institute for Life Science, Asan Medical Center, Seoul, South Korea
| | - Euijin Chang
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Seongman Bae
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, South Korea
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jiwon Jung
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Min Jae Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Yong Pil Chong
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sung-Han Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sang-Ho Choi
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Sang-Oh Lee
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Yun Shin Chung
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yang Soo Kim
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, South Korea.
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Núñez D, Jiménez P, Cortez-San Martín M, Cortés C, Cárdenas M, Michelson S, Garay T, Vecchiola M, Céspedes A, Maldonado JE, Vásquez-Martínez Y. Molecular and Phylogenomic Analysis of a Vancomycin Intermediate Resistance USA300LV Strain in Chile. Microorganisms 2024; 12:1284. [PMID: 39065053 PMCID: PMC11278659 DOI: 10.3390/microorganisms12071284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 07/28/2024] Open
Abstract
Antimicrobial resistance is a major global health problem, and, among Gram-positive bacteria, methicillin-resistant Staphylococcus aureus (MRSA) represents a serious threat. MRSA causes a wide range of infections, including bacteremia, which, due to the limited use of β-lactams, is difficult to treat. This study aimed to analyze 51 MRSA isolates collected in 2018 from samples of patients with bacteremia from two hospitals of the Metropolitan Health Service of Santiago, Chile, both in their resistance profile and in the identification of virulence factors. In addition, genomic characterization was carried out by the WGS of an isolate that was shown to be the one of greatest concern (N°. 42) due to its intermediate resistance to vancomycin, multiple virulence factors and being classified as ST8 PVL-positive. In our study, most of the isolates turned out to be multidrug-resistant, but there are still therapeutic options, such as tetracycline, rifampicin, chloramphenicol and vancomycin, which are currently used for MRSA infections; however, 18% were PVL positive, which suggests greater virulence of these isolates. It was determined that isolate N°42 is grouped within the USA300-LV strains (ST8, PVL+, COMER+); however, it has been suggested that, in Chile, a complete displacement of the PVL-negative ST5 clone has not occurred.
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Affiliation(s)
- Daniela Núñez
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
| | - Pablo Jiménez
- Laboratorio de Multiómica Vegetal y Bioinformática, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile;
| | - Marcelo Cortez-San Martín
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
| | - Carolina Cortés
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
| | - Matías Cárdenas
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
| | - Sofia Michelson
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
| | - Tamara Garay
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (T.G.); (M.V.); (A.C.)
| | - Maggie Vecchiola
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (T.G.); (M.V.); (A.C.)
| | - Alejandra Céspedes
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (T.G.); (M.V.); (A.C.)
| | - Jonathan E. Maldonado
- Laboratorio de Multiómica Vegetal y Bioinformática, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile;
- Millennium Institute for Integrative Biology (iBio), Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago 8380000, Chile
| | - Yesseny Vásquez-Martínez
- Molecular Virology and Pathogen Control Laboratory, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (D.N.); (M.C.-S.M.); (C.C.); (M.C.); (S.M.)
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile (USACH), Santiago 9170022, Chile; (T.G.); (M.V.); (A.C.)
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Thornley EM, Alexander R, Popelka J, Montgomery CP. Risk Factors for Persistent Staphylococcus aureus Bacteremia in Children. Pediatr Infect Dis J 2024:00006454-990000000-00910. [PMID: 38905222 DOI: 10.1097/inf.0000000000004439] [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] [Indexed: 06/23/2024]
Abstract
BACKGROUND Staphylococcus aureus is a leading cause of pediatric bacteremia. Persistent S. aureus bacteremia (SAB) is associated with increased morbidity and mortality in adults and children. Risk factors for S. aureus bacteremia have been well established, but there is a limited understanding of the factors that contribute to the development of persistent SAB in children. METHODS This is a single-center retrospective secondary analysis of a prospective observational study of pediatric patients hospitalized with S. aureus infection over a 3.5-year period at a large, quaternary, children's hospital. RESULTS Two hundred fifty-nine children with confirmed S. aureus infection were enrolled in the study. Sixty-five of these were found to have bacteremia, with 28 (43%) developing persistent bacteremia. Patients with persistent SAB were culture-positive for a median of 3.5 days compared with 1 day for those without (P ≤ 0.001). Children with persistent SAB were more likely to have an identified osteoarticular source of infection (93%, n = 26 vs. 62%, n = 23; P = 0.008) and had a shorter median duration to culture positivity than those without persistent SAB (16 hours vs. 20 hours; P ≤ 0.001). In addition, children with persistent SAB had higher median values of presenting erythrocyte sedimentation rate, peak erythrocyte sedimentation rate, presenting C-reactive protein and peak C-reactive protein. Not surprisingly, hospital length of stay was longer in children with persistent SAB compared with those without. CONCLUSIONS These findings suggest that a shorter time to culture positivity, osteoarticular infection, and higher presenting and peak values for select inflammatory markers are potential risk factors for persistent SAB in children.
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Affiliation(s)
- Erin M Thornley
- From the Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Robin Alexander
- Biostatistics Resource at Nationwide Children's Hospital (BRANCH), Columbus, OH
| | - Jill Popelka
- From the Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Christopher P Montgomery
- From the Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
- Center for Microbial Pathogenesis, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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Parmar R, Pickering H, Ahn R, Rossetti M, Gjertson DW, Ruffin F, Chan LC, Fowler VG, Yeaman MR, Reed EF. Integrated transcriptomic analysis reveals immune signatures distinguishing persistent versus resolving outcomes in MRSA bacteremia. Front Immunol 2024; 15:1373553. [PMID: 38846955 PMCID: PMC11153731 DOI: 10.3389/fimmu.2024.1373553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/02/2024] [Indexed: 06/09/2024] Open
Abstract
Introduction Staphylococcus aureus bacteremia (SAB) is a life-threatening infection particularly involving methicillin-resistant S. aureus (MRSA). In contrast to resolving MRSA bacteremia (RB), persistent MRSA bacteremia (PB) blood cultures remain positive despite appropriate antibiotic treatment. Host immune responses distinguishing PB vs. RB outcomes are poorly understood. Here, integrated transcriptomic, IL-10 cytokine levels, and genomic analyses sought to identify signatures differentiating PB vs. RB outcomes. Methods Whole-blood transcriptomes of propensity-matched PB (n=28) versus RB (n=30) patients treated with vancomycin were compared in one independent training patient cohort. Gene expression (GE) modules were analyzed and prioritized relative to host IL-10 cytokine levels and DNA methyltransferase-3A (DNMT3A) genotype. Results Differential expression of T and B lymphocyte gene expression early in MRSA bacteremia discriminated RB from PB outcomes. Significant increases in effector T and B cell signaling pathways correlated with RB, lower IL-10 cytokine levels and DNMT3A heterozygous A/C genotype. Importantly, a second PB and RB patient cohort analyzed in a masked manner demonstrated high predictive accuracy of differential signatures. Discussion Collectively, the present findings indicate that human PB involves dysregulated immunity characterized by impaired T and B cell responses associated with excessive IL-10 expression in context of the DNMT3A A/A genotype. These findings reveal distinct immunologic programs in PB vs. RB outcomes, enable future studies to define mechanisms by which host and/or pathogen drive differential signatures and may accelerate prediction of PB outcomes. Such prognostic assessment of host risk could significantly enhance early anti-infective interventions to avert PB and improve patient outcomes.
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Affiliation(s)
- Rajesh Parmar
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Richard Ahn
- Department of Microbiology, Immunology, & Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - David W. Gjertson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Felicia Ruffin
- Division of Infectious Diseases, Duke University, Durham, NC, United States
| | - Liana C. Chan
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Divisions of Molecular Medicine and Infectious Diseases, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, United States
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Vance G. Fowler
- Division of Infectious Diseases, Duke University, Durham, NC, United States
| | - Michael R. Yeaman
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Divisions of Molecular Medicine and Infectious Diseases, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, United States
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
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Cabanilla MG, Bernauer ML, Atallah LM, Briski MJ, Koury J, Thompson CM, Rodriguez CN, Jakeman B, Byrd TF. Short versus long duration of ceftaroline combination therapy and outcomes in persistent or high-grade MRSA bacteremia: A retrospective single-center study. PLoS One 2024; 19:e0304103. [PMID: 38768130 PMCID: PMC11104650 DOI: 10.1371/journal.pone.0304103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is associated with high mortality rates. Despite antibiotic therapy, persistent bacteremia is challenging to treat. Combination therapy with ceftaroline has emerged as a potential treatment option; however, the optimal duration and clinical implications after bacteremia clearance are unknown. METHODS This retrospective cohort study examined patients with high-grade or persistent MRSA bacteremia who were treated with ceftaroline combination therapy at the University of New Mexico Hospital between January 2014 and June 2021. Patients were categorized into short- (<7 days) or long-duration (≥7 days) groups based on the duration of combination therapy after bacteremia clearance. Outcomes included 30-day all-cause mortality, bacteremia recurrence, post-bacteremia clearance length of stay, and adverse events. RESULTS A total of 32 patients were included in this study. The most common sources of bacteremia were bone/joint and endovascular (28.1%, 9/32 each). The median duration of combination therapy after clearance was seven days (IQR 2.8, 11). Patients in the long-duration group had a lower Charlson comorbidity index (1.0 vs 5.5, p = 0.017) than those in the short-duration group. After adjusting for confounders, there was no significant difference in the 30-day all-cause mortality between the groups (AOR 0.17, 95% CI 0.007-1.85, p = 0.18). No association was found between combination therapy duration and recurrence (OR 2.53, 95% CI 0.19-inf, p = 0.24) or adverse drug events (OR 3.46, 95% CI 0.39-74.86, p = 0.31). After controlling for total hospital length of stay, there was no significant difference in the post-bacteremia clearance length of stay between the two groups (p = 0.37). CONCLUSIONS Prolonging ceftaroline combination therapy after bacteremia clearance did not significantly improve outcomes in patients with persistent or high-grade MRSA bacteremia. The limitations of this study warrant cautious interpretation of its results. Larger studies are needed to determine the optimal duration and role of combination therapy for this difficult-to-treat infection.
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Affiliation(s)
- M. Gabriela Cabanilla
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | | | - Liana M. Atallah
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Matthew J. Briski
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Jason Koury
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Cecilia M. Thompson
- TriCore Reference Laboratories, Albuquerque, New Mexico, United States of America
| | - Chelsea N. Rodriguez
- Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
| | - Bernadette Jakeman
- Department of Pharmacy Practice and Administrative Sciences, University of New Mexico College of Pharmacy, Albuquerque, New Mexico, United States of America
| | - Thomas F. Byrd
- Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
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Kim T, Lee SR, Park SY, Moon SM, Jung J, Kim MJ, Sung H, Kim MN, Kim SH, Choi SH, Lee SO, Kim YS, Song EH, Chong YP. Validation of a new risk stratification system-based management for methicillin-resistant Staphylococcus aureus bacteraemia: analysis of a multicentre prospective study. Eur J Clin Microbiol Infect Dis 2024; 43:841-851. [PMID: 38411778 DOI: 10.1007/s10096-024-04790-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Distinguishing between complicated and uncomplicated Staphylococcus aureus bacteraemia (SAB) is therapeutically essential. However, this distinction has limitations in reflecting the heterogeneity of SAB and encouraging targeted diagnostics. Recently, a new risk stratification system for SAB metastatic infection, involving stepwise approaches to diagnosis and treatment, has been suggested. We assessed its applicability in methicillin-resistant SAB (MRSAB) patients. METHODS We retrospectively analysed data of a 3-year multicentre, prospective cohort of hospitalised patients with MRSAB. We classified the patients into three risk groups: low, indeterminate, and high, based on the new system and compared between-group management and outcomes. RESULTS Of 380 patients with MRSAB, 6.3% were classified as low-, 7.6% as indeterminate-, and 86.1% as high-risk for metastatic infection. No metastatic infection occurred in the low-, 6.9% in the indeterminate-, and 19.6% in the high-risk groups (P < 0.001). After an in-depth diagnostic work-up, patients were finally diagnosed as 'without metastatic infection (6.3%)', 'with metastatic infection (17.4%)', and 'uncertain for metastatic infection (76.3%)'. 30-day mortality increased as the severity of diagnosis shifted from 'without metastatic infection' to 'uncertain for metastatic infection' and 'with metastatic infection' (P = 0.09). In multivariable analysis, independent factors associated with metastatic complications were suspicion of endocarditis in transthoracic echocardiography, clinical signs of metastatic infection, Pitt bacteraemia score ≥ 4, and persistent bacteraemia. CONCLUSIONS The new risk stratification system shows promise in predicting metastatic complications and guiding work-up and management of MRSAB. However, reducing the number of cases labelled as 'high-risk' and 'uncertain for metastatic infection' remains an area for improvement.
