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Kok CR, Mulakken N, Thissen JB, Grey SF, Avila-Herrera A, Upadhyay MM, Lisboa FA, Mabery S, Elster EA, Schobel SA, Be NA. Targeted metagenomic assessment reflects critical colonization in battlefield injuries. Microbiol Spectr 2023; 11:e0252023. [PMID: 37874143 PMCID: PMC10714869 DOI: 10.1128/spectrum.02520-23] [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: 06/16/2023] [Accepted: 09/18/2023] [Indexed: 10/25/2023] Open
Abstract
IMPORTANCE Microbial contamination in combat wounds can lead to opportunistic infections and adverse outcomes. However, current microbiological detection has a limited ability to capture microbial functional genes. This work describes the application of targeted metagenomic sequencing to profile wound bioburden and capture relevant wound-associated signatures for clinical utility. Ultimately, the ability to detect such signatures will help guide clinical decisions regarding wound care and management and aid in the prediction of wound outcomes.
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Affiliation(s)
- Car Reen Kok
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Nisha Mulakken
- Computing Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - James B. Thissen
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Scott F. Grey
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Aram Avila-Herrera
- Computing Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Meenu M. Upadhyay
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Felipe A. Lisboa
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Shalini Mabery
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
| | - Eric A. Elster
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Seth A. Schobel
- Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Nicholas A. Be
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, USA
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Baucom MR, Wallen TE, Youngs J, Singer KE, Delman AM, Schuster RM, Blakeman TC, Strilka R, Pritts TA, Goodman MD. Effectiveness of Negative Pressure Wound Therapy During Aeromedical Evacuation Following Soft Tissue Injury and Infection. Mil Med 2023; 188:295-303. [PMID: 37948243 PMCID: PMC10637296 DOI: 10.1093/milmed/usad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/09/2023] [Accepted: 08/08/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is utilized early after soft tissue injury to promote tissue granulation and wound contraction. Early post-injury transfers via aeromedical evacuation (AE) to definitive care centers may actually induce wound bacterial proliferation. However, the effectiveness of NPWT or instillation NPWT in limiting bacterial proliferation during post-injury AE has not been studied. We hypothesized that instillation NPWT during simulated AE would decrease bacterial colonization within simple and complex soft tissue wounds. METHODS The porcine models were anesthetized before any experiments. For the simple tissue wound model, two 4-cm dorsal wounds were created in 34.9 ± 0.6 kg pigs and were inoculated with Acinetobacter baumannii (AB) or Staphylococcus aureus 24 hours before a 4-hour simulated AE or ground control. During AE, animals were randomized to one of the five groups: wet-to-dry (WTD) dressing, NPWT, instillation NPWT with normal saline (NS-NPWT), instillation NPWT with Normosol-R® (NM-NPWT), and RX-4-NPWT with the RX-4 system. For the complex musculoskeletal wound, hind-limb wounds in the skin, subcutaneous tissue, peroneus tertius muscle, and tibia were created and inoculated with AB 24 hours before simulated AE with WTD or RX-4-NPWT dressings. Blood samples were collected at baseline, pre-flight, and 72 hours post-flight for inflammatory cytokines interleukin (IL)-1β, IL-6, IL-8 and tumor necrosis factor alpha. Wound biopsies were obtained at 24 hours and 72 hours post-flight, and the bacteria were quantified. Vital signs were measured continuously during simulated AE and at each wound reassessment. RESULTS No significant differences in hemodynamics or serum cytokines were noted between ground or simulated flight groups or over time in either wound model. Simulated AE alone did not affect bacterial proliferation compared to ground controls. The simple tissue wound arm demonstrated a significant decrease in Staphylococcus aureus and AB colony-forming units at 72 hours after simulated AE using RX-4-NPWT. NS-NPWT during AE more effectively prevented bacterial proliferation than the WTD dressing. There was no difference in colony-forming units among the various treatment groups at the ground level. CONCLUSION The hypoxic, hypobaric environment of AE did not independently affect the bacterial growth after simple tissue wound or complex musculoskeletal wound. RX-4-NPWT provided the most effective bacterial reduction following simulated AE, followed by NS-NPWT. Future research will be necessary to determine ideal instillation fluids, negative pressure settings, and dressing change frequency before and during AE.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Jaclyn Youngs
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Kathleen E Singer
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Aaron M Delman
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Rebecca M Schuster
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Thomas C Blakeman
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Richard Strilka
- United States Air Force School of Aerospace Medicine, En Route Care Training Department, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
| | - Michael D Goodman
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267-0558, USA
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Metagenomic features of bioburden serve as outcome indicators in combat extremity wounds. Sci Rep 2022; 12:13816. [PMID: 35970993 PMCID: PMC9378645 DOI: 10.1038/s41598-022-16170-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 07/05/2022] [Indexed: 11/09/2022] Open
Abstract
Battlefield injury management requires specialized care, and wound infection is a frequent complication. Challenges related to characterizing relevant pathogens further complicates treatment. Applying metagenomics to wounds offers a comprehensive path toward assessing microbial genomic fingerprints and could indicate prognostic variables for future decision support tools. Wound specimens from combat-injured U.S. service members, obtained during surgical debridements before delayed wound closure, were subjected to whole metagenome analysis and targeted enrichment of antimicrobial resistance genes. Results did not indicate a singular, common microbial metagenomic profile for wound failure, instead reflecting a complex microenvironment with varying bioburden diversity across outcomes. Genus-level Pseudomonas detection was associated with wound failure at all surgeries. A logistic regression model was fit to the presence and absence of antimicrobial resistance classes to assess associations with nosocomial pathogens. A. baumannii detection was associated with detection of genomic signatures for resistance to trimethoprim, aminoglycosides, bacitracin, and polymyxin. Machine learning classifiers were applied to identify wound and microbial variables associated with outcome. Feature importance rankings averaged across models indicated the variables with the largest effects on predicting wound outcome, including an increase in P. putida sequence reads. These results describe the microbial genomic determinants in combat wound bioburden and demonstrate metagenomic investigation as a comprehensive tool for providing information toward aiding treatment of combat-related injuries.
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Cascading Risks for Preventable Infectious Diseases in Children and Adolescents during the 2022 Invasion of Ukraine. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127005. [PMID: 35742254 PMCID: PMC9223098 DOI: 10.3390/ijerph19127005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 01/25/2023]
Abstract
Russia’s military incursion into Ukraine triggered the mass displacement of two-thirds of Ukrainian children and adolescents, creating a cascade of population health consequences and producing extraordinary challenges for monitoring and controlling preventable pediatric infectious diseases. From the onset of the war, infectious disease surveillance and healthcare systems were severely disrupted. Prior to the reestablishment of dependable infectious disease surveillance systems, and during the early months of the conflict, our international team of pediatricians, infectious disease specialists, and population health scientists assessed the health implications for child and adolescent populations. The invasion occurred just as the COVID-19 Omicron surge was peaking throughout Europe and Ukrainian children had not received COVID-19 vaccines. In addition, vaccine coverage for multiple vaccine-preventable diseases, most notably measles, was alarmingly low as Ukrainian children and adolescents were forced to migrate from their home communities, living precariously as internally displaced persons inside Ukraine or streaming into European border nations as refugees. The incursion created immediate impediments in accessing HIV treatment services, aimed at preventing serial transmission from HIV-positive persons to adolescent sexual or drug-injection partners and to prevent vertical transmission from HIV-positive pregnant women to their newborns. The war also led to new-onset, conflict-associated, preventable infectious diseases in children and adolescents. First, children and adolescents were at risk of wound infections from medical trauma sustained during bombardment and other acts of war. Second, young people were at risk of sexually transmitted infections resulting from sexual assault perpetrated by invading Russian military personnel on youth trapped in occupied territories or from sexual assault perpetrated on vulnerable youth attempting to migrate to safety. Given the cascading risks that Ukrainian children and adolescents faced in the early months of the war—and will likely continue to face—infectious disease specialists and pediatricians are using their international networks to assist refugee-receiving host nations to improve infectious disease screening and interventions.