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Affiliation(s)
- Taeeun Kim
- Division of Infectious Diseases, Department of Medicine, Nowon Eulji University Hospital, Seoul, Republic of Korea
| | - Sang-Rok Lee
- Division of Infectious Diseases, Department of Internal Medicine, Cheongju St Mary's Hospital, Cheongju, Chungcheongbuk-do, Republic of Korea
| | - Seong Yeon Park
- Division of Infectious Diseases, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Gyeonggi-do, Republic of Korea
| | - Song Mi Moon
- Department of Internal Medicine at Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
- Department of Internal Medicine, Gil Medical Center, Gachon University School of Medicine, Incheon, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Eun Hee Song
- Departments of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Republic of Korea.
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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10
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Yamazaki Y, Ito T, Tamai M, Nakagawa S, Nakamura Y. The role of Staphylococcus aureus quorum sensing in cutaneous and systemic infections. Inflamm Regen 2024; 44:9. [PMID: 38429810 PMCID: PMC10905890 DOI: 10.1186/s41232-024-00323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/15/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Staphylococcus aureus is a leading cause of human bacterial infections worldwide. It is the most common causative agent of skin and soft tissue infections, and can also cause various other infections, including pneumonia, osteomyelitis, as well as life-threatening infections, such as sepsis and infective endocarditis. The pathogen can also asymptomatically colonize human skin, nasal cavity, and the intestine. S. aureus colonizes approximately 20-30% of human nostrils, being an opportunistic pathogen for subsequent infection. Its strong ability to silently spread via human contact makes it difficult to eradicate S. aureus. A major concern with S. aureus is its capacity to develop antibiotic resistance and adapt to diverse environmental conditions. The variability in the accessory gene regulator (Agr) region of the genome contributes to a spectrum of phenotypes within the bacterial population, enhancing the likelihood of survival in different environments. Agr functions as a central quorum sensing (QS) system in S. aureus, allowing bacteria to adjust gene expression in response to population density. Depending on Agr expression, S. aureus secretes various toxins, contributing to virulence in infectious diseases. Paradoxically, expressing Agr may be disadvantageous in certain situations, such as in hospitals, causing S. aureus to generate Agr mutants responsible for infections in healthcare settings. MAIN BODY This review aims to demonstrate the molecular mechanisms governing the diverse phenotypes of S. aureus, ranging from a harmless colonizer to an organism capable of infecting various human organs. Emphasis will be placed on QS and its role in orchestrating S. aureus behavior across different contexts. SHORT CONCLUSION The pathophysiology of S. aureus infection is substantially influenced by phenotypic changes resulting from factors beyond Agr. Future studies are expected to give the comprehensive understanding of S. aureus overall profile in various settings.
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Affiliation(s)
- Yuriko Yamazaki
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka, University, Osaka, 565-0871, Japan
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Tomoka Ito
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Masakazu Tamai
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Seitaro Nakagawa
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Yuumi Nakamura
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka, University, Osaka, 565-0871, Japan.
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan.
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Kinamon T, Dagher M, Park L, Ruffin F, Fowler VG, Maskarinec SA. Risk Factors and Outcomes of Hematogenous Vertebral Osteomyelitis in Patients With Staphylococcus aureus Bacteremia. Clin Infect Dis 2023; 77:1226-1233. [PMID: 37747828 PMCID: PMC10640688 DOI: 10.1093/cid/ciad377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Hematogenous vertebral osteomyelitis (HVOM) is an incompletely understood complication of Staphylococcus aureus bacteremia (SAB). METHODS Eligible SAB patients with and without HVOM were prospectively enrolled from 1995 through 2019 at Duke University Health System. HVOM was diagnosed either radiographically or microbiologically. Multivariable logistic regression analysis was performed to identify clinical and microbial factors associated with HVOM risk. All bloodstream S. aureus isolates were genotyped using spa typing. RESULTS Of 3165 cases of SAB, 127 (4.0%) developed HVOM. Patients who experienced HVOM were more likely to have community-acquired SAB (30.7% vs 16.7%, P < .001), have a longer time to diagnosis of SAB (median, 5 days; interquartile range [IQR], 2-10.5 vs median, 2 days; IQR, 0-4; P < .001), and to exhibit persistent bacteremia (48.8% vs 20.6%, P < .001). A significant number of HVOM patients developed infective endocarditis (26% vs 15.2%, P = .002). Overall, 26.2% (n = 33) of SAB patients with HVOM underwent surgical intervention. Methicillin resistance (46.6% vs 41.7%, P = .318) and bacterial genotype were not associated with the development of HVOM. At the 12-month follow-up, 22% of patients with HVOM had died. Of the surviving patients, 20.4% remained on antibiotic therapy, and 29.6% had recurrence of either HVOM or SAB. CONCLUSIONS Among patients with SAB, HVOM risk was associated with clinical factors and not bacterial genotype. Despite being a rare complication of SAB, patients with HVOM had high all-cause mortality rates and healthcare resource requirements up to 1 year after their HVOM diagnosis. Close clinical monitoring is indicated in this vulnerable population.
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Affiliation(s)
- Tori Kinamon
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Michael Dagher
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Lawrence Park
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Felicia Ruffin
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Stacey A Maskarinec
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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12
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Cerenzio J, Truong J. Efficacy and Safety of Vancomycin Bayesian-Estimated Area Under the Curve Versus Trough-Based Dosing. Ann Pharmacother 2023; 57:931-939. [PMID: 36476049 DOI: 10.1177/10600280221141402] [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: 07/20/2023] Open
Abstract
BACKGROUND Vancomycin guidelines by the Infectious Diseases Society of America and American Society of Health-System Pharmacists endorse Bayesian-software-assisted area under the curve (AUC24h) in their 2020 update. At this time, there are limited clinical data that support its use. OBJECTIVES The purpose of this study is to evaluate the safety benefits and efficacy outcomes of using Bayesian-assisted AUC24h dosing compared to trough dosing. METHODS Hospitalized patients from before February 1, 2020, (preimplementation of AUC24h dosing) and after August 1, 2020, (postimplementation) were reviewed. Patients with confirmed or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection of the lungs, heart, bones, prosthetic joint, or blood receiving vancomycin for at least 72 hours were included. The primary endpoint was the percentage of patients experiencing an acute kidney injury (AKI) in the trough-based group versus those experiencing AKI in the AUC24h group. The composite of all-cause mortality, 30-day readmission, or change in antibiotic therapy due to clinical worsening in patients with confirmed MRSA infections was included as a secondary endpoint. Data were analyzed with statistical testing methods as appropriate. RESULTS There was a significant reduction in AKI between the AUC24h dosing and trough dosing groups (3% vs 12%; P < 0.01). The efficacy for MRSA infections was also similar between groups (11% vs 14%; P = 0.72). CONCLUSION AND RELEVANCE Bayesian-assisted AUC24h dosing was associated with a significant reduction in incidence of AKI when compared to trough-based dosing. There was no difference in the composite efficacy endpoint for patients with confirmed MRSA infection, although the study was not powered for this analysis. These data may provide evidence for more institutions to adopt the Bayesian software to assist in dosing of vancomycin.
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Affiliation(s)
- John Cerenzio
- Department of Pharmacy, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - James Truong
- Department of Pharmacy, The Brooklyn Hospital Center, Brooklyn, NY, USA
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13
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Kitaya S, Kanamori H, Katori Y, Tokuda K. Clinical Characteristics and Outcomes of Persistent Staphylococcal Bacteremia in a Tertiary Care Hospital. Antibiotics (Basel) 2023; 12:antibiotics12030454. [PMID: 36978326 PMCID: PMC10044455 DOI: 10.3390/antibiotics12030454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Clinical outcomes of persistent staphylococcal bacteremia vary depending on the causative organism. This secondary data analysis study compared the clinical characteristics of persistent Staphylococcus aureus (S. aureus)- and coagulase-negative staphylococci (CoNS)-caused bacteremia, focusing on the methicillin-resistant status. This study used data collected from patients who underwent blood cultures between January 2012 and December 2021 at Tohoku University Hospital, Japan. Patients with persistent staphylococcal bacteremia were divided into groups based on the pathogen and methicillin-resistant status, and their characteristics were analyzed. The primary outcomes were early (30-day), late (30–90 days), and 90-day mortality rates. The early, late, and 90-day mortality rates were similar between the persistent CoNS and S. aureus bacteremia groups. Patients with persistent methicillin-resistant S. aureus (MRSA) bacteremia tended to have higher early, late, and 90-day mortality rates than those with persistent methicillin-susceptible S. aureus bacteremia (not statistically significant). No differences were observed between the methicillin-resistant and-susceptible CoNS groups. In patients with persistent CoNS bacteremia, mortality tended to increase, especially in debilitated or immunocompromised patients with distant metastases, underscoring the importance of infection source control. Mortality tended to be high in patients with persistent MRSA bacteremia, especially when persistent bacteremia clearance was not confirmed, illustrating the need for careful therapeutic management.
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Affiliation(s)
- Shiori Kitaya
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.); Tel.: +81-22-717-7373 (S.K.)
| | - Hajime Kanamori
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.); Tel.: +81-22-717-7373 (S.K.)
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Koichi Tokuda
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
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14
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Parsons JB, Westgeest AC, Conlon BP, Fowler VG. Persistent Methicillin-Resistant Staphylococcus aureus Bacteremia: Host, Pathogen, and Treatment. Antibiotics (Basel) 2023; 12:455. [PMID: 36978320 PMCID: PMC10044482 DOI: 10.3390/antibiotics12030455] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a devastating pathogen responsible for a variety of life-threatening infections. A distinctive characteristic of this pathogen is its ability to persist in the bloodstream for several days despite seemingly appropriate antibiotics. Persistent MRSA bacteremia is common and is associated with poor clinical outcomes. The etiology of persistent MRSA bacteremia is a result of the complex interplay between the host, the pathogen, and the antibiotic used to treat the infection. In this review, we explore the factors related to each component of the host-pathogen interaction and discuss the clinical relevance of each element. Next, we discuss the treatment options and diagnostic approaches for the management of persistent MRSA bacteremia.
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Affiliation(s)
- Joshua B. Parsons
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center, Durham, NC 27710, USA
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Annette C. Westgeest
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center, Durham, NC 27710, USA
- Department of Infectious Diseases, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Brian P. Conlon
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Vance G. Fowler
- Department of Medicine, Division of Infectious Disease, Duke University Medical Center, Durham, NC 27710, USA
- Duke Clinical Research Institute, Durham, NC 27710, USA
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15
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Inappropriate empirical antibiotic therapy was an independent risk factor of pediatric persistent S. aureus bloodstream infection. Eur J Pediatr 2023; 182:719-729. [PMID: 36454297 DOI: 10.1007/s00431-022-04729-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/15/2022] [Accepted: 11/20/2022] [Indexed: 12/02/2022]
Abstract
UNLABELLED Persistent S. aureus bloodstream infection (PSBSI) increased the incidence of metastatic infection and mortality. We aimed to clarify its risk factors and correlation with metastatic infection and septic shock in children. This retrospective and observational study enrolled children with S. aureus bloodstream infection who admitted to Children's Hospital of Chongqing Medical University between January 2016 and December 2021. The logistic regression model was used for multivariable analyses to determine independent factors associated with PSBSI and clarify the effect of persistent S. aureus bloodstream infection and other factors on metastatic infection and septic shock. One hundred and twenty-seven children were included in this study retrospectively. There were thirty-two cases in the persistent S. aureus bloodstream infection group and ninety-five children in the non-persistent infection group. Multivariate logistic regression analysis indicated that inappropriate empirical antibiotic therapy (OR, 7.26; 95%CI, 2.48-21.30; P<0.01) was an independent risk factor of persistent S. aureus bloodstream infection. Persistent S. aureus bloodstream infection (OR, 6.40; 95%CI, 2.08-19.70; P<0.01) and community-acquired S. aureus bloodstream infection (OR, 4.75; 95%CI, 1.34-16.89; P=0.02) were independent predictors of metastatic infection. Pittsburgh bacteremia scores ≥ 2 (OR, 28.81; 95%CI, 5.26-157.99; P<0.01), hypoalbuminemia (OR, 13.34; 95%CI, 2.43-73.28; P<0.01) and persistent S. aureus bloodstream infection (OR, 5.48; 95%CI, 1.13-26.54; P=0.04) were independent risk factors of septic shock. CONCLUSION Inappropriate empirical antibiotic therapy was an independent risk factor of pediatric persistent S. aureus bloodstream infection. Pediatric persistent S. aureus bloodstream infection was associated with metastatic infection and septic shock. WHAT IS KNOWN • Pathogenic features such as Methicillin-resistant S. aureus and sources of infection such as central venous catheter related infection were risk factors of PSBSI in adults. • PSBSI increased the incidence of metastatic infection and mortality in adults. WHAT IS NEW • Inappropriate empirical antibiotic therapy was an independent risk factor of pediatric persistent S. aureus bloodstream infection. • Pediatric persistent S. aureus bloodstream infection was associated with metastatic infection and septic shock.