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Higgins PG, Kniel M, Rojak S, Balczun C, Rohde H, Frickmann H, Hagen RM. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Strains Isolated at the German Military Field Laboratory in Mazar-e Sharif, Afghanistan. Microorganisms 2021; 9:microorganisms9112229. [PMID: 34835355 PMCID: PMC8622437 DOI: 10.3390/microorganisms9112229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2022] Open
Abstract
The study was performed to provide an overview of the molecular epidemiology of carbapenem-resistant Acinetobacter baumannii in Afghanistan isolated by the German military medical service during the Afghanistan conflict. A total of 18 isolates were collected between 2012 and 2018 at the microbiological laboratory of the field hospital in Camp Marmal near Mazar-e Sharif, Afghanistan, from Afghan patients. The isolates were subjected to phenotypic and genotypic differentiation and antimicrobial susceptibility testing as well as to a core genome multi-locus sequence typing (cgMLST) approach based on whole-genome next-generation sequence (wgNGS) data. Next to several sporadic isolates, four transmission clusters comprising strains from the international clonal lineages IC1, IC2, and IC9 were identified. Acquired carbapenem resistance was due to blaOXA-23 in 17/18 isolates, while genes mediating resistance against sulfonamides, macrolides, tetracyclines, and aminoglycosides were frequently identified as well. In conclusion, the assessment confirmed both the frequent occurrence of A. baumannii associated with outbreak events and a variety of different clones in Afghanistan. The fact that acquired carbapenem resistance was almost exclusively associated with blaOXA-23 may facilitate molecular resistance screening based on rapid molecular assays targeting this resistance determinant.
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Affiliation(s)
- Paul G. Higgins
- Institute for Medical Microbiology, Immunology, and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany;
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50935 Cologne, Germany
| | - Meret Kniel
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Sandra Rojak
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Carsten Balczun
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf (UKE), 20251 Hamburg, Germany;
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany; or
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
- Correspondence: ; Tel.: +49-261-896-77200
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Stanbro J, Park JM, Bond M, Stockelman MG, Simons MP, Watters C. Topical Delivery of Lactobacillus Culture Supernatant Increases Survival and Wound Resolution in Traumatic Acinetobacter baumannii Infections. Probiotics Antimicrob Proteins 2021; 12:809-818. [PMID: 31741312 DOI: 10.1007/s12602-019-09603-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Species of Lactobacillus have been proposed as potential candidates for treating wound infections due to their ability to lower pH, decrease inflammation, and release antimicrobial compounds. This study investigated the impact of lactobacilli (Lactobacillus acidophilus ATCC 4356, Lactobacillus casei ATCC 393, Lactobacillus reuteri ATCC 23272) secreted products on wound pathogens in vitro and in a murine wound infection model. Evaluation of 1-5 day lactobacilli conditioned media (CM) revealed maximal inhibition against wound pathogens using the 5-day CM. The minimum inhibitory concentration (MIC) of 5-day Lactobacillus CMs was tested by diluting CM in Mueller-Hinton (MH) broth from 0 to 25% and was found to be 12.5% for A. baumannii. Concentrating the CM to 10× with a 3 kDa centrifuge filter decreased the CM MIC to 6.25-12.5% for A. baumannii planktonic cells. Minimal impact of 5-day CMs was observed against bacterial biofilms. No toxicity was observed when these Lactobacillus CMs were injected into Galleria melonella waxworms. For the murine A. baumannii wound infection studies, improved survival was observed following topical treatment with L. acidophilus ATCC 4356 or L. reuteri ATCC 23272, while L. reuteri ATCC 23272 treatment alone improved wound resolution. Overall, this study suggests that the topical application of certain Lactobacillus species byproducts could be effective against gram-negative multi-drug resistant (MDR) wound pathogens, such as A. baumannii.
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Affiliation(s)
- Josh Stanbro
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Ju Me Park
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Matthew Bond
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Michael G Stockelman
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Mark P Simons
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA
| | - Chase Watters
- Wound Infections Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD, 20910, USA.
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7
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Buchek G, Mende K, Telu K, Kaiser S, Fraser J, Mitra I, Stam J, Lalani T, Tribble D, Yun HC. Travel-associated multidrug-resistant organism acquisition and risk factors among US military personnel. J Travel Med 2021; 28:6154715. [PMID: 33675647 PMCID: PMC8045176 DOI: 10.1093/jtm/taab028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel travelling internationally for official duty. METHODS TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analysed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travellers to regions outside the continental USA, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015 to 12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveller were analysed to determine risk factors for MDR organism colonization. RESULTS 110 trips were planned by 99 travellers (74% male, median age 38 years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travellers. Median duration was 21 days (IQR 12.75, 79.5). 17% travelled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travellers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travellers' diarrhoea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travellers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4-19%]), all ESBL-producing Escherichia coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials. CONCLUSIONS Incident colonization with MDR organisms occurs at a lower rate in this military population compared with civilian travellers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.
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Affiliation(s)
- Gregory Buchek
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Susan Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jason Stam
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Heather C Yun
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Velasco JM, Valderama MT, Margulieux K, Diones PC, Peacock T, Navarro FC, Liao C, Chua D, Macareo L, Crawford J, Swierczewski B. Comparison of Carbapenem-Resistant Microbial Pathogens in Combat and Non-combat Wounds of Military and Civilian Patients Seen at a Tertiary Military Hospital, Philippines (2013-2017). Mil Med 2021; 185:e197-e202. [PMID: 31247085 DOI: 10.1093/milmed/usz148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/31/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Bacterial wound infections are a danger to both military and civilian populations. The nature of injury and infection associated with combat related wounds are important in guiding antibiotic prophylaxis and empiric treatment guidelines. MATERIALS AND METHODS The isolates were screened for drug-resistance by the MicroScan Walkaway Plus System using either the Negative Breakpoint Combo Panel (NBCP) 30 or 34 or Positive Breakpoint Combo Panel (PBPC) 20 or 23. Isolates with a minimum inhibitory concentration (MIC) of ≥8 μg/mL to imipenem and/or meropenem were tested for both carbapenemase production using the CarbaNP test and real-time PCR to determine molecular resistance mechanisms. Plasmid conjugation analysis was performed to define potential for horizontal gene transfer. RESULTS We characterized 634 bacterial wound isolates collected from September 2013 to December 2017 from patients seen at a Philippine military tertiary hospital presenting with combat or non-combat injuries [354 (military) and 280 (civilians)]. Staphylococcus aureus was the most predominant bacterial species isolated from wounds in both populations (104/634, 16%). A variety of Gram-negative bacterial species comprised 442/634 (70%) of the isolates identified, with the most prevalent shown to be Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter sp. Carbapenemase production was detected in 34/442 (8%) Gram-negative isolates. Testing for molecular resistance mechanisms showed 32/34 (17 military, 15 civilian) wound isolates were blaNDM positive and 2 were blaVIM positive, with the two blaVIM isolates found in the civilian population. Plasmid conjugation of 14 blaNDM and 2 blaVIM positive wound isolates representatives showed 2/16 (13%) produced E. coli J53 transconjugants (E. coli from a civilian; E. cloacae from a military). CONCLUSION We describe in this study the wound bacterial and antibiotic resistance profile in the military (combat vs non-combat associated) and civilian population. We observed that, with the exception of Acinetobacter sp., resistance of prevalent Gram-negative bacterial species to imipenem or meropenem were not significantly different between the military and civilian populations. We also presented data on the prevalent bacterial species isolated from both combat and non-combat wounds in a military tertiary care hospital setting as well as the carbapenemase-encoding gene primarily responsible for carbapenem resistance as well as evidence of horizontal transfer via mobile genetic elements. Clinicians may use this information to guide empiric antibiotic coverage for the predominant organisms if wound culture results are not readily available.A prospective, longitudinal evaluation of the wound bacterial profile documenting the changing bacterial flora using higher resolution molecular strategies can provide a more comprehensive understanding of the diversity, composition, and abundance of bacterial composition of the wound microbial community from the time of injury, during the course of evacuation from the field to higher level of care facilities, and up to wound resolution.