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Kitaya S, Kanamori H, Baba H, Oshima K, Takei K, Seike I, Katsumi M, Katori Y, Tokuda K. Clinical and Epidemiological Characteristics of Persistent Bacteremia: A Decadal Observational Study. Pathogens 2023; 12:pathogens12020212. [PMID: 36839484 PMCID: PMC9960527 DOI: 10.3390/pathogens12020212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Background: Bloodstream infections (BSIs), including persistent bacteremia (PB), are a leading source of morbidity and mortality globally. PB has a higher mortality rate than non- PB, but the clinical aspects of PB in terms of the causative pathogens and the presence of clearance of PB are not well elucidated. Therefore, this study aimed to describe the clinical and epidemiological characteristics of PB in a real-world clinical setting. Methods: We performed a retrospective observational survey of patients who underwent blood culture between January 2012 and December 2021 at Tohoku University Hospital. Cases of PB were divided into three groups depending on the causative pathogen: gram-positive cocci (GPC), gram-negative rods (GNRs), and Candida spp. For each group, we examined the clinical and epidemiological characteristics of PB, including differences in clinical features depending on the clearance of PB. The main outcome variable was mortality, assessed as early (30-day), late (30-90 day), and 90-day mortality. Results: Overall, we identified 31,591 cases of single bacteremia; in 6709 (21.2%) cases, the first blood culture was positive, and in 3124 (46.6%) cases, a follow-up blood culture (FUBC) was performed. Of the cases with FUBCs, 414 (13.2%) were confirmed to be PB. The proportion of PB cases caused by Candida spp. was significantly higher (29.6%, 67/226 episodes) than that for GPC (11.1%, 220/1974 episodes, p < 0.001) and GNRs (12.1%, 100/824 episodes, p < 0.001). The Candida spp. group also had the highest late (30-90 day) and 90-day mortality rates. In all three pathogen groups, the subgroup without the clearance of PB tended to have a higher mortality rate than the subgroup with clearance. Conclusions: Patients with PB due to Candida spp. have a higher late (30-90 day) and 90-day mortality rate than patients with PB due to GPC or GNRs. In patients with PB, FUBCs and confirming the clearance of PB are useful to improve the survival rate.
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Affiliation(s)
- Shiori Kitaya
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.)
| | - Hajime Kanamori
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.)
| | - Hiroaki Baba
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Kengo Oshima
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Kentarou Takei
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Issei Seike
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Makoto Katsumi
- Department of Laboratory Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Koichi Tokuda
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
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Lam JC, Stokes W. The Golden Grapes of Wrath - Staphylococcus aureus Bacteremia: A Clinical Review. Am J Med 2023; 136:19-26. [PMID: 36179908 DOI: 10.1016/j.amjmed.2022.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus bacteremia is common and associated with fatality rates approximating 25%. We provide a brief overview of S. aureus bacteremia from a clinical and microbiological lens and review the relevant evidence and literature gaps in its management. Using a case-based approach, evidence and clinical judgement are meshed to highlight and justify the 5 core interventions that ought to be performed for all cases of S. aureus bacteremia: 1) appropriate anti-staphylococcal therapy, 2) screening echocardiography, 3) assessment for metastatic phenomena and source control, 4) decision on duration of antimicrobial therapy, and 5) Infectious Diseases consultation.
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Affiliation(s)
- John C Lam
- Division of Infectious Diseases, Department of Medicine, University of California Los Angeles.
| | - William Stokes
- Provincial Laboratory for Public Health, Alberta Precision Laboratories, Alberta, Canada; Department of Pathology and Laboratory Medicine; Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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18
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Fox E, Ha D, Bounthavong M, Meng L, Mui E, Holubar M, Deresinski S, Alegria W. Risk factors and outcomes associated with persistent vancomycin resistant Enterococcal Bacteremia. BMC Infect Dis 2022; 22:855. [DOI: 10.1186/s12879-022-07864-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
Prior studies have identified that vancomycin resistant enterococcus (VRE) bacteremia that persists for four days or more is an independent predictor of mortality. Despite this, there is no published data to identify those patients at highest risk of developing persistent VRE bacteremia.
Methods
This was a single center, retrospective, case-control study of adult patients with a VRE bloodstream infection (BSI). Case patients were those with persistent bacteremia (≥ 4 days despite VRE-directed therapy) and control patients were those with non-persistent bacteremia. Logistic regression was used to assess risk factors associated with persistent VRE BSIs. Secondary outcomes included in-hospital mortality, recurrent bacteremia, and breakthrough bacteremia.
Results
During the study period, 24/108 (22%) patients had persistently positive blood cultures. Risk factors for persistent bacteremia included severe neutropenia (OR 2.13), 4 out of 4 positive index blood cultures (OR 11.29) and lack of source control (OR 11.88). In an unadjusted analysis, no statistically significant differences in in-hospital mortality (58% versus 40%; p = 0.121), recurrent bacteremia (17% versus 6%; p = 0.090), or breakthrough bacteremia (13% versus 7%; p = 0.402) were observed between groups.
Conclusion
Patients with severe neutropenia, 4 out of 4 positive index blood culture bottles, and lack of source control were more likely to develop persistent VRE bacteremia despite directed antibiotic treatment.
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Sequence Type 5 (ST5) as a Possible Predictor of Bacterial Persistence in Adult Patients with Methicillin-Resistant Staphylococcus aureus Pneumonia Treated with Vancomycin. Microbiol Spectr 2022; 10:e0134822. [PMID: 36094217 PMCID: PMC9603198 DOI: 10.1128/spectrum.01348-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vancomycin remains the mainstay of treatment for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. This study assessed risk factors for vancomycin failure in 63 patients with MRSA pneumonia through detailed clinical, microbiological, pharmacokinetic/pharmacodynamic, and genetic analyses of prospective multicenter studies conducted from February 2012 to July 2018. Therapeutic drug monitoring was performed during vancomycin treatment, and the 24-h area under the curve (AUC0-24) was calculated. All baseline strains were collected for MIC determination, heterogeneous vancomycin-intermediate S. aureus (hVISA) screening, and biofilm determination. Whole-genome sequencing was performed on the isolates to analyze their molecular typing and virulence and adhesion genes. Clinical signs and symptoms improved in 44 patients (44/63, 69.8%), with vancomycin daily dose (P = 0.045), peak concentration (P = 0.020), and sdrC (P = 0.047) being significant factors. Isolates were eradicated in 51 patients (51/63, 81.0%), with vancomycin daily dose (P = 0.009), cardiovascular disease (P = 0.043), sequence type 5 (ST5; P = 0.017), tst (P = 0.050), and sec gene (P = 0.044) associated with bacteriological failure. Although the AUC0-24/MIC was higher in the groups with bacterial eradication, the difference was not statistically significant (P = 0.108). Multivariate analysis showed that no variables were associated with clinical efficacy; ST5 was a risk factor for bacterial persistence (adjusted odds ratio, 4.449; 95% confidence interval, 1.103 to 17.943; P = 0.036). ST5 strains had higher frequencies of the hVISA phenotype, biofilm expression, and presence of some adhesion and virulence genes such as fnbB, tst, and sec than non-ST5 strains. Our study suggests that ST5 is a possible predictor of bacterial persistence in MRSA pneumonia treated with vancomycin. IMPORTANCE Few studies have simultaneously examined the influence of clinical characteristics of patients with pneumonia, the vancomycin pharmacokinetic/pharmacodynamic (PK/PD) index, and the phenotypic and genetic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) strains. We assessed risk factors for vancomycin failure in patients with MRSA pneumonia by analyzing these influences in a prospective multicenter study. Sequence type 5 (ST5) was a possible predictor of bacterial persistence in adult patients with MRSA pneumonia (adjusted odds ratio, 4.449). We found that this may be related to ST5 strains having higher levels of vancomycin heterogeneous resistance, biofilms, and the presence of adhesion and virulence genes such as fnbB, tst, and sec.
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Persistent Methicillin-Susceptible Bacteremia Rapidly Cleared with Cefazolin and Ertapenem Combination Therapy in a Patient with COVID-19. Case Rep Infect Dis 2022; 2022:6828538. [PMID: 35462678 PMCID: PMC9020139 DOI: 10.1155/2022/6828538] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/17/2022] [Accepted: 04/08/2022] [Indexed: 12/04/2022] Open
Abstract
Methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSIs) are associated with significant morbidity and mortality. MSSA BSIs can rapidly disseminate, resulting in deep-seated infections, prolonged durations of bacteremia, and further metastases. Recently, cefazolin and ertapenem combination therapy has emerged as a potential therapeutic strategy to sterilize the blood in patients with persistent MSSA bacteremia. Here, we present a patient with COVID-19 pneumonia and concomitant MSSA BSI achieving blood culture sterilization within 24 hours of cefazolin and ertapenem combination therapy initiation following 11 days of positive blood cultures.
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Ledger EVK, Mesnage S, Edwards AM. Human serum triggers antibiotic tolerance in Staphylococcus aureus. Nat Commun 2022; 13:2041. [PMID: 35440121 PMCID: PMC9018823 DOI: 10.1038/s41467-022-29717-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/30/2022] [Indexed: 12/13/2022] Open
Abstract
Staphylococcus aureus frequently causes infections that are challenging to treat, leading to high rates of persistent and relapsing infection. Here, to understand how the host environment influences treatment outcomes, we study the impact of human serum on staphylococcal antibiotic susceptibility. We show that serum triggers a high degree of tolerance to the lipopeptide antibiotic daptomycin and several other classes of antibiotic. Serum-induced daptomycin tolerance is due to two independent mechanisms. Firstly, the host defence peptide LL-37 induces tolerance by triggering the staphylococcal GraRS two-component system, leading to increased peptidoglycan accumulation. Secondly, GraRS-independent increases in membrane cardiolipin abundance are required for full tolerance. When both mechanisms are blocked, S. aureus incubated in serum is as susceptible to daptomycin as when grown in laboratory media. Our work demonstrates that host factors can significantly modulate antibiotic susceptibility via diverse mechanisms, and combination therapy may provide a way to mitigate this.
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Affiliation(s)
- Elizabeth V K Ledger
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, Armstrong Rd, London, SW7 2AZ, UK
| | - Stéphane Mesnage
- School of Biosciences, University of Sheffield, Sheffield, S10 2TN, UK
| | - Andrew M Edwards
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, Armstrong Rd, London, SW7 2AZ, UK.
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22
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Bioactivity of Mupirocin Nanoparticle-Loaded Hydrogel against Methicillin-Resistant Staphylococcus aureus (MRSA). Appl Microbiol 2022. [DOI: 10.3390/applmicrobiol2010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This novel study investigated the loading of mupirocin nanoparticles into a hydrogel which was expected to enhance the antibacterial activity of mupirocin. The inhibition of isoleucyl-tRNA synthetase and global gene expression in methicillin-resistant Staphylococcus aureus (MRSA) by the mupirocin nanoparticle-loaded hydrogel (MLH) and by pure mupirocin was compared. MLH and mupirocin rapidly inhibited the growth of bacterial populations after 1 h of treatment. At 12 h, mupirocin and MLH inhibited isoleucyl-tRNA synthetase in MRSA. Transcriptome profiles of MRSA showed that gene expression alterations after treatment with mupirocin were similar to those after treatment with MLH at MICs. These alterations included changes to DNA transcription, translation, and replication pathways, and the fold changes in these genes decreased more rapidly with MLH than with mupirocin only after 1 h of treatment. MLH released the mupirocin from the nanoparticles and hydrogel systems and then the drug permeated the cell wall and bound to bacterial isoleucyl-tRNA synthetase. The research also showed that MLH could be further developed for use in clinics for infected wounds.
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Sinclair MR, Souli M, Ruffin F, Park LP, Dagher M, Eichenberger EM, Maskarinec SA, Thaden JT, Mohnasky M, Wyatt CM, Fowler VG. Staphylococcus aureus Bacteremia Among Patients Receiving Maintenance Hemodialysis: Trends in Clinical Characteristics and Outcomes. Am J Kidney Dis 2022; 79:393-403.e1. [PMID: 34303771 PMCID: PMC8783931 DOI: 10.1053/j.ajkd.2021.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/06/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE & OBJECTIVE Staphylococcus aureus (Saureus) bacteremia (SAB) is associated with morbidity and mortality in patients receiving maintenance hemodialysis (HD). We evaluated changes in clinical and bacterial characteristics, and their associations with clinical outcomes with SAB in this population over a 21-year period. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 453 hospitalized, non-neutropenic adults receiving maintenance HD who developed monomicrobial SAB between 1995 and 2015. EXPOSURE Clinical characteristics and bacterial genotype. OUTCOME All-cause and SAB-attributable mortality, persistent bacteremia, and metastatic complications. ANALYTICAL APPROACH Proportions of participants experiencing each outcome were calculated overall and by calendar year. Secular trends were estimated using binomial risk regression, a generalized linear model with the log link function for a binomial outcome. Associations with outcomes were estimated using logistic regression. RESULTS Over the 21-year study period, patients receiving maintenance HD experienced significant increases in age- and diabetes-adjusted SAB-attributable mortality (0.45% [95% CI, 0.36%-0.46%] per year), persistent bacteremia (0.86% [95% CI, 0.14%-1.55%] per year), metastatic complications (0.84% [95% CI, 0.11%-1.56%] per year), and infection with the virulent Saureus clone USA300 (1.47% [95% CI, 0.33%-2.52%] per year). Over time, the suspected source of SAB was less likely to be a central venous catheter (-1.32% [95% CI, -2.05 to-0.56%] per year) or arteriovenous graft (-1.08% [95% CI, -1.54 to-0.56] per year), and more likely to be a nonvascular access source (1.89% [95% CI, 1.29%-2.43%] per year). Patients with a nonvascular access suspected source of infection were more likely to die as a result of their S aureus infection (OR, 3.20 [95% CI, 1.36-7.55]). The increase in USA300 infections may have contributed to the observed increase in persistent bacteremia (OR, 2.96 [95% CI, 1.12-7.83]) but did not explain the observed increases in SAB-attributable mortality (OR, 0.83 [95% CI, 0.19-3.61]) or metastatic complications (OR, 1.34 [95% CI, 0.53-3.41]). LIMITATIONS Single-center, inpatient cohort. CONCLUSIONS The clinical and molecular epidemiology of SAB in patients receiving maintenance HD has changed over time, with an increase in SAB-attributable mortality and morbidity despite a decline in catheter-related infections.
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Affiliation(s)
- Matthew R. Sinclair
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Nephrology, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | - Maria Souli
- Duke Clinical Research Institute, Durham, North Carolina
| | - Felicia Ruffin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Lawrence P. Park
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina,Duke Global Health Institute, Durham, North Carolina
| | - Michael Dagher
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Emily M. Eichenberger
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Stacey A. Maskarinec
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Joshua T. Thaden
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Michael Mohnasky
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Christina M. Wyatt
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Nephrology, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | - Vance G. Fowler
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
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24
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Onyedibe KI, Dayal N, Sintim HO. SF 5- and SCF 3-substituted tetrahydroquinoline compounds as potent bactericidal agents against multidrug-resistant persister Gram-positive bacteria. RSC Med Chem 2021; 12:1879-1893. [PMID: 34825185 DOI: 10.1039/d1md00211b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/09/2021] [Indexed: 11/21/2022] Open
Abstract
Bacteria persister cells are immune to most antibiotics and hence compounds that are active against persister bacteria are needed. We screened a chemical library of SF5- and SCF3-substituted tetrahydroquinoline compounds, synthesized via the Povarov reaction, for antibacterial activity and identified active compounds that displayed good activities against many Gram-positive bacteria, including persisters. The most potent of these compounds, HSD1835, inhibited the growth of drug-resistant Gram-positive bacterial pathogens (including clinical strains) at concentrations ranging from 1 μg mL-1 to 4 μg mL-1. Several of the SCF3- and SF5-containing compounds were active against methicillin-resistant Staphylococcus aureus (MRSA) and against the two most fatal strains of vancomycin-resistant Enterococcus (VRE), VRE faecalis and VRE faecium. The compounds showed bactericidal activity against stationary phase persister MRSA in time-kill assays. Mechanistic studies showed that HSD1835 acts by disrupting bacterial membranes. Scanning electron microscopy (SEM) was used to confirm bacterial membrane disruption. Interestingly, in a 30 day serial exposure experiment, MRSA remained susceptible to low-dose HSD1835 whilst resistance to ciprofloxacin and mupirocin emerged by day 10. Analogs of HSD1835, which did not bear the SF5 or SCF3 moieties, were inactive against bacteria. Recent reports (G. A. Naclerio, N. S. Abutaleb, K. I. Onyedibe, M. N. Seleem and H. O. Sintim, RSC Med. Chem. 2020, 11, 102-110 and G. A. Naclerio, N. S. Abutaleb, D. Li, M. N. Seleem and H. O. Sintim, J. Med. Chem. 2020, 63(20), 11934-11944) also demonstrated that adding the SF5 or SCF3 groups to a different scaffold (oxadiazoles) enhanced the antibacterial properties of the compounds, so it appears that these groups are privileged moieties that enhance the antimicrobial activities of compounds.
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Affiliation(s)
- Kenneth I Onyedibe
- Department of Chemistry, Purdue University 560 Oval Drive, West Lafayette Indiana 47907 USA .,Purdue Institute of Inflammation, Immunology, and Infectious Disease West Lafayette IN 47907 USA
| | - Neetu Dayal
- Department of Chemistry, Purdue University 560 Oval Drive, West Lafayette Indiana 47907 USA
| | - Herman O Sintim
- Department of Chemistry, Purdue University 560 Oval Drive, West Lafayette Indiana 47907 USA .,Purdue Institute of Inflammation, Immunology, and Infectious Disease West Lafayette IN 47907 USA.,Center for Drug Discovery, Purdue University 720 Clinic Drive, West Lafayette Indiana 47907 USA
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25
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Willekens R, Puig-Asensio M, Suanzes P, Fernández-Hidalgo N, Larrosa MN, González-López JJ, Rodríguez-Pardo D, Pigrau C, Almirante B. "Mortality in Staphylococcus aureus bacteraemia remains high despite adherence to quality indicators: secondary analysis of a prospective cohort study". J Infect 2021; 83:656-663. [PMID: 34626700 DOI: 10.1016/j.jinf.2021.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the association between compliance with previously published quality indicators (QIs) for the management of Staphylococcus aureus bacteraemia (SAB) and 30-day mortality. METHODS We conducted a post hoc analysis of all adult patients with SAB who were hospitalized at a Spanish university hospital between 2013 and 2018. We evaluated the compliance with 7 QIs of SAB management (i.e., Infectious Diseases consultation, follow-up blood cultures, early source control, echocardiography, early cloxacillin or cefazolin, vancomycin monitoring, and appropriate treatment duration). The QIs compliance rate was considered good if ≥75% of the QIs recommended in each patient were performed. We studied the impact of different risk factors (including QIs compliance) on 30-day all-cause mortality adjusting by multivariable modeling and propensity-matched analysis. RESULTS We included 441 patients with SAB. The QIs compliance rate was ≥75% in 361 patients (81.9%). A total of 95 patients (21.5%) died within 30 days after the index blood culture. In the multivariable model, the variables associated with 30-day mortality were: age (OR, 1.1; 95% CI, 1.0-1.1), Charlson comorbidity index (OR, 1.2; 95% CI, 1.1-1.4), persistent bacteraemia >72 h (OR, 6.0; 95% CI, 3.2-11.5), infective endocarditis (OR, 2.8; 95% CI, 1.2-6.7), and SAB of unknown source (OR, 3.3; 95% CI, 1.5-7.1). We did not find an association between a global QIs compliance rate of ≥75% or any individual QI with 30-day mortality. CONCLUSIONS SAB 30-day mortality remains high despite good adherence to previously published QIs for the management of SAB. Future research should focus on additional factors to further improve SAB-related mortality.
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Affiliation(s)
- Rein Willekens
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Paula Suanzes
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Research Institute, Barcelona, Spain
| | - Nuria Fernández-Hidalgo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Maria N Larrosa
- Spanish Network for the Study of Infectious Diseases (REIPI), Spain; Department of Microbiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Juan J González-López
- Spanish Network for the Study of Infectious Diseases (REIPI), Spain; Department of Microbiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dolors Rodríguez-Pardo
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Carles Pigrau
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
| | - Benito Almirante
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Spanish Network for the Study of Infectious Diseases (REIPI), Spain
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26
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El-Dalati S, Sridaran S, Uricchio M, Kline EG, Shields R. Oxacillin plus ertapenem combination therapy leads to rapid blood culture clearance and positive outcomes among patients with persistent MSSA bacteraemia: a case series. JAC Antimicrob Resist 2021; 3:dlab148. [PMID: 34604746 PMCID: PMC8480914 DOI: 10.1093/jacamr/dlab148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Background Bloodstream infections caused by MSSA are associated with significant morbidity and mortality. Traditional treatment of MSSA bacteraemia includes an IV antistaphylococcal β-lactam and surgical source control when indicated. Objectives To evaluate the time to blood culture clearance as well as in-hospital and 90 day mortality in patients with persistent MSSA bacteraemia treated with combination antistaphylococcal penicillin plus carbapenem therapy. Methods Consecutive patients with persistent MSSA bacteraemia treated with combination therapy were identified by study investigators and reviewed by independent clinicians. The decision to initiate combination therapy was made by the consulting clinician or by the institution’s multidisciplinary endocarditis team. Results Among 10 patients with a median of 5 days of persistent MSSA bacteraemia, treatment with an antistaphylococcal penicillin plus carbapenem led to sterilization of blood cultures in all patients. Blood culture clearance occurred in a median of 1 day and patients received a median of 6 days of combination treatment. Four of seven patients who underwent source control of their primary site of infection cleared their bacteraemia on combination therapy prior to the surgical intervention. All patients survived to hospital discharge and 90 days post-discharge. Conclusions These data extend prior findings and provide further evidence that suggests the potential benefits of combination therapy among patients with persistent MSSA bacteraemia.
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Affiliation(s)
- Sami El-Dalati
- Division of Infectious Diseases, Department of Internal Medicine, University of Pittsburgh Medical Center, 3601 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Sanjay Sridaran
- Department of Internal Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Marissa Uricchio
- Department of Pharmacy, University of Pittsburgh Medical Center, 3501 Terrace Street, Pittsburgh, PA 15213, USA
| | - Ellen G Kline
- Division of Infectious Diseases, Department of Internal Medicine, University of Pittsburgh Medical Center, 3601 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Ryan Shields
- Division of Infectious Diseases, Department of Internal Medicine, University of Pittsburgh Medical Center, 3601 Fifth Avenue, Pittsburgh, PA 15213, USA
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27
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Suarez JF, Ong’uti S, Holubar M. Select controversies in the management of methicillin-resistant Staphylococcus aureus bacteremia: answers and remaining questions from recent evidence. Fac Rev 2021; 10:66. [PMID: 34557870 PMCID: PMC8441996 DOI: 10.12703/r/10-66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia continues to cause significant morbidity and mortality despite advances in medical therapy. Vancomycin therapy remains the standard of care for most cases of MRSA bacteremia but has pharmacokinetic and pharmacodynamic limitations, dosing complications, and known toxicity. Welcomed clinical trials have recently addressed some of the controversies that plague this field, including optimization of vancomycin dosing and use of combination therapy. In this review, we discuss these trials and their implications for clinical care and future research.
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Affiliation(s)
- Jose F Suarez
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Division of Infectious Diseases, Miami, FL, USA
| | - Sharon Ong’uti
- Stanford University School of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
| | - Marisa Holubar
- Stanford University School of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
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28
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Impact of agr Functionality on the Outcome of Patients with Methicillin-Susceptible Staphylococcus aureus Bacteremia. Microbiol Spectr 2021; 9:e0011621. [PMID: 34378959 PMCID: PMC8552762 DOI: 10.1128/spectrum.00116-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Dysfunctional accessory gene regulator (agr) is associated with unfavorable outcomes in invasive methicillin-resistant Staphylococcus aureus infections. However, it is unknown whether this association persists in methicillin-susceptible Staphylococcus aureus bacteremia (MSSA-B). This study evaluated the association between agr dysfunction and mortality in patients with MSSA-B. This retrospective cohort study included MSSA-B patients (≥15 years) enrolled from June 2014 to June 2019 and retrospectively collected their demographic and clinical information. Stored causative strains were measured for agr functionality by δ-hemolysin production assays. Among 244 MSSA-B patients, 91 (37.3%) and 153 (62.7%) had dysfunctional and functional agr MSSA-B, respectively. Ninety-day mortality occurred in 18.7% and 17.6% dysfunctional and functional groups, respectively (P = 0.97). Kaplan-Meier analysis showed that mortality due to dysfunctional agr MSSA-B was not significantly higher (P = 0.82). Age, sites, the severity of infection, and comorbidity adjusted hazard ratio (aHR) of the dysfunctional group for 90-day mortality was 1.303 (95% confidence interval [CI], 0.698 to 2.436, P = 0.41). Mortality due to MSSA-B with sequential organ failure assessment (SOFA) scores of 2 to 5 was significantly higher in the dysfunctional group (P = 0.03), and the dysfunctional agr aHR for 90-day mortality was 3.260 (95% CI, 1.050 to 10.118, P = 0.04). The agr dysfunction of causative organisms can have a significant effect on the outcomes of MSSA-B in patients with moderate severity (SOFA scores 2 to 5). IMPORTANCE Few studies have examined the association between methicillin-susceptible Staphylococcus aureus (MSSA) infection and accessory gene regulator (agr) functionality. We evaluated the association between agr dysfunction and mortality in patients with MSSA bacteremia. Dysfunctional agr is associated with lower survival in MSSA bacteremia patients with moderately severe sequential organ failure assessment (SOFA) scores of 2 to 5. We found that the agr functionality of causative organisms may have an effect on patients’ outcomes in MSSA like in methicillin-resistant S. aureus.