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Affiliation(s)
- John Mark Velasco
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400.,University of the Philippines Manila, Ermita, Manila, Philippines 1000
| | - Ma Theresa Valderama
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Katie Margulieux
- Department of Bacterial and Parasitic Diseases, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Paula Corazon Diones
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Trent Peacock
- Department of Bacterial and Parasitic Diseases, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Fatima Claire Navarro
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Cynthia Liao
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Domingo Chua
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Louis Macareo
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - John Crawford
- University of the Philippines Manila, Ermita, Manila, Philippines 1000
| | - Brett Swierczewski
- Bacterial Disease Branch, Walter Reed Army Institute of Research, MD 20910-7500
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9
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Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Isolates from Northern Africa and the Middle East. Antibiotics (Basel) 2021; 10:antibiotics10030291. [PMID: 33799540 PMCID: PMC8002098 DOI: 10.3390/antibiotics10030291] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
At the Bundeswehr Hospitals of Hamburg and Westerstede, patients repatriated from subtropical war and crisis zones of Northern Africa and the Middle East were medically treated, including microbiological assessment. Within a six-year interval, 16 Acinetobacter spp. strains, including 14 Acinetobacter baumannii (Ab) isolates with resistance against carbapenems and origins in Afghanistan (n = 4), Iraq (n = 2), Libya (n = 2), and Syria (n = 8) were collected. While clonal relationships of Libyan and Syrian strains had been assessed by superficial next generation sequencing (NGS) and “DiversiLab” repetitive elements sequence-based (rep-)PCR so far, this study provides core genome-based sequence typing and thus more detailed epidemiological information. In detail, sequencing allowed a definitive species identification and comparison with international outbreak-associated Ab strains by core genome multi locus sequence typing (cgMLST) and the identification of MLST lineages, as well as the identification of known resistance genes. The sequence analysis allowed for the confirmation of outbreak-associated clonal clusters among the Syrian and Afghan Ab isolates, indicating likely transmission events. The identified acquired carbapenem resistance genes comprised blaOXA-23, blaOXA-58, blaNDM-1, and blaGES-11, next to other intrinsic and acquired, partly mobile resistance-associated genes. Eleven out of 14 Ab isolates clustered with the previously described international clonal lineages IC1 (4 Afghan strains), IC2 (6 Syrian strains), and IC7 (1 Syrian strain). Identified Pasteur sequence types of the 14 Ab strains comprised ST2 (Syrian), ST25 (Libyan), ST32 (Iraqi), ST81 (Afghan), ST85 (Libyan), and ST1112 (Syrian), respectively. In conclusion, the study revealed a broad spectrum of resistance genes in Ab isolated from war-injured patients from Northern Africa and the Middle East, thereby broadening the scarcely available data on locally abundant clonal lineages and resistance mechanisms.
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Higgins PG, Hagen RM, Podbielski A, Frickmann H, Warnke P. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Isolated from War-Injured Patients from the Eastern Ukraine. Antibiotics (Basel) 2020; 9:antibiotics9090579. [PMID: 32899463 PMCID: PMC7558915 DOI: 10.3390/antibiotics9090579] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 01/06/2023] Open
Abstract
Recently, a total of 32 carbapenem- and fluoroquinolone-resistant Acinetobacter baumannii (Ab) isolates was isolated from war-injured patients who were treated at German Bundeswehr Hospitals, and preliminarily typed by “DiversiLab” repetitive elements sequence-based (rep-) PCR. Core genome-based sequence typing was also used to provide more detailed epidemiological information. From the clusters observed by rep-PCR, selected Ab strains were subjected to Next Generation Sequencing (NGS) in order to compare them with international outbreak-associated Ab strains and to identify MLST (multi-locus sequence type) lineages, as well as to identify known resistance genes. Accordingly, NGS indicated higher diversity than rep-PCR, but also confirmed likely transmission events. The identified acquired carbapenem-resistant genes comprised blaOXA-23, blaOXA-72 and blaGES-12, as well as various other intrinsic and acquired resistance-associated genetic elements. All isolates clustered with the previously identified international clonal lineages IC1, IC2, IC6 and IC7, with corresponding Pasteur sequence types ST1, ST2, ST78 and ST25, respectively. In conclusion, the assessment confirmed a broad spectrum of resistance-associated genes in Ab isolated from war-injured patients from the Eastern Ukraine, and provided the first insights into locally abundant clonal lineages.
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Affiliation(s)
- Paul G. Higgins
- Institute for Medical Microbiology, Immunology, and Hygiene, University of Cologne, 50935 Cologne, Germany;
- German Centre for Infection Research (DZIF), partner site Bonn-Cologne, 50935 Cologne, Germany
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany;
| | - Andreas Podbielski
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (H.F.); (P.W.)
- Correspondence: ; Tel.: +49-381-494-5901
| | - Hagen Frickmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (H.F.); (P.W.)
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany; (H.F.); (P.W.)
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11
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Lanteri C, Mende K, Kortepeter M. Emerging Infectious Diseases and Antimicrobial Resistance (EIDAR). Mil Med 2020; 184:59-65. [PMID: 31004432 PMCID: PMC6802279 DOI: 10.1093/milmed/usz081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/18/2019] [Indexed: 01/06/2023] Open
Abstract
Introduction The Infectious Disease Clinical Research Program’s (IDCRP) Emerging Infectious Diseases and Antimicrobial Resistance (EIDAR) Research Area is a Department of Defense (DoD) clinical research capability that is responsive and adaptive to emerging infectious disease (EID) threats to US military readiness. Among active-duty and other Military Health System (MHS) beneficiaries, EIDAR research is largely focused on evaluating the incidence, risk factors, and acute- and long-term health effects of military-relevant EIDs, especially those caused by high-consequence pathogens or are responsible for outbreaks among US military populations. The EIDAR efforts also address Force Health Protection concerns associated with antimicrobial resistance and antimicrobial stewardship practices within the MHS. Methods The EIDAR studies utilize the approach of: (1) Preparing for emergent conditions to systematically collect clinical specimens and data and conduct clinical trials to assist the military with a scientifically appropriate response; and (2) Evaluating burden of emergent military-relevant infectious diseases and assessing risks for exposure and development of post-infectious complications and overall impact on military readiness. Results In response to the Ebola virus epidemic in West Africa, the IDCRP partnered with the National Institutes of Health in developing a multicenter, randomized safety and efficacy study of investigational therapeutics in Ebola patients. Subsequently, the EIDAR team developed a protocol to serve as a contingency plan (EpICC-EID) to allow clinical research activities to occur during future outbreaks of viral hemorrhagic fever and severe acute respiratory infections among MHS patients. The EIDAR portfolio recently expanded to include studies to understand exposure risks and impact on military readiness for a diversity of EIDs, such as seroincidence of non-Lyme disease borreliosis and Coccidioides fungal infections among high-risk military populations. The team also launched a new prospective study in response to the recent Zika epidemic to conduct surveillance for Zika and other related viruses among MHS beneficiaries in Puerto Rico. Another new study will prospectively follow U.S. Marines via an online health assessment survey to assess long-term health effects following the largest DoD Shiga Toxin-Producing Escherichia coli outbreak at the U.S. Marine Corps Recruit Depot-San Diego. In cooperation with the Trauma-Related Infections Research Area, the EIDAR Research Area is also involved with the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative, which is a collaborative effort across DoD laboratories to characterize bacterial and fungal isolates infecting combat-related extremity wounds and link lab findings to clinical outcomes. Furthermore, the EIDAR team has developed an Antimicrobial Resistance and Stewardship Collaborative Clinical Research Consortium, comprised of Infectious Disease and Pharmacy specialists. Conclusions The EIDAR Research Area is responsive to military-relevant infectious disease threats that are also frequently global public health concerns. Several new EIDAR efforts are underway that will provide Combatant Command Surgeons, Infectious Diseases Service Chiefs, and other Force Health Protection stakeholders with epidemiological information to mitigate the impact of EIDs and antimicrobial resistance on the health of U.S. military service members and their dependents.
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Affiliation(s)
- Charlotte Lanteri
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Katrin Mende
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817.,Brooke Army Military Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Mark Kortepeter
- University of Nebraska Medical Center College of Public Health, 984355 Medical Center, Omaha, NB 68198.,Departments of Medicine and Preventive Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road Bethesda, MD 20814
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12
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Zemke JN, Sanchez JL, Pang J, Gray GC. The Double-Edged Sword of Military Response to Societal Disruptions: A Systematic Review of the Evidence for Military Personnel as Pathogen Transmitters. J Infect Dis 2020; 220:1873-1884. [PMID: 31519020 DOI: 10.1093/infdis/jiz400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/02/2019] [Indexed: 11/12/2022] Open
Abstract
Given their lack of immunity and increased exposure, military personnel have the potential to serve as carriers or reservoirs for infectious diseases into or out of the deployment areas, but, to our knowledge, the historical evidence for such transmission events has not previously been reviewed. Using PubMed, we performed a systematic review of published literature between 1955 and 2018, which documented evidence for military personnel transporting infectious pathogens into or out of deployment areas. Of the 439 articles screened, 67 were included for final qualitative and quantitative review. The data extracted from these articles described numerous instances in which thousands of military service members demonstrated potential or actual transmission and transportation of multiple diverse pathogens. These data underscore the immense importance preventive medical professionals play in mitigating such risk, how their public health efforts must be supported, and the importance of surveillance in protecting both military and civilian populations.
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Affiliation(s)
- Juliana N Zemke
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Jose L Sanchez
- Department of Defense, Defense Health Agency, Public Health Division, Armed Forces Health Surveillance Branch, Silver Spring, Maryland
| | - Junxiong Pang
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Centre for Infectious Disease Epidemiology & Research, Saw Swee Hock School of Public Health, National University of Singapore
| | - Gregory C Gray
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases, Duke University, Durham, North Carolina.,Emerging Infectious Disease Program, Duke-National University of Singapore Medical School, Singapore.,Global Health Research Center, Duke-Kunshan University, Kunshan, China
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13
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Nawfal Dagher T, Al-Bayssari C, Diene SM, Azar E, Rolain JM. Bacterial infection during wars, conflicts and post-natural disasters in Asia and the Middle East: a narrative review. Expert Rev Anti Infect Ther 2020; 18:511-529. [PMID: 32267179 DOI: 10.1080/14787210.2020.1750952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Bacterial infections resulting from wars and natural disasters represent a major public health problem. Over the past 50 years, Asia and the Middle East have suffered several wars. Moreover, East-Asian countries are considered the most natural disaster-prone countries in the world.Areas covered: This review focuses on bacterial infection occurring during wars and after natural disasters, among refugees, wounded citizens and soldiers as well as the prevention and control measures that must be taken.Expert opinion: During wars, refugees and soldiers represent the two main sources of bacterial infections. Refugees coming from countries with a high prevalence of antimicrobial resistance can spread these pathogens to their final destination. In addition, these refugees living in inadequate shelters can contribute to the spread of bacterial infections. Moreover, some factors including the presence of fixed imported fragments; environmental contamination and nosocomial transmissions, play a key role in the dissemination of bacteria among soldiers. As for natural disasters, several factors are associated with increased bacterial transmissions such as the displacement of large numbers of people into over-crowded shelters, high exposure to disease vectors, lack of water and sanitation. Here, we carry out a systematic review of the bacterial infections that follow these two phenomena.
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Affiliation(s)
- Tania Nawfal Dagher
- Faculté de Médecine et de Pharmacie, Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France.,Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Charbel Al-Bayssari
- Faculty of Sciences 3, Lebanese University, Michel Slayman Tripoli Campus, Ras Maska, Lebanon
| | - Seydina M Diene
- Faculté de Médecine et de Pharmacie, Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Eid Azar
- Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Jean-Marc Rolain
- Faculté de Médecine et de Pharmacie, Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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14
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Patterson SB, Mende K, Li P, Lu D, Carson ML, Murray CK, Tribble DR, Blyth DM. Stenotrophomonas maltophilia infections: Clinical characteristics in a military trauma population. Diagn Microbiol Infect Dis 2019; 96:114953. [PMID: 31791809 DOI: 10.1016/j.diagmicrobio.2019.114953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 01/27/2023]
Abstract
Stenotrophomonas maltophilia is a pathogen with unique resistance patterns. We assessed 70 combat casualties with S. maltophilia clinical isolates to examine its role as a nosocomial pathogen in critically-ill trauma patients. Incidence density was 0.36 S. maltophilia infections per 100 patient-days (95% CI: 0.29-0.44). Patients predominantly had blast trauma (97%) and were critically injured (injury severity score [ISS] >25; 80%). Restricting to patients with ISS >15, 50 patients with S. maltophilia infections were compared to 441 patients with infections attributed to other gram-negative bacilli. Patients with S. maltophilia infections had significantly more operating room visits prior to isolation, traumatic or early surgical amputations, longer hospitalization (median 71 vs 47 days), and higher overall mortality (10% vs 2%; P = 0.01). Initial and serial (≥7 days between initial and subsequent isolation) S. maltophilia isolates had high susceptibility to trimethoprim-sulfamethoxazole and minocycline. Evaluation of newer agents awaiting CLSI breakpoints, including moxifloxacin, showed promising results.
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Affiliation(s)
- Shane B Patterson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA.
| | - Katrin Mende
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Clinton K Murray
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
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15
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Geisinger E, Huo W, Hernandez-Bird J, Isberg RR. Acinetobacter baumannii: Envelope Determinants That Control Drug Resistance, Virulence, and Surface Variability. Annu Rev Microbiol 2019; 73:481-506. [DOI: 10.1146/annurev-micro-020518-115714] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acinetobacter baumannii has emerged as an important nosocomial pathogen, particularly for patients in intensive care units and with invasive indwelling devices. The most recent clinical isolates are resistant to several classes of clinically important antibiotics, greatly restricting the ability to effectively treat critically ill patients. The bacterial envelope is an important driver of A. baumannii disease, both at the level of battling against antibiotic therapy and at the level of protecting from host innate immune function. This review provides a comprehensive overview of key features of the envelope that interface with both the host and antimicrobial therapies. Carbohydrate structures that contribute to protecting from the host are detailed, and mutations that alter these structures, resulting in increased antimicrobial resistance, are explored. In addition, protein complexes involved in both intermicrobial and host-microbe interactions are described. Finally we discuss regulatory mechanisms that control the nature of the cell envelope and its impact on host innate immune function.
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Affiliation(s)
- Edward Geisinger
- Department of Biology, Northeastern University, Boston, Massachusetts 02115, USA
| | - Wenwen Huo
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
| | - Juan Hernandez-Bird
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
| | - Ralph R. Isberg
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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16
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Fischer D, Schlößer RL, Kempf VAJ, Wichelhaus TA, Klingebiel T, Philippi S, Falgenhauer L, Imirzalioglu C, Dahl U, Brandt C, Reinheimer C. Overcrowding in a neonatal intermediate care unit: impact on the incidence of multidrug-resistant gram-negative organisms. BMC Infect Dis 2019; 19:357. [PMID: 31035966 PMCID: PMC6489334 DOI: 10.1186/s12879-019-3981-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overcrowding, reduced nurse to patient ratio, limited distance between incubators and absence of microbiological surveillance have been shown to promote spread of multidrug-resistant gram-negative organisms (MDRGN) in patients with birthweight < 1500 g. Patients > 1500 g treated on an intermediate care unit are unrepresented in recent literature. We therefore intended to present data obtained from a short-term overcrowded neonatal intermediate care unit (NIMCU) at a level III (international categorization) perinatal center at University Hospital Frankfurt, Germany. METHODS During a 25 day overcrowding (OV) and 28 day post-overcrowding period (POST-OV) on NIMCU, epidemiological data obtained from continuously hold microbiological surveillance were investigated and compared to the last 12 months of ward-regular bed occupancy preceding OV (PRAE-OV). RESULTS During OV, the number of patients simultaneously treated at the NIMCU increased from 18 to 22, resulting in a reduced bed-to-bed space. Nurse: patient ratio was 4:22 during OV compared to 3:18 during PRAE-OV. Cumulative incidence of MDRGN was 4.7% in OV and 2.4% POST-OV compared to 4.8% to PRAE-OV, respectively, without any significant variations. During OV and POST-OV, septic episodes due to MDRGN were not observed. In one case, potential nosocomial transmission of Enterobacter cloacae resistant to Piperacillin and 3rd/4th generation cephalosporins was observed. CONCLUSIONS Prevention of nosocomial spread of MDRGN in an overcrowded NIMCU is based on staff's diligent training and adequate staffing. Concise microbiological surveillance should be guaranteed to escort through overcrowding periods. In our setting, impact of bed-to-bed distance on MDRGN transmission seemed to be less strong.