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Yang E, Kim E, Chung H, Lee YW, Bae S, Jung J, Kim MJ, Chong YP, Kim SH, Choi SH, Lee SO, Kim YS. Changing characteristics of S. aureus bacteremia caused by PVL-negative, MRSA strain over 11 years. Sci Rep 2021; 11:15677. [PMID: 34344954 PMCID: PMC8333258 DOI: 10.1038/s41598-021-95115-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/21/2021] [Indexed: 11/09/2022] Open
Abstract
Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has emerged as an important cause of infection. We conducted a longitudinal study to evaluate changes in clinical and microbiological characteristics as well as outcomes of sequence type (ST) 72 MRSA bacteremia. We reviewed adult patients enrolled in a prospective cohort with ST72 MRSA bacteremia from August 2008 to December 2018 at Asan Medical Center, Seoul, South Korea. Changes in clinical characteristics, outcomes, and microbiological characteristics of patients over time were evaluated. Generalized linear and linear regression models were used to evaluate changes. Of the 1,760 isolates, 915 (62%) were MRSA bacteremia and 292 (31.9%) were ST72 MRSA. During the study period, the relative risk (RR) of MRSA bacteremia decreased annually by 3.7%; however, among MRSA bacteremia, RR of ST72 MRSA increased annually by 8.5%. Vancomycin minimum inhibitory concentration (MIC) decreased over the study period. Metastatic infection, persistent bacteremia, and recurrence of bacteremia within 12 weeks decreased significantly. There were no significant changes in 30-d and 12-week mortality. Antibiotic susceptibility of ST72 MRSA was evaluated, and the resistance rate to erythromycin decreased significantly. ST72 MRSA incidence increased annually; its vancomycin MIC and erythromycin resistance rate decreased over the 11 years.
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Affiliation(s)
- Eunmi Yang
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eunsil Kim
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyemin Chung
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yun Woo Lee
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seongman Bae
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.,Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Min Jae Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong Pil Chong
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sung-Han Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang-Ho Choi
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang-Oh Lee
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yang Soo Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 05505, Republic of Korea. .,Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Chung H, Kim E, Yang E, Lee YW, Park JH, Bae S, Jung J, Kim MJ, Chong YP, Kim SH, Lee SO, Choi SH, Kim YS. C-reactive protein predicts persistent bacteremia caused by community-acquired methicillin-resistant Staphylococcus aureus strain. Eur J Clin Microbiol Infect Dis 2021; 40:2497-2504. [PMID: 34245388 DOI: 10.1007/s10096-021-04303-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
There is limited data on persistent bacteremia (PB) caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Here, we aimed to investigate the clinical and microbiological characteristics of PB caused by the major CA-MRSA strain in Korea (ST72-SCCmecIV). All adult patients with S. aureus bacteremia were prospectively investigated from August 2008 to December 2018. Patients with ST72 MRSA bacteremia were included in the study. Patients were stratified into the PB group (defined as positive blood cultures for ≥ 3 days) and short bacteremia (SB) group. A total of 291 patients were included, comprising 115 (39.5%) with PB and 176 (60.5%) with SB. Although the 30-day mortality did not differ between PB and SB, recurrent bacteremia within 12 weeks was significantly more common in PB (8.7% vs 1.7%; P = 0.01). Multivariate analysis showed risk factors of PB were liver cirrhosis (adjusted odds ratio [aOR], 3.27; 95% confidence interval [CI], 1.50-7.12), infective endocarditis (aOR, 7.13; 95% CI, 1.37-37.12), bone and joint infections (aOR, 3.76; 95% CI, 1.62-8.77), C-reactive protein ≥ 10 mg/dL (aOR, 2.20; 95% CI, 1.22-3.95), metastatic infection (aOR, 7.35; 95% CI, 3.53-15.29), and agr dysfunction (aOR, 2.47; 95% CI, 1.05-5.81). PB occurred in approximately 40% of bacteremia caused by ST72 MRSA with a significantly higher recurrence rate. Patients with risk factors of PB, including liver cirrhosis, high initial CRP, infective endocarditis, or bone and joint infections, might require early aggressive treatment.
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Affiliation(s)
- Hyemin Chung
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunsil Kim
- Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan, 88 Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eunmi Yang
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun Woo Lee
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joung Ha Park
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Division of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. .,Center for Antimicrobial Resistance and Microbial Genetics, University of Ulsan, 88 Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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31
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McAleenan A, Ambrose PG, Bhavnani SM, Drusano GL, Hope WW, Mouton JW, Higgins JPT, MacGowan AP. Methodological features of clinical pharmacokinetic-pharmacodynamic studies of antibacterials and antifungals: a systematic review. J Antimicrob Chemother 2021; 75:1374-1389. [PMID: 32083674 DOI: 10.1093/jac/dkaa005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK)-pharmacodynamic (PD) indices relate measures of drug exposure to antibacterial effect. Clinical PK-PD studies aim to correlate PK-PD indices with outcomes in patients. Optimization of dosing based on pre-clinical studies means that PK-PD relationships are difficult to establish; therefore studies need to be designed and reported carefully to validate pre-clinical findings. OBJECTIVES To describe the methodological features of clinical antibacterial and antifungal PK-PD studies that reported the relationship between PK-PD indices and clinical or microbiological responses. METHODS Studies published between 1980 and 2015 were identified through systematic searches. Methodological features of eligible studies were extracted. RESULTS We identified 85 publications containing 97 PK-PD analyses. Most studies were small, with fewer than 100 patients. Around a quarter were performed on patients with infections due to a single specific pathogen. In approximately one-third of studies, patients received concurrent antibiotics/antifungals and in some other studies patients received other treatments that may confound the PK-PD-outcome relationship. Most studies measured antimicrobial concentrations in blood/serum and only four measured free concentrations. Most performed some form of regression, time-to-event analysis or used the Hill/Emax equation to examine the association between PK-PD index and outcome. Target values of PK-PD indices that predict outcomes were investigated in 52% of studies. Target identification was most commonly done using recursive partitioning or logistic regression. CONCLUSIONS Given the variability in conduct and reporting, we suggest that an agreed set of standards for the conduct and reporting of studies should be developed.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Paul G Ambrose
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - Sujata M Bhavnani
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - George L Drusano
- Institute for Therapeutic Innovation, Department of Medicine, University of Florida, UF Research and Academic Center at Lake Nowa, 6550 Sanger Road, Orlando, Florida 32827, USA
| | - William W Hope
- Centre for Antimicrobial Pharmacodynamics, Institute of Translational Medicine, University of Liverpool, Liverpool L69 4BX, UK
| | - Johan W Mouton
- Department of Medical Microbiology & Infectious Diseases, Erasmus Medical Centre, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation, Infection Sciences, Pathology Science Quarter, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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32
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Tsai CY, Lee CH, Chen IL. Teicoplanin versus β-lactam for febrile patients with Staphylococcus-like bacteremia: focus on methicillin-susceptible Staphylococcus aureus bacteremia. BMC Infect Dis 2021; 21:437. [PMID: 33980167 PMCID: PMC8117599 DOI: 10.1186/s12879-021-06111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 04/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background Many studies have shown that vancomycin is inferior to β-lactam antibiotics in terms of effectiveness in the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia. However, limited data are available regarding the comparison of clinical outcomes between patients receiving initial teicoplanin and those receiving β-lactam antibiotics for MSSA bacteremia. Methods Eighty-four adults with MSSA bacteremia were included: initial teicoplanin treatment group (n = 28) and β-lactam treatment group (n = 56). The two groups were further stratified based on propensity score matching according to the outcome analysis using a logistic regression model. We investigated the clinical outcomes between the groups before and after propensity score matching after treatment completion. Results Pittsburgh bacteremia score ≥ 4 (odds ratio, 60.6; 95%CI, 7.4–496.8) was an independent risk factor for unfavorable outcome. After propensity score matching, the initial teicoplanin treatment group and the β-lactam treatment group consisted of 28 patients each. No statistically significant differences were observed in the proportions of patients with favorable outcomes and 30-day overall mortality rates between the groups before and after propensity score matching after the completion of teicoplanin or β-lactam treatment. The Kaplan-Meier 30-day survival curve also showed no significant difference between the patients receiving initial teicoplanin treatment and those receiving β-lactam treatment before and after matching (hazard ratio, 1.84, 95%CI, 0.60–5.64; and 3.12, 95%CI, 0.98–9.99, respectively). Conclusions There were no significant difference in clinical outcomes between initial teicoplanin treatment and β-lactam treatment among patients with MSSA bacteremia. Pittsburgh bacteremia score ≥ 4 was a significant risk factor for mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06111-w.
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Affiliation(s)
- Ching-Yen Tsai
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan
| | - Chen-Hsiang Lee
- Department of Internal Medicine, Division of Infectious Diseases, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung, 833, Taiwan. .,Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
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33
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Ren J, Hou Y, Li J, Gao Y, Li R, Jin X, Zhang J, Wang X, Wang G. An evaluation on the association of vancomycin trough concentration with mortality in critically ill patients: A multicenter retrospective study. Clin Transl Sci 2021; 14:1780-1790. [PMID: 33835715 PMCID: PMC8504840 DOI: 10.1111/cts.13020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/29/2022] Open
Abstract
To determine the impact of initial vancomycin trough concentration (VTC) on mortality in adult patients in the intensive care unit (ICU) undergoing vancomycin therapy. During their first ICU stay, patients with initial VTC records after vancomycin treatment were recruited from the eICU Collaborative Research Database to this multicenter retrospective cohort study, and classified into four groups according to VTC: less than 10, 10–15, 15–20, and greater than 20 mg/L. Multivariable logistic regression and sensitivity analyses were performed to explore the association of VTC, as a continuous and categorical variable, with mortality. This study enrolled 7220 patients from 335 different ICUs at 208 hospitals. Multivariable logistic regression models indicated that VTC was positively correlated with ICU (odds ratio [OR], 1.028, 95% confidence interval [CI], 1.019–1.037) and hospital (OR 1.028, 95% CI, 1.020–1.036) mortalities. Moreover, compared with VTC less than 10 mg/L, VTCs of 10–15, 15–20, and greater than 20 mg/L were associated with a higher risk of ICU mortality (OR, 1.330, 95% CI, 1.070–1.653; OR, 1.596, 95% CI, 1.265–2.015; abd OR, 1.875, 95% CI, 1.491–2.357, respectively), and VTCs of 15–20 and greater than 20 mg/L were also correlated with increased hospital mortality (OR, 1.482, 95% CI, 1.225–1.793; and OR, 1.831, 95% CI, 1.517–2.210, respectively). Similar results persisted in patients with different Acute Physiology and Chronic Health Evaluation Ⅳ scores, creatinine clearance levels, ages, and body mass indexes. Our findings indicated a potential relationship of initial VTC with ICU and hospital mortalities in patients in the ICU. However, due to the retrospective nature of this study, future prospective studies or randomized controlled trials are needed to validate those results.
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Affiliation(s)
- Jiajia Ren
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yanli Hou
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiamei Li
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ya Gao
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ruohan Li
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xuting Jin
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jingjing Zhang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaochuang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Gang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Tan K, Minejima E, Lou M, Mack WJ, Nieberg P, Wong-Beringer A. Cytokine measurements add value to clinical variables in predicting outcomes for Staphylococcus aureus bacteremia. BMC Infect Dis 2021; 21:317. [PMID: 33820537 PMCID: PMC8022397 DOI: 10.1186/s12879-021-06010-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background We demonstrated that an early dysregulated cytokine response [high interleukin-10 to tissue necrosis factor (IL-10/TNF) ratio] predicted poor outcomes in patients with Staphylococcus aureus bacteremia (SAB). However, high interpatient variability in cytokine levels were observed. We grouped cytokine measurements in quartiles and assessed their additive value to clinical variables for predicting bacterial persistence and 30-day mortality in patients with SAB. Methods A multicenter observational study was conducted in hospitalized patients with SAB. Medical charts were reviewed for relevant information. Blood samples were obtained for cytokine measurements by ELISA: interferon-gamma (IFNγ), interleukin (IL-1β, IL-6, IL-8, IL-10, IL-17) and tissue necrosis factor (TNF). Cytokine measurements were grouped into quartiles. Significant predictors for bacterial persistence and 30-day mortality were determined by multivariable logistic regression analysis. Area under the ROC curve (AUC) analysis was performed and predictive performance was compared between models with and without cytokine quartiles. Results Among 606 patients with SAB, a subset of patients (n = 239) had Day 1 cytokine measurements and clinical data collected; of those, 53 (22%) had persistent bacteremia. Accounting for septic shock, the addition of either IL-10 (AUC 0.708) or TNF (AUC 0.714) quartiles measured on Day 1 improved model performance for predicting bacterial persistence. All patients had Day 4 cytokine measurements; 52 patients (8.5%) died within 30-days of SAB onset. Inclusion of either IL-10 (AUC 0.873) or TNF (AUC 0.879) quartiles, but not both, measured on Day 4 to the significant clinical predictors (coronary artery disease, Pitt bacteremia score ≥ 4, and septic shock) improved model performance for mortality. Conclusions IL-10 or TNF levels falling within the range in the upper quartiles, when combined with clinical variables, improved model performance for predicting outcomes, and may potentially be used to support aggressive management and biomarker-guided studies to evaluate the benefit of adjunctive immunotherapy for SAB in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06010-0.