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Affiliation(s)
- Doris Fischer
- Department of Pediatrics, Division of Neonatology, University Hospital Frankfurt, St. Vincenz Hospital, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Rolf L Schlößer
- Department of Pediatrics, Division of Neonatology, University Hospital Frankfurt, St. Vincenz Hospital, Auf dem Schafsberg, 65549, Limburg, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
| | - Thomas Klingebiel
- Department of Pediatrics, Division of Neonatology, University Hospital Frankfurt, St. Vincenz Hospital, Auf dem Schafsberg, 65549, Limburg, Germany
| | - Sabine Philippi
- Department of Pediatrics, Division of Neonatology, University Hospital Frankfurt, St. Vincenz Hospital, Auf dem Schafsberg, 65549, Limburg, Germany
| | - Linda Falgenhauer
- Justus Liebig University, Institute of Medical Microbiology, and German Center for Infection Research (DZIF), Partner site Giessen-Marburg-Langen, Giessen, Germany
| | - Can Imirzalioglu
- Justus Liebig University, Institute of Medical Microbiology, and German Center for Infection Research (DZIF), Partner site Giessen-Marburg-Langen, Giessen, Germany
| | - Udo Dahl
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
| | - Christian Brandt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
| | - Claudia Reinheimer
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, 60590, Frankfurt at the Main, Germany
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17
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Bogie KM. The Modular Adaptive Electrotherapy Delivery System (MAEDS): An Electroceutical Approach for Effective Treatment of Wound Infection and Promotion of Healing. Mil Med 2019; 184:92-96. [DOI: 10.1093/milmed/usy276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/24/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Infected wounds are painful and cannot heal, with antibiotics showing reduced efficacy. Appropriate wound electrotherapy may limit incident planktonic and polymicrobial colonization, inhibit biofilm formation and accelerate healing.
Methods
The Modular Adaptive Electrotherapy Delivery System (MAEDS) is a lightweight, flexible, battery-powered disposable bandage which delivers controlled reliable electrotherapy to the wound for up to 7 days. Large full-thickness excisional wounds (6 cm diameter) were created in a porcine model and freshly cultured 0.5 McFarland green fluorescent protein-labeled Pseudomonas aeruginosa evenly applied to the wound bed. Control wounds received standard wound care, Tegaderm HP Transparent Dressing (3 M Health Care, St. Paul, MN, USA) applied in a sterile fashion. Treatment wounds received MAEDS electrotherapy for up to 28 days or until healed. Onboard Bluetooth facilitated remote real-time monitoring of MAEDS function. Dressing changes occurred on postoperative day (POD) 1, 3, 5, 7, 10, 14, 21, and 28. Punch biopsies were taken at the wound margin and center. Bacterial samples were processed to determine infection status.
Results
Acute infected wounds treated with MAEDS electrotherapy were 92% smaller than baseline by POD21. Healing rate was significantly faster (p < 0.01) and infection significantly decreased (p < 0.0001) at POD10, relative to control wounds.
Conclusion
The MAEDS electrotherapy can significantly inhibit infection and enhance healing rate in acute infected wounds.
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Affiliation(s)
- Kath M Bogie
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center 10701 East Blvd, Cleveland, OH
- Department of Orthopaedics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH
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18
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Blake DP. Key Ways to Prevent Infection When There Is No "Building": Aspects for the Field. Surg Infect (Larchmt) 2019; 20:115-118. [PMID: 30676276 DOI: 10.1089/sur.2018.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infection control is a critical aspect in the continuum of surgical care. Much of what is outlined in the literature pertains to hospital-based practice, with only recent attention paid to the more austere environments, particularly those faced during humanitarian or combat operations. OBJECTIVE This manuscript provides a brief historical review of the development of infection control practices and further identifies and outlines several aspects necessary to successful program applications in austere environments. RESULTS Hand hygiene remains the simplest form of infection control. Use of alcohol-based hand sanitizer is a logistically reasonable option for most circumstances, mitigating the requirement for clean running water to facilitate more traditional "soap and water" methods of hand disinfection. Environmental decontamination, patient cohorting, and patient isolation based on existing colonization/infection also has demonstrated efficacy in controlling cross-contamination and is feasible in most austere environments. Finally, senior leadership engagement with deliberate planning, antimicrobial stewardship, and vigorous quality and process improvement algorithms have resulted in reduced rates of critical infections in these settings. CONCLUSIONS Basic tenets of infection control can be achieved even in resource-poor environments. Meticulous attention to adhering to these principles, with support from senior medical and operational leadership, facilitates improvements in infection control outcomes. There remains, however, a need for additional robust outcomes data regarding best practices in these environments.
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Affiliation(s)
- David P Blake
- Division of Acute Care Surgery, Department of Surgery, Hartford Hospital, Hartford, Connecticut and Department of Surgery, Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Maryland
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19
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Microbiology of combat-related extremity wounds: Trauma Infectious Disease Outcomes Study. Diagn Microbiol Infect Dis 2018; 94:173-179. [PMID: 30691724 DOI: 10.1016/j.diagmicrobio.2018.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 12/03/2018] [Accepted: 12/14/2018] [Indexed: 11/21/2022]
Abstract
We present extremity wound microbiology data from 250 combat casualties (2009-2012). Confirmed extremity wound infections (EWIs) were based on clinical and laboratory findings. Suspected EWIs had isolation of organisms from wound cultures with associated signs/symptoms not meeting clinical diagnostic criteria. Colonized wounds had organisms isolated without any infection suspicion. A total of 335 confirmed EWIs (131 monomicrobial and 204 polymicrobial) were assessed. Gram-negative bacteria were predominant (57% and 86% of monomicrobial and polymicrobial infections, respectively). In polymicrobial infections, 61% grew only bacteria, while 30% isolated bacteria and mold. Multidrug resistance was observed in 32% of isolates from first monomicrobial EWIs ±3 days of diagnosis, while it was 44% of isolates from polymicrobial EWIs. Approximately 96% and 52% of the suspected and colonized wounds, respectively, shared ≥1 organism in common with the confirmed EWI on the same patient. Understanding of combat-related EWIs can lead to improvements in combat casualty care.
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Acinetobacter baumannii Gastrointestinal Colonization Is Facilitated by Secretory IgA Which Is Reductively Dissociated by Bacterial Thioredoxin A. mBio 2018; 9:mBio.01298-18. [PMID: 29991584 PMCID: PMC6050963 DOI: 10.1128/mbio.01298-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Multidrug-resistant Acinetobacter baumannii is among the most common causes of infectious complications associated with combat-related trauma in military personnel serving overseas. However, little is currently known about its pathogenesis. While the gastrointestinal (GI) tract has been found to be a major reservoir for A. baumannii, as well as to potentially contribute to development of multidrug resistance, no studies have addressed the mechanisms involved in gut colonization. In this study, we address this critical gap in knowledge by first assessing the interaction between secretory IgA (SIgA), the principal humoral immune defense on mucosal surfaces, and the A. baumannii clinical isolate Ci79. Surprisingly, SIgA appeared to enhance A. baumannii GI tract colonization, in a process mediated by bacterial thioredoxin A (TrxA), as evidenced by reduction of bacterial attachment in the presence of TrxA inhibitors. Additionally, a trxA targeted deletion mutant (ΔtrxA) showed reduced bacterial burdens within the GI tract 24 h after oral challenge by in vivo live imaging, along with loss of thiol-reductase activity. Surprisingly, not only was GI tract colonization greatly reduced but the associated 50% lethal dose (LD50) of the ΔtrxA mutant was increased nearly 100-fold in an intraperitoneal sepsis model. These data suggest that TrxA not only mediates A. baumannii GI tract colonization but also may contribute to pathogenesis in A. baumannii sepsis following escape from the GI tract under conditions when the intestinal barrier is compromised, as occurs with cases of severe shock and trauma. Acinetobacter baumannii is an emerging bacterial pathogen recently classified as a serious threat to U.S. and global health by both the Centers for Disease Control and Prevention and the World Health Organization. It also is one of the leading causes of combat-related infections associated with injured military personnel serving overseas. Little is known regarding mechanisms of gastrointestinal tract colonization despite this site being shown to serve as a reservoir for multidrug-resistant (MDR) A. baumannii isolates. Here, we establish that secretory IgA, the major immunoglobulin of mucosal surfaces, promotes A. baumannii GI tract colonization via bacterial thioredoxin A as evidenced through significant reduction in colonization in IgA-deficient animals. Additionally, bacterial colonization and mortality were significantly reduced in animals challenged with a thioredoxin A-deficient A. baumannii mutant. Combined, these data suggest that thioredoxin A is a novel virulence factor, for which antithioredoxin therapies could be developed, for this important multidrug-resistant pathogen.
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Larréché S, Bousquet A, Soler C, Mac Nab C, de Briel D, Delaune D, Bigaillon C, Pasquier P, Dubost C, Demoures T, Malgras B, Ausset S, de Rudnicki S, Leclerc T, de Loynes B, Bonnet S, Mocellin N, Ficko C, Haus R, Hersan O, Rigal S, Mérens A. Microbiology of French military casualties repatriated from overseas for an open traumatic injury. Med Mal Infect 2018; 48:403-409. [PMID: 29709404 DOI: 10.1016/j.medmal.2018.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.
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Affiliation(s)
- S Larréché
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France.
| | - A Bousquet
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - C Soler
- Microbiologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - C Mac Nab
- Microbiologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - D de Briel
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Microbiologie, hôpitaux civils de Colmar, 39, avenue de la Liberté, 68024 Colmar, France
| | - D Delaune
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - C Bigaillon
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - P Pasquier
- Anesthésie-réanimation, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
| | - C Dubost
- Anesthésie-réanimation, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - T Demoures
- Chirurgie orthopédique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - B Malgras
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie viscérale, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - S Ausset
- Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
| | - S de Rudnicki
- Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - T Leclerc
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Centre de traitement des brulés, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - B de Loynes
- Chirurgie orthopédique, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - S Bonnet
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie viscérale, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Chirurgie viscérale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - N Mocellin
- Chirurgie viscérale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - C Ficko
- Maladies infectieuses et tropicales, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - R Haus
- Direction centrale du service de santé des armées, 158, cours des Maréchaux, 94300 Vincennes, France
| | - O Hersan
- Direction centrale du service de santé des armées, 158, cours des Maréchaux, 94300 Vincennes, France
| | - S Rigal
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie orthopédique, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - A Mérens
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
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Prevalence and risk factors for Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae in French military and civilian travelers: A cross-sectional analysis. Travel Med Infect Dis 2018; 23:44-48. [PMID: 29604430 DOI: 10.1016/j.tmaid.2018.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 03/17/2018] [Accepted: 03/27/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND International travel is a risk factor for colonization with Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae (ESBL-E). We describe the prevalence of and risk-factors for ESBL-E colonization in civilian and military travelers. METHODS Patients hospitalized in the infectious diseases department of Bégin Military Hospital (France) from May 2012 to November 2015, who had traveled abroad over the past two months, were screened for intestinal colonization with ESBL-E. RESULTS Forty-one out of 166 travelers (24.7%) had ESBL-E colonization, predominantly Escherichia coli. The risk factors for ESBL-E colonization in the univariate analysis were a treatment with any antibiotic in the last two months (OR 4.19, 95% CI 1.91-9.16) or with a beta-lactam in the same period (OR 3.35, 95% CI 1.44-7.82), and an hospitalization in the last two months (OR 3.96, 95% CI 1.91-9.16). The military status, military mission or military accommodation were not associated with an increased risk of ESBL-E colonization. In the multivariate analysis, a treatment with any antibiotic in the last two months was significantly associated with ESBL-E colonization (OR 6.71, 95% CI 3.36-19.08). CONCLUSION Antibiotic treatment in the two previous months is strongly predictive of ESBL-E colonization in international travelers, while the military status and its specific living conditions are not.
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Infectious Complications After Battlefield Injuries: Epidemiology, Prevention, and Treatment. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0102-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Tribble DR, Li P, Warkentien TE, Lloyd BA, Schnaubelt ER, Ganesan A, Bradley W, Aggarwal D, Carson ML, Weintrob AC, Murray CK. Impact of Operational Theater on Combat and Noncombat Trauma-Related Infections. Mil Med 2017; 181:1258-1268. [PMID: 27753561 DOI: 10.7205/milmed-d-15-00368] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The Trauma Infectious Disease Outcomes Study began in June 2009 as combat operations were decreasing in Iraq and increasing in Afghanistan. Our analysis examines the rate of infections of wounded U.S. military personnel from operational theaters in Iraq and Afghanistan admitted to Landstuhl Regional Medical Center between June 2009 and December 2013 and transferred to a participating U.S. hospital. Infection risk factors were examined in a multivariate logistic regression analysis (expressed as odds ratios [OR]; 95% confidence intervals [CI]). The study population includes 524 wounded military personnel from Iraq and 4,766 from Afghanistan. The proportion of patients with at least one infection was 28% and 34% from the Iraq and Afghanistan theaters, respectively. The incidence density rate was 2.0 (per 100 person-days) for Iraq and 2.7 infections for Afghanistan. Independent risk factors included large-volume blood product transfusions (OR: 10.68; CI: 6.73-16.95), high Injury Severity Score (OR: 2.48; CI: 1.81-3.41), and improvised explosive device injury mechanism (OR: 1.84; CI: 1.35-2.49). Operational theater (OR: 1.32; CI: 0.87-1.99) was not a risk factor. The difference in infection rates between operational theaters is primarily a result of increased injury severity in Afghanistan from a higher proportion of blast-related trauma during the study period.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Tyler E Warkentien
- Infectious Disease, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Bradley A Lloyd
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
| | - Elizabeth R Schnaubelt
- Infectious Disease, Landstuhl Regional Medical Center, CMR 402, Box 1559, APO AE 09180, Landstuhl, Germany
| | - Anuradha Ganesan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
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Campbell WR, Li P, Whitman TJ, Blyth DM, Schnaubelt ER, Mende K, Tribble DR. Multi-Drug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients. Surg Infect (Larchmt) 2017; 18:357-367. [PMID: 29173084 DOI: 10.1089/sur.2017.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The contribution of multi-drug-resistant gram-negative bacilli infections (MDRGN-I) in patients with trauma is not well described. We present characteristics of MDRGN-Is among military personnel with deployment-related trauma (2009-2014). PATIENTS AND METHODS Data from the Trauma Infectious Disease Outcomes Study were assessed for infectious outcomes and microbial recovery. Infections were classified using standardized definitions. Gram-negative bacilli were defined as multi-drug-resistant if they showed resistance to ≥3 antibiotic classes or were producers of extended-spectrum β-lactamase or carbapenemases. RESULTS Among 2,699 patients admitted to participating U.S. hospitals, 913 (33.8%) experienced ≥1 infection event, of which 245 (26.8%) had a MDRGN-I. There were 543 MDRGN-I events (24.6% of unique 2,210 infections) with Escherichia coli (48.3%), Acinetobacter spp. (38.6%), and Klebsiella pneumoniae (8.4%) as the most common MDRGN isolates. Incidence of MDRGN-I was 9.1% (95% confidence interval [CI]: 8.0-10.2). Median time to MDRGN-I event was seven days with 75% occurring within 13 days post-trauma. Patients with MDRGN-Is had a greater proportion of blast injuries (84.1% vs. 62.5%; p < 0.0001), traumatic amputations (57.5% vs. 16.3%; p < 0.0001), and higher injury severity (82.0% had injury severity score ≥25 vs. 33.7%; p < 0.0001) compared with patients with either no infections or non-MDRGN-Is. Furthermore, MDRGN-I patients were more frequently admitted to the intensive care unit (90.5% vs. 48.5%; p < 0.0001), colonized with a MDRGN before infection (58.0% vs. 14.7%; p < 0.0001), and required mechanical ventilation (78.0% vs. 28.8% p < 0.0001). Antibiotic exposure before the MDRGN-I event was significantly higher across antibiotic classes except first generation cephalosporins and tetracyclines, which were very commonly used with all patients. Regarding outcomes, patients with MDRGN-Is had a longer length of hospitalization than the comparator group (53 vs. 18 days; p < 0.0001). CONCLUSIONS We found a high rate of MDRGN-I in our population characterized by longer hospitalization and greater injury severity. These findings inform treatment and infection control decisions in the trauma patient population.