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Affiliation(s)
- Karen Tan
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA
| | - Emi Minejima
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA
| | - Mimi Lou
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA
| | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Paul Nieberg
- Department of Medicine - Infectious Diseases, Huntington Hospital, Pasadena, USA
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA. .,Department of Pharmacy, Huntington Hospital, Pasadena, USA.
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Johnson TM, Molina KC, Miller MA, Kiser TH, Huang M, Mueller SW. Combination ceftaroline and daptomycin salvage therapy for complicated methicillin-resistant Staphylococcus aureus bacteraemia compared with standard of care. Int J Antimicrob Agents 2021; 57:106310. [PMID: 33609718 DOI: 10.1016/j.ijantimicag.2021.106310] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/20/2021] [Accepted: 02/14/2021] [Indexed: 01/03/2023]
Abstract
Complicated methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSIs), particularly those with delayed culture clearance, are associated with high mortality. Combination therapy with daptomycin and ceftaroline (DAP+CPT) represents a novel therapeutic approach to MRSA-BSI owing to synergistic bactericidal activity. This study aimed to compare DAP+CPT with historical standard of care (SoC) for treatment of complicated MRSA-BSI. This single-centre retrospective cohort study included patients with complicated MRSA-BSI at University of Colorado Hospital. Patients receiving DAP+CPT for ≥48 h between November 2013 and March 2020 or SoC with vancomycin or DAP ± gentamicin and/or rifampicin from November 2011 to December 2013 were compared. The primary outcome was clinical failure defined as a composite of MRSA-related mortality and recurrent infection at 60 days. A total of 60 patients received DAP+CPT (n = 30) or SoC (n = 30). Median age was 56 years and median Pitt bacteremia score was 3. Common infectious sites were endovascular (63%) and musculoskeletal (40%). DAP+CPT was associated with a numerically lower incidence of clinical failure compared with SoC (20% vs. 43%; P = 0.052). Multivariable analysis controlling for immunocompromised status (OR, 6.90, 95% CI 1.08-44.15), Charlson comorbidity index (OR, 1.12, 95% CI 0.90-1.39) and source control (OR, 0.35, 95% CI 0.08-1.46) associated DAP+CPT with 77% lower odds of clinical failure (OR, 0.23, 95% CI 0.06-0.89). In patients with complicated MRSA-BSI with delayed clearance, DAP+CPT trended towards lower rates of clinical failure than SoC and was significantly associated with decreased clinical failure after adjustment for baseline differences.
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Affiliation(s)
- Tanner M Johnson
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kyle C Molina
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Matthew A Miller
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Misha Huang
- Department of Medicine-Infectious Diseases, University of Colorado Hospital, Aurora, CO, USA; Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
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36
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Liu A, Yo CH, Nie L, Yu H, Wu K, Tong HS, Hsu TC, Hsu WT, Lee CC. Comparing mortality between positive and negative blood culture results: an inverse probability of treatment weighting analysis of a multicenter cohort. BMC Infect Dis 2021; 21:182. [PMID: 33596842 PMCID: PMC7887786 DOI: 10.1186/s12879-021-05862-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/31/2021] [Indexed: 01/20/2023] Open
Abstract
Background The association between blood culture status and mortality among sepsis patients remains controversial hence we conducted a tri-center retrospective cohort study to compare the early and late mortality of culture-negative versus culture-positive sepsis using the inverse probability of treatment weighting (IPTW) method. Methods Adult patients with suspected sepsis who completed the blood culture and procalcitonin tests in the emergency department or hospital floor were eligible for inclusion. Early mortality was defined as 30-day mortality, and late mortality was defined as 30- to 90-day mortality. IPTW was calculated from propensity score and was employed to create two equal-sized hypothetical cohorts with similar covariates for outcome comparison. Results A total of 1405 patients met the inclusion criteria, of which 216 (15.4%) yielded positive culture results and 46 (21.3%) died before hospital discharge. The propensity score model showed that diabetes mellitus, urinary tract infection, and hepatobiliary infection were independently associated with positive blood culture results. There was no significant difference in early mortality between patients with positive or negative blood culture results. However, culture-positive patients had increased late mortality as compared with culture-negative patients in the full cohort (IPTW-OR, 1.95, 95%CI: 1.14–3.32) and in patients with severe sepsis or septic shock (IPTW-OR, 1.92, 95%CI: 1.10–3.33). After excluding Staphylococcal bacteremia patients, late mortality difference became nonsignificant (IPTW-OR, 1.78, 95%CI: 0.87–3.62). Conclusions Culture-positive sepsis patients had comparable early mortality but worse late mortality than culture-negative sepsis patients in this cohort. Persistent Staphylococcal bacteremia may have contributed to the increased late mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05862-w.
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Affiliation(s)
- Aibo Liu
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital , Chengdu, China
| | - Chia-Hung Yo
- Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Lu Nie
- Department of Laboratory Medicine, The First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Hua Yu
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital , Chengdu, China
| | - Kuihai Wu
- Department of Laboratory Medicine, The First People's Hospital of Foshan, Foshan, Guangdong, China
| | | | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan. .,Health Data Science Research Group, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan. .,The Centre for Intelligent Healthcare, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
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Endogenous endophthalmitis in patients with intravenous opioid use: demographics and associated comorbidities. Int Ophthalmol 2021; 41:1513-1520. [PMID: 33506370 DOI: 10.1007/s10792-021-01709-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/09/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE To identify risk factors for endogenous endophthalmitis (EE) in hospitalized adults, under 65 years of age, with a history of intravenous opioid use and non-ocular infection. METHODS The National Inpatient Sample Database was used to identify cases of EE with a recent history of intravenous opioid use disorder with associated non-ocular infection. Systemic and ocular comorbidities were identified using codes from the International Classification of Diseases, Ninth Revision (ICD-9). Descriptive and regression analyses were performed to evaluate the risk factors for EE using IBM SPSS 23. RESULTS Of the 605,859 inpatients, 21-65 years age, who had a history of recent opioid-IVDU and an associated IVDU-associated systemic infection, 363 (0.1%) had EE. Systemic comorbidities such as diabetes mellitus, mitral valve disease, aortic valve disease, history of cardiac valve transplantation, chronic kidney disease/renal failure, cirrhosis, active or previous radiation therapy, and history of solid organ transplantation were significantly more prevalent in patients with EE. A significantly increased risk of EE in intravenous opioid users was noted if they were of male gender (OR = 1.84), Asian/Pacific Islander ethnicity (OR = 4.41), had history of cirrhosis (OR = 2.33), active or history of radiation therapy (OR = 14.74), history of solid organ transplantation (OR = 5.91), candidemia (OR = 15.22), and infectious endocarditis (OR = 4.83). Conversely, concurrent alcohol use disorder (OR = 0.35) decreased the risk of EE. CONCLUSION Various demographic variables and systemic comorbidities increased the risk of developing EE in inpatients with a history of intravenous opioid use with associated non-ocular infection.
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Algorri M, Jorth P, Wong-Beringer A. Variable Release of Lipoteichoic Acid From Staphylococcus aureus Bloodstream Isolates Relates to Distinct Clinical Phenotypes, Strain Background, and Antibiotic Exposure. Front Microbiol 2021; 11:609280. [PMID: 33519759 PMCID: PMC7840697 DOI: 10.3389/fmicb.2020.609280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022] Open
Abstract
Background Staphylococcus aureus is a leading cause of bacterial bloodstream infections. The heterogeneity in patient outcomes in S. aureus bacteremia (SAB) can be attributed in part to strain characteristics, which may influence host response to infection. We specifically examined the relationship between lipoteichoic acid (LTA) release from S. aureus and disease phenotype, strain background, and antibiotic exposure. Methods Seven strains of S. aureus causing different clinical phenotypes of bacteremia and two reference strains (LAC USA 300 and Mu3) were analyzed for LTA release at baseline and following exposure to antibiotics from different pharmacologic classes (vancomycin, ceftaroline, and tedizolid). LTA release was quantified by LTA-specific ELISA. Whole genome sequencing was performed on the clinical strains and analyzed using open-source bioinformatics tools. Results Lipoteichoic acid release varied by 4-fold amongst the clinical strains and appeared to be related to duration of bacteremia, independent of MLST type. Low LTA releasing strains were isolated from patients who had prolonged duration of bacteremia and died. Antibiotic-mediated differences in LTA release appeared to be associated with MLST type, as ST8 strains released maximal LTA in response to tedizolid while other non-ST8 strains demonstrated high LTA release with vancomycin. Genetic variations related to the LTA biosynthesis pathway were detected in all non-ST8 strains, though ST8 strains showed no variations despite demonstrating differential LTA release. Conclusion Our findings provide the basis for future studies to evaluate the relationship between LTA release-mediated host immune response and clinical outcomes as well as the potential for antibiotic modulation of LTA release as a therapeutic strategy and deserve confirmation with larger number of strains with known clinical phenotypes.
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Affiliation(s)
- Marquerita Algorri
- School of Pharmacy, University of Southern California, Los Angeles, CA, United States
| | - Peter Jorth
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States.,Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Annie Wong-Beringer
- School of Pharmacy, University of Southern California, Los Angeles, CA, United States
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Minejima E, Mai N, Bui N, Mert M, Mack WJ, She RC, Nieberg P, Spellberg B, Wong-Beringer A. Defining the Breakpoint Duration of Staphylococcus aureus Bacteremia Predictive of Poor Outcomes. Clin Infect Dis 2021; 70:566-573. [PMID: 30949675 DOI: 10.1093/cid/ciz257] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 04/04/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Persistent Staphylococcus aureus bacteremia (SAB) is defined based on varying duration in literature. The primary objective was to determine the risk of poor outcomes in relation to bacteremia duration. METHODS Multicenter, prospective, observational study of adult hospitalized patients with SAB. Medical records were reviewed for pertinent data. Patients were grouped by bacteremia duration: short (1-2 days), intermediate (3-6 days), and prolonged (≥7 days) and compared for risk factors and outcomes. RESULTS Of 884 patients, 63% had short, 28% intermediate, and 9% prolonged bacteremia. Overall mean age was 57 years, and 70% were male. The prolonged group had the highest proportion of methicillin-resistant SAB (P < .0001). Choice of antibiotic therapy did not significantly affect bacteremia duration; however, time to source-control procedure was delayed in the prolonged and intermediate groups compared with the short group (3.5 vs 3 vs 1 day, P < .0001). Metastatic complications, length of stay, and 30-day mortality were progressively worse as bacteremia duration increased (P < .0001). Every continued day of bacteremia was associated with a relative risk of death of 1.16 (95% confidence interval, 1.10-1.22; P < .0001), with a significant increase in risk starting at 3 days as determined by receiver operating characteristic analysis. CONCLUSIONS Optimal management of SAB should target bacterial clearance as soon as possible to minimize incremental risk of mortality with each day of positive blood culture. Delay in source control but not type of antistaphylococcal therapy was significantly associated with prolonged bacteremia and worse outcomes.