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Affiliation(s)
- Wesley R Campbell
- 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Ping Li
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | | | - Dana M Blyth
- 5 San Antonio Military Medical Center , Fort Sam Houston, Texas
| | | | - Katrin Mende
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland.,5 San Antonio Military Medical Center , Fort Sam Houston, Texas
| | - David R Tribble
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
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Reinheimer C, Kempf VAJ, Jozsa K, Wichelhaus TA, Hogardt M, O'Rourke F, Brandt C. Prevalence of multidrug-resistant organisms in refugee patients, medical tourists and domestic patients admitted to a German university hospital. BMC Infect Dis 2017; 17:17. [PMID: 28056820 PMCID: PMC5217604 DOI: 10.1186/s12879-016-2105-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/10/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with contact to healthcare-system in high-prevalence countries (HPC) and refugee patients in hospital settings (REF) have previously been identified to be at risk of carrying multidrug-resistant organisms (MDRO). Comparative studies addressing the epidemiology of MDRO in patients transferred from hospitals abroad (ABROAD) and REF are lacking but are necessary to introduce refined infection control measures. METHODS From December 2015 to June 2016, 117 REF, 84 ABROAD and 495 patients admitted to intensive care unit, with no refugee history or pre-treatment abroad (ICU), at University Hospital Frankfurt, Germany (UHF) were screened for MDRO on day of admittance. Data within these groups were compared and set in an epidemiological context. RESULTS 52.1% (95% confidence interval = 42.7-61.5) of REF and 41.6% (31.0-52.9) of ABROAD, were positive for at least one MDRGN, respectively. In contrast, 7.9% (5.6-10.6) of ICU were positive for MDRGN. Thereof, 0.9% (0.0-4.7) of REF, 15.5% (8.5-25.0) of ABROAD and 0% (0.0-0.7) of ICU were positive for at least one MDRGN with carbapenem resistance (CR). In total, 19 MDRGN with CR were detected in ABROAD, with the most frequent species with CR being A. baumannii with 42.1% (20.3-66.5). Regarding MRSA, 10.3% (5.4-17.2) of REF, 5.9% (1.9-13.3) of ABROAD and a significantly lower proportion 1.4% (0.6-2.9) of ICU, respectively, were tested positive. CONCLUSIONS Both REF and ABROAD pose a relevant hospital hygiene risk. High prevalence of MDRGN with CR in ABROAD was observed. Concise screening and infection control guidelines are needed in patient cohorts with increased risk for MDRO carriage.
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Affiliation(s)
- Claudia Reinheimer
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany.
| | - Katalin Jozsa
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
| | - Thomas A Wichelhaus
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
| | - Fiona O'Rourke
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
| | - Christian Brandt
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul Ehrlich-Straße 40, 60596, Frankfurt am Main, Germany
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Yun HC, Weintrob AC, Conger NG, Li P, Lu D, Tribble DR, Murray CK. Healthcare-associated pneumonia among U.S. combat casualties, 2009 to 2010. Mil Med 2016; 180:104-10. [PMID: 25562865 DOI: 10.7205/milmed-d-14-00209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Although there is literature evaluating infectious complications associated with combat-related injuries from Iraq and Afghanistan, none have evaluated pneumonia specifically. Therefore, we assessed a series of pneumonia cases among wounded military personnel admitted to Landstuhl Regional Medical Center, and then evacuated further to participating U.S. military hospitals. Of the 423 casualties evacuated to the United States, 36 developed pneumonia (8.5%) and 30 of these (83.3%) were ventilator-associated. Restricting to 162 subjects admitted to intensive care, 30 patients had pneumonia (18.5%). The median Injury Severity Score was higher among subjects with pneumonia (23.0 vs. 6.0; p < 0.01). There were 61 first-isolate respiratory specimens recovered from 31 pneumonia subjects, of which 56.1% were gram-negative, 18.2% were gram-positive, and 18.2% were fungal. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly recovered (10.6%, and 9.1%, respectively). Thirteen bacterial isolates (26.5%) were multidrug-resistant. Outcome data were available for 32 patients, of which 26 resolved their infection without progression, 5 resolved after initial progression, and 1 died. Overall, combat-injured casualties suffer a relatively high rate of pneumonia, particularly those requiring mechanical ventilation. Although gram-negative pathogens were common, S. aureus was most frequently isolated. Continued focus on pneumonia prevention strategies is necessary for improving combat care.
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Affiliation(s)
- Heather C Yun
- San Antonio Military Medical Center, 3551 Roger Brooke Drive MCHE-MDI, JBSA Fort Sam Houston, TX 78234
| | - Amy C Weintrob
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814
| | - Nicholas G Conger
- Keesler Medical Center, 301 Fisher Street, Keesler Air Force Base, MS 39534
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Dan Lu
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biometrics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive MCHE-MDI, JBSA Fort Sam Houston, TX 78234
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Granzer H, Hagen RM, Warnke P, Bock W, Baumann T, Schwarz NG, Podbielski A, Frickmann H, Koeller T. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter Baumannii Complex Isolates from Patients that were Injured During the Eastern Ukrainian Conflict. Eur J Microbiol Immunol (Bp) 2016; 6:109-17. [PMID: 27429793 PMCID: PMC4936333 DOI: 10.1556/1886.2016.00014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 12/30/2022] Open
Abstract
This study addressed carbapenem-resistant Acinetobacter baumannii complex (ABC) isolates from patients that were injured during the military conflict in the Eastern Ukraine and treated at German Armed Forces Hospitals in 2014 and 2015. Clonal diversity of the strains and potential ways of transmission were analyzed. Patients with one or several isolation events of carbapenem-resistant ABC were included. Isolates were characterized by VITEK II-based identification and resistance testing, molecular screening for frequent carbapenemase genes, and DiversiLab rep-PCR-based typing. Available clinical information of the patients was assessed. From 21 young male Ukrainian patients with battle injuries, 32 carbapenem- and fluoroquinolone-resistant ABC strains were isolated. Four major clonal clusters were detected. From four patients (19%), ABC isolates from more than one clonal cluster were isolated. The composition of the clusters suggested transmission events prior to the admission to the German hospitals. The infection and colonization pressure in the conflict regions of the Eastern Ukraine with ABC of low clonal diversity is considerable. Respective infection risks have to be considered in case of battle-related injuries in these regions. The low number of local clones makes any molecular exclusion of transmission events difficult.
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Affiliation(s)
- Heike Granzer
- Laboratory Department I, Central Institute of the German Armed Forces in Koblenz , Germany
| | - Ralf Matthias Hagen
- North Atlantic Treaty Organization Center of Excellence in Military Medicine (NATO MilMedCOE) , Munich, Germany
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock , Germany
| | - Wolfgang Bock
- Laboratory Department I, Central Institute of the German Armed Forces in Munich , Germany
| | - Tobias Baumann
- Laboratory Department I, Central Institute of the German Armed Forces in Kiel (branch office in Berlin) , Germany
| | - Norbert Georg Schwarz
- Infectious Disease Epidemiology Group, Bernhard Nocht Institute of Tropical Medicine Hamburg , Germany
| | - Andreas Podbielski
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock , Germany
| | - Hagen Frickmann
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Germany; Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, Germany
| | - Thomas Koeller
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock , Germany
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Lessons of war: Combat-related injury infections during the Vietnam War and Operation Iraqi and Enduring Freedom. J Trauma Acute Care Surg 2016; 79:S227-35. [PMID: 26406435 DOI: 10.1097/ta.0000000000000768] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Mountziaris PM, Shah SR, Lam J, Bennett GN, Mikos AG. A rapid, flexible method for incorporating controlled antibiotic release into porous polymethylmethacrylate space maintainers for craniofacial reconstruction. Biomater Sci 2016; 4:121-9. [PMID: 26340063 PMCID: PMC4679697 DOI: 10.1039/c5bm00175g] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Severe injuries in the craniofacial complex, resulting from trauma or pathology, present several challenges to functional and aesthetic reconstruction. The anatomy and position of the craniofacial region make it vulnerable to injury and subsequent local infection due to external bacteria as well as those from neighbouring structures like the sinuses, nasal passages, and mouth. Porous polymethylmethacrylate (PMMA) "space maintainers" have proven useful in staged craniofacial reconstruction by promoting healing of overlying soft tissue prior to reconstruction of craniofacial bones. We describe herein a method by which the porosity of a prefabricated porous PMMA space maintainer, generated by porogen leaching, can be loaded with a thermogelling copolymer-based drug delivery system. Porogen leaching, space maintainer prewetting, and thermogel loading all significantly affected the loading of a model antibiotic, colistin. Weeks-long release of antibiotic at clinically relevant levels was achieved with several formulations. In vitro assays confirmed that the released colistin maintained its antibiotic activity against several bacterial targets. Our results suggest that this method is a valuable tool in the development of novel therapeutic approaches for the treatment of severe complex, infected craniofacial injuries.