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Affiliation(s)
- Emi Minejima
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, Los Angeles.,Los Angeles County and USC Medical Center, Los Angeles
| | - Nikki Mai
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, Los Angeles
| | - Nancy Bui
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, Los Angeles
| | - Melissa Mert
- Departments of Preventive Medicine and Clinical and Translational Science Institute, Los Angeles
| | - Wendy J Mack
- Departments of Preventive Medicine of Keck School of Medicine, Los Angeles
| | - Rosemary C She
- Departments of Pathology, Keck School of Medicine at USC, Los Angeles
| | - Paul Nieberg
- Department of Medicine-Infectious Diseases, Huntington Hospital, Pasadena, California
| | - Brad Spellberg
- Los Angeles County and USC Medical Center, Los Angeles.,Department of Medicine, Keck School of Medicine at USC, Los Angeles
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California (USC) School of Pharmacy, Los Angeles.,Department of Pharmacy, Huntington Hospital, Pasadena, California
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Lee SO, Lee S, Lee JE, Song KH, Kang CK, Wi YM, San-Juan R, López-Cortés LE, Lacoma A, Prat C, Jang HC, Kim ES, Kim HB, Lee SH. Dysfunctional accessory gene regulator (agr) as a prognostic factor in invasive Staphylococcus aureus infection: a systematic review and meta-analysis. Sci Rep 2020; 10:20697. [PMID: 33244173 PMCID: PMC7691521 DOI: 10.1038/s41598-020-77729-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
The accessory gene regulator (agr) locus of Staphylococcus aureus is a quorum-sensing virulence regulator. Although there are many studies concerning the effect of dysfunctional agr on the outcomes of S. aureus infection, there is no systematic review to date. We systematically searched for clinical studies reporting outcomes of invasive S. aureus infections and the proportion of dysfunctional agr among their causative strains, and we performed a meta-analysis to obtain estimates of the odds of outcomes of invasive S. aureus infection with dysfunctional versus functional agr. Of 289 articles identified by our research strategy, 20 studies were meta-analysed for crude analysis of the impact of dysfunctional agr on outcomes of invasive S. aureus infection. Dysfunctional agr was generally associated with unfavourable outcomes (OR 1.32, 95% CI 1.05–1.66), and the impact of dysfunctional agr on outcome was more prominent in invasive methicillin-resistant S. aureus (MRSA) infections (OR 1.54, CI 1.20–1.97). Nine studies were meta-analysed for the impact of dysfunctional agr on the 30-day mortality of invasive S. aureus infection. Invasive MRSA infection with dysfunctional agr exhibited higher 30-day mortality (OR 1.40, CI 1.03–1.90) than that with functional agr. On the other hand, invasive MSSA infection with dysfunctional agr exhibited lower 30-day mortality (OR 0.51, CI 0.27–0.95). In the post hoc subgroup analysis by the site of MRSA infection, dysfunctional agr was associated with higher 30-day mortality in MRSA pneumonia (OR 2.48, CI 1.17–5.25). The effect of dysfunctional agr on the outcome of invasive S. aureus infection may vary depending on various conditions, such as oxacillin susceptibility and the site of infection. Dysfunctional agr was generally associated with unfavourable clinical outcomes and its effect was prominent in MRSA and pneumonia. Dysfunctional agr may be applicable for outcome prediction in cases of invasive MRSA infection with hardly eradicable foci such as pneumonia.
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Affiliation(s)
- Soon Ok Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea.
| | - Jeong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chang Kyung Kang
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Rafael San-Juan
- Unit of Infectious Diseases, University Hospital 12 de Octubre, Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense, Avenida de Córdoba, s/n, Madrid, Spain
| | - Luis E López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Alicia Lacoma
- Microbiology Department, Hospital Universitari Germans Trias i Pujol, Institut d' Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Badalona, Spain
| | - Cristina Prat
- Microbiology Department, Hospital Universitari Germans Trias i Pujol, Institut d' Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Badalona, Spain.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hee-Chang Jang
- Department of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sun Hee Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea
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Algorri M, Wong-Beringer A. Differential effects of antibiotics on neutrophils exposed to lipoteichoic acid derived from Staphylococcus aureus. Ann Clin Microbiol Antimicrob 2020; 19:50. [PMID: 33143710 PMCID: PMC7641855 DOI: 10.1186/s12941-020-00392-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 10/20/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Persistent bacteremia occurs in at least 30% of patients with Staphylococcus aureus bloodstream infection (SAB) and may be attributable to a dysregulated host immune response. Neutrophils interact with a variety of S. aureus microbial factors, including lipoteichoic acid (LTA), to activate phagocytic function in a concentration-dependent manner. Antibiotics have been shown to exert both direct antimicrobial action as well as immunomodulatory effects. In this study, we compared the effects of different anti-staphylococcal antibiotics on LTA-mediated immune activation of neutrophils. METHODS Neutrophils obtained from healthy volunteers were exposed to two levels of LTA (1 and 10 μg/ml) with or without addition of antibiotics from different pharmacologic classes (vancomycin, daptomycin, ceftaroline). Neutrophil function was assessed by examining phagocytic response, activation (CD11b, CD62L expression), Toll-like receptor-2 expression, cell survival and apoptosis, and CXCL8 release. RESULTS Differential LTA-mediated antibiotic effects on neutrophil function were observed primarily at the high LTA exposure level. Ceftaroline in the presence of 10 μg/ml LTA had the most prominent effects on phagocytosis and CD11b and CD62L expression, with trends towards increased neutrophil survival and preservation of CXCL8 release when compared to daptomycin and vancomycin with the latter significantly dampening PMN CXCL8 release. CONCLUSIONS Select antimicrobial agents, such as ceftaroline, exert immunostimulatory effects on neutrophils exposed to S. aureus LTA, which when confirmed in vivo, could be leveraged for its dual immunomodulatory and antibacterial actions for the treatment of persistent SAB mediated by a dysregulated host response.
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Affiliation(s)
- Marquerita Algorri
- University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA
| | - Annie Wong-Beringer
- University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA, 90089, USA.
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Jung J, Song KH, Jun KI, Kang CK, Kim NH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Predictive scoring models for persistent gram-negative bacteremia that reduce the need for follow-up blood cultures: a retrospective observational cohort study. BMC Infect Dis 2020; 20:680. [PMID: 32942993 PMCID: PMC7499917 DOI: 10.1186/s12879-020-05395-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background Although the risk factors for positive follow-up blood cultures (FUBCs) in gram-negative bacteremia (GNB) have not been investigated extensively, FUBC has been routinely carried out in many acute care hospitals. We attempted to identify the risk factors and develop a predictive scoring model for positive FUBC in GNB cases. Methods All adults with GNB in a tertiary care hospital were retrospectively identified during a 2-year period, and GNB cases were assigned to eradicable and non-eradicable groups based on whether removal of the source of infection was possible. We performed multivariate logistic analyses to identify risk factors for positive FUBC and built predictive scoring models accordingly. Results Out of 1473 GNB cases, FUBCs were carried out in 1268 cases, and the results were positive in 122 cases. In case of eradicable source of infection, we assigned points according to the coefficients from the multivariate logistic regression analysis: Extended spectrum beta-lactamase-producing microorganism (+ 1 point), catheter-related bloodstream infection (+ 1), unfavorable treatment response (+ 1), quick sequential organ failure assessment score of 2 points or more (+ 1), administration of effective antibiotics (− 1), and adequate source control (− 2). In case of non-eradicable source of infection, the assigned points were end-stage renal disease on hemodialysis (+ 1), unfavorable treatment response (+ 1), and the administration of effective antibiotics (− 2). The areas under the curves were 0.861 (95% confidence interval [95CI] 0.806–0.916) and 0.792 (95CI, 0.724–0.861), respectively. When we applied a cut-off of 0, the specificities and negative predictive values (NPVs) in the eradicable and non-eradicable sources of infection groups were 95.6/92.6% and 95.5/95.0%, respectively. Conclusions FUBC is commonly carried out in GNB cases, but the rate of positive results is less than 10%. In our simple predictive scoring model, zero scores—which were easily achieved following the administration of effective antibiotics and/or adequate source control in both groups—had high NPVs. We expect that the model reported herein will reduce the necessity for FUBCs in GNB cases.
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Affiliation(s)
- Jongtak Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Kang Il Jun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang Kyoung Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Grillo S, Cuervo G, Carratalà J, Grau I, Pallarès N, Tebé C, Guillem Tió L, Murillo O, Ardanuy C, Domínguez MA, Shaw E, Gudiol C, Pujol M. Impact of β-Lactam and Daptomycin Combination Therapy on Clinical Outcomes in Methicillin-susceptible Staphylococcus aureus Bacteremia: A Propensity Score-matched Analysis. Clin Infect Dis 2020; 69:1480-1488. [PMID: 30615122 DOI: 10.1093/cid/ciz018] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/04/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Mortality rates from Staphylococcus aureus bacteremia are high and have only modestly improved in recent decades. We compared the efficacies of a β-lactam in combination with daptomycin (BL/D-C) and β-lactam monotherapy (BL-M) in improving clinical outcomes in methicillin-susceptible S. aureus (MSSA) bacteremia. METHODS A retrospective cohort study of MSSA bacteremia was performed in a tertiary hospital from January 2011 to December 2017. Patients receiving BL/D-C and BL-M were compared to assess 7-, 30-, and 90-day mortality rates. A 1:2 propensity score matching analysis was performed. Differences were assessed using Cox regression models. RESULTS Of the 514 patients with MSSA bacteremia, 164 were excluded as they had received combination therapies other than BL/D-C, had pneumonia, or died within 48 hours of admission. Of the remaining 350 patients, 136 and 214 received BL/D-C and BL-M, respectively. BL/D-C patients had higher Pitt scores and persistent bacteremia more often than BL-M patients. In the raw analysis, there were no differences in mortality rates between groups. After propensity score matching, there were no significant differences between the BL/D-C (110 patients) and BL-M (168 patients) groups for all-cause mortality rates at 7 days (8.18% vs 7.74%; P = 1.000), 30 days (17.3% vs 16.1%; P = .922), and 90 days (22.7% vs 23.2%; P = 1.000), even in a subanalysis of patients with high-risk source of infection and in a subgroup excluding catheter-related bacteremia. CONCLUSIONS BL/D-C failed to reduce mortality rates in patients with MSSA bacteremia. Treatment strategies to improve survival in MSSA bacteremia are urgently needed.
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Affiliation(s)
- Sara Grillo
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona
| | - Guillermo Cuervo
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville
| | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville.,University of Barcelona, Istituto de Salud Carlos III, Madrid
| | - Immaculada Grau
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,University of Barcelona, Istituto de Salud Carlos III, Madrid.,Centro Investigación Biomédica en Red Enfermedades Respiratorias, Istituto de Salud Carlos III, Madrid
| | - Natàlia Pallarès
- Biostatistics Unit, IDIBELL, L'Hospitalet de Llobregat, Reus.,Basic Clinical Practice Department, University of Barcelona, Reus
| | - Cristian Tebé
- Biostatistics Unit, IDIBELL, L'Hospitalet de Llobregat, Reus.,Basic Clinical Practice Department, Rovira Virgili University, Reus
| | - Lluisa Guillem Tió
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona
| | - Oscar Murillo
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville.,University of Barcelona, Istituto de Salud Carlos III, Madrid
| | - Carmen Ardanuy
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,University of Barcelona, Istituto de Salud Carlos III, Madrid.,Centro Investigación Biomédica en Red Enfermedades Respiratorias, Istituto de Salud Carlos III, Madrid.,Department of Microbiology, Bellvitge University Hospital, Barcelona, Spain
| | - M Angeles Domínguez
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville.,University of Barcelona, Istituto de Salud Carlos III, Madrid.,Department of Microbiology, Bellvitge University Hospital, Barcelona, Spain
| | - Evelyn Shaw
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville.,University of Barcelona, Istituto de Salud Carlos III, Madrid
| | - Miquel Pujol
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona.,Red Española de Investigación en Patología Infecciosa, Seville
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Kuehl R, Morata L, Boeing C, Subirana I, Seifert H, Rieg S, Kern WV, Kim HB, Kim ES, Liao CH, Tilley R, Lopez-Cortés LE, Llewelyn MJ, Fowler VG, Thwaites G, Cisneros JM, Scarborough M, Nsutebu E, Gurgui Ferrer M, Pérez JL, Barlow G, Hopkins S, Ternavasio-de la Vega HG, Török ME, Wilson P, Kaasch AJ, Soriano A. Defining persistent Staphylococcus aureus bacteraemia: secondary analysis of a prospective cohort study. THE LANCET. INFECTIOUS DISEASES 2020; 20:1409-1417. [PMID: 32763194 DOI: 10.1016/s1473-3099(20)30447-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Staphylococcus aureus persistent bacteraemia is only vaguely defined and the effect of different durations of bacteraemia on mortality is not well established. Our primary aim was to analyse mortality according to duration of bacteraemia and to derive a clinically relevant definition for persistent bacteraemia. METHODS We did a secondary analysis of a prospective observational cohort study at 17 European centres (nine in the UK, six in Spain, and two in Germany), with recruitment between Jan 1, 2013, and April 30, 2015. Adult patients who were consecutively hospitalised with monomicrobial S aureus bacteraemia were included. Patients were excluded if no follow-up blood culture was taken, if the first follow-up blood-culture was after 7 days, or if active antibiotic therapy was started more than 3 days after first blood culture. The primary outcome was 90-day mortality. Univariable and time-dependent multivariable Cox regression analysis were used to assess predictors of mortality. Duration of bacteraemia was defined as bacteraemic days under active antibiotic therapy counting the first day as day 1. FINDINGS Of 1588 individuals assessed for eligibility, 987 were included (median age 65 years [IQR 51-75]; 625 [63%] male). Death within 90 days occurred in 273 (28%) patients. Patients with more than 1 day of bacteraemia (315 [32%]) had higher Charlson comorbidity index and sequential organ failure assessment scores and a longer interval from first symptom to first blood culture. Crude 90-day mortality increased from 22% (148 of 672) with 1 day of bacteraemia, to 39% (85 of 218) with 2-4 days, 43% (30 of 69) with 5-7 days, and 36% (10 of 28) with more than 7 days of bacteraemia. Metastatic infections developed in 39 (6%) of 672 patients with 1 day of bacteraemia versus 40 (13%) of 315 patients if bacteraemia lasted for at least 2 days. The second day of bacteraemia had the highest HR and earliest cutoff significantly associated with mortality (adjusted hazard ratio 1·93, 95% CI 1·51-2·46; p<0·0001). INTERPRETATION We suggest redefining the cutoff duration for persistent bacteraemia as 2 days or more despite active antibiotic therapy. Our results favour follow-up blood cultures after 24 h for early identification of all patients with increased risk of death and metastatic infection. FUNDING None.
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Affiliation(s)
- Richard Kuehl
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Christian Boeing
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Isaac Subirana
- CIBER en Epidemiología y Salud Pública, Barcelona, Spain
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University of Cologne, Cologne, Germany; German Center for Infection Research, Partner site Bonn-Cologne, Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - Hong Bin Kim
- Division of Infectious Diseases, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Eu Suk Kim
- Division of Infectious Diseases, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Chun-Hsing Liao
- Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei City, Taiwan
| | - Robert Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Luis Eduardo Lopez-Cortés
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vance G Fowler
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - José Miguel Cisneros
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, CSIC, Universidad de Sevilla, Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Matt Scarborough
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Oxford, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - José L Pérez
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears, Palma de Mallorca, Spain
| | - Gavin Barlow
- Department of Infection, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Susan Hopkins
- Infectious Diseases Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - M Estée Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter Wilson
- Department of Microbiology and Virology, University College London Hospital NHS Foundation Trust, London, UK
| | - Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain.
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Eichenberger EM, Fowler VG, Holland TL. Duration of antibiotic therapy for Staphylococcus aureus bacteraemia: the long and the short of it. Clin Microbiol Infect 2020; 26:536-538. [PMID: 31968272 PMCID: PMC7278270 DOI: 10.1016/j.cmi.2020.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Affiliation(s)
- E M Eichenberger
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - V G Fowler
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| | - T L Holland
- Department of Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
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Kuehl R, Morata L, Meylan S, Mensa J, Soriano A. When antibiotics fail: a clinical and microbiological perspective on antibiotic tolerance and persistence of Staphylococcus aureus. J Antimicrob Chemother 2020; 75:1071-1086. [PMID: 32016348 DOI: 10.1093/jac/dkz559] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Staphylococcus aureus is a major human pathogen causing a vast array of infections with significant mortality. Its versatile physiology enables it to adapt to various environments. Specific physiological changes are thought to underlie the frequent failure of antimicrobial therapy despite susceptibility in standard microbiological assays. Bacteria capable of surviving high antibiotic concentrations despite having a genetically susceptible background are described as 'antibiotic tolerant'. In this review, we put current knowledge on environmental triggers and molecular mechanisms of increased antibiotic survival of S. aureus into its clinical context. We discuss animal and clinical evidence of its significance and outline strategies to overcome infections with antibiotic-tolerant S. aureus.
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Affiliation(s)
- Richard Kuehl
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Sylvain Meylan
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- Division de Maladies Infectieuses, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Josep Mensa
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
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Kim T, Lee SC, Kim MJ, Jung J, Sung H, Kim MN, Kim SH, Lee SO, Choi SH, Woo JH, Kim YS, Chong YP. Clinical significance of follow-up blood culture in patients with a single Staphylococcus aureus-positive blood culture. Infect Dis (Lond) 2019; 52:207-212. [PMID: 31833431 DOI: 10.1080/23744235.2019.1701198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background: We evaluated the frequency of a positive result in follow-up blood cultures (FUBCs) and clinical outcome when FUBCs were not performed, in patients with a single Staphylococcus aureus-positive blood culture.Methods: We analyzed blood culture results in a prospective, observational cohort of patients with S. aureus bacteraemia (SAB) at a tertiary-care hospital. All adult patients with only a single positive blood culture set from at least two blood culture sets drawn at the initial SAB episode were enrolled in the study. We analyzed FUBC results performed within 5 days after bacteraemia onset and compared the characteristics and outcomes between patients with and without FUBCs.Results: Of 305 patients with a single S. aureus-positive blood culture, FUBCs were obtained in 274 (90%) and were positive in 15% (42/274), of whom 50% were afebrile. The rate of positivity of FUBCs was significantly higher in methicillin-resistant S. aureus (MRSA) than in methicillin-susceptible S. aureus (19% versus 9%, p = .03). In 190 patients with a single MRSA-positive blood culture, the demographic and clinical characteristics were similar between patients with and without FUBCs (167 versus 23). Although mortality was comparable between the two groups, relapse of SAB was significantly more frequent in patients in whom FUBCs were not performed (17% versus 2%, p = .008).Conclusions: Even if a patient has a single S. aureus-positive blood culture and no fever, FUBCs should be performed to manage the infection properly and to prevent SAB relapse.
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Affiliation(s)
- Taeeun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Seung Cheol Lee
- Department of Infectious Diseases, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Hornak JP, Anjum S, Reynoso D. Adjunctive ceftaroline in combination with daptomycin or vancomycin for complicated methicillin-resistant Staphylococcus aureus bacteremia after monotherapy failure. Ther Adv Infect Dis 2019; 6:2049936119886504. [PMID: 31857898 PMCID: PMC6915839 DOI: 10.1177/2049936119886504] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/14/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B) may fail to improve with standard monotherapy, particularly in patients with multifocal infection, incomplete source control, or persistent bacteremia. Synergy observed in vitro between ceftaroline (CPT) and daptomycin (DAP) or vancomycin (VAN) may translate into clinical benefit. Here, we describe our experience with DAP/CPT and VAN/CPT for complicated MRSA-B after monotherapy failure. Methods: Single-center, retrospective review of consecutive patients treated with DAP/CPT or VAN/CPT for MRSA-B after monotherapy failure from 1 January 2016 to 30 November 2018. Results: We identified 11 instances of combination therapy in 10 patients (DAP/CPT = 6, VAN/CPT = 5) with 1 patient receiving VAN/CPT followed by DAP/CPT. Rates of multifocal infection, incomplete source control, persistent bacteremia, and infective endocarditis were high (100%, 80%, 60%, and 60%, respectively). Combination therapy was initiated most commonly for persistent bacteremia (60%). When patients were persistently bacteremic, median preceding duration was 13 days and median time to clearance was 3 days. Total microbiologic cure rate was 100%. There were zero instances of bacteremia relapse at 30 days (30D) or 60 days (60D). All-cause 30D and 60D mortality rates were 11.1% and 33.3%, respectively. Conclusions: Combination therapy demonstrated success in diverse cases of refractory MRSA-B, including instances of persistent bacteremia paired with incomplete source control. Optimal timing and therapeutic cadence for combination therapy remain unclear. Our findings suggest that DAP/CPT and VAN/CPT can be considered for complicated MRSA bacteremia when other treatment options fail or are unavailable. We propose persistent bacteremia with incomplete source control to be a clinical niche particularly worthy of further investigation.
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Affiliation(s)
- Joseph Patrik Hornak
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Seher Anjum
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - David Reynoso
- The University of Texas Medical Branch, Division of Infectious Diseases, 301 University Blvd., Rte. 0435, Marvin Graves Building 4.210H, Galveston, TX, 77555-0435, USA
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49
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Stover KR, Morrison A, Collier T, Schneider E, Wagner JL, Capino AC, Barber KE. Epidemiology and Risk Factors for Bacteremia in Pediatric and Adolescent Patients. J Pharm Pract 2019; 34:360-364. [PMID: 31451019 DOI: 10.1177/0897190019868056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Epidemiology and risk factors for bacteremia in pediatric and adolescent patients have not been fully elucidated. OBJECTIVE The purpose of this study was to identify primary causative agents of bacteremia in pediatric and adolescent patients and associated risk factors. We hypothesized that these would be different than those seen in adults. PATIENTS AND METHODS This retrospective cohort, epidemiologic evaluation included patients admitted to a tertiary referral center from January 01, 2013, to December 31, 2015. Patients <18 years old with a confirmed positive blood culture were included; the first positive culture per organism per patient was analyzed. The primary outcome was to determine the most frequent causative organisms of bacteremia; the secondary outcome was an evaluation of risk factors for acquiring staphylococcal bacteremia. RESULTS A total of 913 isolates were evaluated, including 92 unique organisms. The most frequently identified were Staphylococcus epidermidis (238/913, 26.1%), followed by Staphylococcus aureus (136/913, 14.9%). Methicillin resistance was observed in 60.3% of S aureus. Two hundred thirty-six patients were included in the risk factor analysis. Prematurity, previous antibiotics, and intubation/ventilation were more likely associated with S epidermidis (P < .001, P < .001, and P = .032, respectively). Patients with a recent or previous hospitalization and those with dermatitis/eczema were statistically more likely to grow S aureus (P < .001, P = .029, respectively). CONCLUSIONS Although epidemiology of organisms associated with pediatric and adolescent bacteremia was similar to adults, risk factors were different than seen in that population. Further understanding of these risk factors may be helpful in developing preemptive infection control strategies in patients at risk.
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Affiliation(s)
- Kayla R Stover
- 15516University of Mississippi School of Pharmacy, Jackson, MS, USA.,Division of Infectious Diseases, Department of Medicine, 15516University of Mississippi Medical Center, Jackson, MS, USA
| | - Austin Morrison
- Department of Pharmacy, 24016Henry Ford Hospital, Detroit, MI, USA
| | - Tia Collier
- Department of Pharmacy, 22683Baylor University Medical Center, Dallas, TX, USA
| | - Elisabeth Schneider
- Department of Pharmacy, Centura Health St. Anthony Hospital, Lakewood, CO, USA
| | - Jamie L Wagner
- 15516University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Amanda C Capino
- 15516University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Katie E Barber
- 15516University of Mississippi School of Pharmacy, Jackson, MS, USA
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Mikkaichi T, Yeaman MR, Hoffmann A. Identifying determinants of persistent MRSA bacteremia using mathematical modeling. PLoS Comput Biol 2019; 15:e1007087. [PMID: 31295255 PMCID: PMC6622483 DOI: 10.1371/journal.pcbi.1007087] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 05/10/2019] [Indexed: 11/18/2022] Open
Abstract
Persistent bacteremia caused by Staphylococcus aureus (SA), especially methicillin-resistant SA (MRSA), is a significant cause of morbidity and mortality. Despite susceptibility phenotypes in vitro, persistent MRSA strains fail to clear with appropriate anti-MRSA therapy during bacteremia in vivo. Thus, identifying the factors that cause such MRSA persistence is of direct and urgent clinical relevance. To address the dynamics of MRSA persistence in the face of host immunity and typical antibiotic regimens, we developed a mathematical model based on the overarching assumption that phenotypic heterogeneity is a hallmark of MRSA persistence. First, we applied an ensemble modeling approach and obtained parameter sets that satisfied the condition of a minimum inoculum dose to establish infection. Second, by simulating with the selected parameter sets under vancomycin therapy which follows clinical practices, we distinguished the models resulting in resolving or persistent bacteremia, based on the total SA exceeding a detection limit after five days of treatment. Third, to find key determinants that discriminate resolving and persistent bacteremia, we applied a machine learning approach and found that the immune clearance rate of persister cells is a key feature. But, fourth, when relapsing bacteremia was considered, the growth rate of persister cells was also found to be a key feature. Finally, we explored pharmacological strategies for persistent and relapsing bacteremia and found that a persister killer, but not a persister formation inhibitor, could provide for an effective cure the persistent bacteremia. Thus, to develop better clinical solutions for MRSA persistence and relapse, our modeling results indicate that we need to better understand the pathogen-host interactions of persister MRSAs in vivo. Staphylococcus aureus causes potentially lethal infections of the bloodstream and target organs when able to enter the body, often via skin trauma or catheterization. Methicillin-resistant Staphylococcus aureus (MRSA) resist common antibiotics, but are often successfully treated with vancomycin. However, in some MRSA patients, vancomycin is less effective. This results in persistent bacteremia, even though the isolates can be effectively killed in vitro. MRSA bacteria are thought to switch between two forms, normal and persister cells, that are genetically identical. Persisters, the minor subpopulation, are slow-growing and show lower susceptibility to vancomycin than normal MRSA. To understand the dynamic interplay between the two bacterial populations when challenged by host immunity and vancomycin treatment, we developed a mathematical model and analyzed it in simulations of clinically relevant scenarios. Our work suggests that the immune clearance rate of persister MRSA rather than the MRSA switch rate is a key determinant to establish persistent bacteremia. The model also suggests that increasing killing rate of persisters is a promising therapeutic strategy. Our findings emphasize the need to better understand the interactions of persister MRSAs with host cells and immune responses in vivo.
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Affiliation(s)
- Tsuyoshi Mikkaichi
- Institute for Quantitative and Computational Biosciences, University of California, Los Angeles, California, United States of America
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, California, United States of America
- * E-mail: (TM); (AH)
| | - Michael R. Yeaman
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- Divisions of Molecular Medicine and Infectious Diseases, Harbor-UCLA Medical Center, Torrance, California, United States of America
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Alexander Hoffmann
- Institute for Quantitative and Computational Biosciences, University of California, Los Angeles, California, United States of America
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, California, United States of America
- David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
- * E-mail: (TM); (AH)
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