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Affiliation(s)
- P M Mountziaris
- Department of Bioengineering, Rice University, Houston, Texas, USA. and Division of Plastic Surgery, Albany Medical Center, Albany, NY, USA
| | - S R Shah
- Department of Bioengineering, Rice University, Houston, Texas, USA.
| | - J Lam
- Department of Bioengineering, Rice University, Houston, Texas, USA.
| | - G N Bennett
- Department of BioSciences, Rice University, Houston, Texas, USA.
| | - A G Mikos
- Department of Bioengineering, Rice University, Houston, Texas, USA.
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Hrabák J, Študentová V, Adámková V, Šemberová L, Kabelíková P, Hedlová D, Čurdová M, Zemlickova H, Papagiannitsis CC. Report on a transborder spread of carbapenemase-producing bacteria by a patient injured during Euromaidan, Ukraine. New Microbes New Infect 2015; 8:28-30. [PMID: 26594376 PMCID: PMC4610961 DOI: 10.1016/j.nmni.2015.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/06/2015] [Accepted: 09/07/2015] [Indexed: 11/15/2022] Open
Abstract
Spread of carbapenemase-producing bacteria has been described all over the world. This phenomenon may be accelerated by many factors, including wars and natural disasters. In this report, we described an NDM-1-producing Klebsiella pneumonia ST11 recovered from a patient injured during the Maidan revolution in Ukraine. To our knowledge, this is the first report of a carbapenemase-producing Enterobacteriaceae in Ukraine and one of several reports describing wound colonization/infection of humans injured during war.
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Affiliation(s)
- J Hrabák
- Biomedical Center, Faculty of Medicine in Plzeň, Plzeň, Czech Republic ; Department of Microbiology, Faculty of Medicine and University Hospital in Plzeň, Charles University in Prague, Plzeň, Czech Republic
| | - V Študentová
- Biomedical Center, Faculty of Medicine in Plzeň, Plzeň, Czech Republic ; Department of Microbiology, Faculty of Medicine and University Hospital in Plzeň, Charles University in Prague, Plzeň, Czech Republic
| | - V Adámková
- Department of Clinical Microbiology, General University Hospital, Prague, Czech Republic
| | - L Šemberová
- Department of Clinical Microbiology, General University Hospital, Prague, Czech Republic
| | - P Kabelíková
- Department of Medical Microbiology, Motol University Hospital, Charles University, Prague, Czech Republic
| | - D Hedlová
- Department of Hospital Epidemiology, Prague, Czech Republic
| | - M Čurdová
- Department of Clinical Microbiology, Military University Hospital, Prague, Czech Republic
| | - H Zemlickova
- Biomedical Center, Faculty of Medicine in Plzeň, Plzeň, Czech Republic ; National Reference Laboratory for Antibiotics, National Institute of Public Health, Prague, Czech Republic
| | - C C Papagiannitsis
- Biomedical Center, Faculty of Medicine in Plzeň, Plzeň, Czech Republic ; Department of Microbiology, Faculty of Medicine and University Hospital in Plzeň, Charles University in Prague, Plzeň, Czech Republic
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Pavey GJ, Qureshi AT, Hope DN, Pavlicek RL, Potter BK, Forsberg JA, Davis TA. Bioburden Increases Heterotopic Ossification Formation in an Established Rat Model. Clin Orthop Relat Res 2015; 473:2840-7. [PMID: 25822455 PMCID: PMC4523512 DOI: 10.1007/s11999-015-4272-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) develops in a majority of combat-related amputations wherein early bacterial colonization has been considered a potential early risk factor. Our group has recently developed a small animal model of trauma-induced HO that incorporates many of the multifaceted injury patterns of combat trauma in the absence of bacterial contamination and subsequent wound colonization. QUESTIONS/PURPOSES We sought to determine if (1) the presence of bioburden (Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus [MRSA]) increases the magnitude of ectopic bone formation in traumatized muscle after amputation; and (2) what persistent effects bacterial contamination has on late microbial flora within the amputation site. METHODS Using a blast-related HO model, we exposed 48 rats to blast overpressure, femur fracture, crush injury, and subsequent immediate transfemoral amputation through the zone of injury. Control injured rats (n = 8) were inoculated beneath the myodesis with phosphate-buffered saline not containing bacteria (vehicle) and treatment rats were inoculated with 1 × 10(6) colony-forming units of A baumannii (n = 20) or MRSA (n = 20). All animals formed HO. Heterotopic ossification was determined by quantitative volumetric measurements of ectopic bone at 12-weeks postinjury using micro-CT and qualitative histomorphometry for assessment of new bone formation in the residual limb. Bone marrow and muscle tissue biopsies were collected from the residual limb at 12 weeks to quantitatively measure the bioburden load and to qualitatively determine the species-level identification of the bacterial flora. RESULTS At 12 weeks, we observed a greater volume of HO in rats infected with MRSA (68.9 ± 8.6 mm(3); 95% confidence interval [CI], 50.52-85.55) when compared with A baumannii (20.9 ± 3.7 mm(3); 95% CI, 13.61-28.14; p < 0.001) or vehicle (16.3 ± 3.2 mm(3); 95% CI, 10.06-22.47; p < 0.001). Soft tissue and marrow from the residual limb of rats inoculated with A baumannii tested negative for A baumannii infection but were positive for other strains of bacteria (1.33 × 10(2) ± 0.89 × 10(2); 95% CI, -0.42 × 10(2)-3.08 × 10(2) and 1.25 × 10(6) ± 0.69 × 10(6); 95% CI, -0.13 × 10(6)-2.60 × 10(6) colony-forming units in bone marrow and muscle tissue, respectively), whereas tissue from MRSA-infected rats contained MRSA only (4.84 × 10(1) ± 3.22 × 10(1); 95% CI, -1.47 × 10(1)-11.1 × 10(1) and 2.80 × 10(7) ± 1.73 × 10(7); 95% CI, -0.60 × 10(7)-6.20 × 10(7) in bone marrow and muscle tissue, respectively). CONCLUSIONS Our findings demonstrate that persistent infection with MRSA results in a greater volume of ectopic bone formation, which may be the result of chronic soft tissue inflammation, and that early wound colonization may be a key risk factor. CLINICAL RELEVANCE Interventions that mitigate wound contamination and inflammation (such as early débridement, systemic and local antibiotics) may also have a beneficial effect with regard to the mitigation of HO formation and should be evaluated with that potential in mind in future preclinical studies.
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MESH Headings
- Acinetobacter baumannii/pathogenicity
- Amputation, Surgical
- Animals
- Bacterial Load
- Biopsy
- Blast Injuries/complications
- Colony Count, Microbial
- Disease Models, Animal
- Femoral Fractures/complications
- Male
- Methicillin-Resistant Staphylococcus aureus/pathogenicity
- Muscle, Skeletal/diagnostic imaging
- Muscle, Skeletal/injuries
- Muscle, Skeletal/microbiology
- Muscle, Skeletal/pathology
- Ossification, Heterotopic/diagnosis
- Ossification, Heterotopic/microbiology
- Osteogenesis
- Rats, Sprague-Dawley
- Risk Factors
- Staphylococcal Infections/diagnosis
- Staphylococcal Infections/microbiology
- Time Factors
- Wound Infection/diagnosis
- Wound Infection/microbiology
- X-Ray Microtomography
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Affiliation(s)
- Gabriel J. Pavey
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Ammar T. Qureshi
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Donald N. Hope
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Rebecca L. Pavlicek
- />Department of Wound Infections, Naval Medical Research Center, Silver Spring, MD USA
| | - Benjamin K. Potter
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Jonathan A. Forsberg
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Thomas A. Davis
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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Franke A, Bieler D, Wilms A, Hentsch S, Johann M, Kollig E. [Treatment of gunshot fractures of the lower extremity: Part 2: Procedures for secondary reconstruction and treatment results]. Unfallchirurg 2015; 117:985-94. [PMID: 25398508 DOI: 10.1007/s00113-014-2636-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gunshot wounds of the lower extremities are always serious injuries, especially in cases in which bone is affected. Contamination and extensive tissue damage can be life-threatening for the patient and severely affect the function of the extremity. Contamination and local infections with multidrug resistant pathogens are regularly encountered particularly in casualties evacuated from crisis regions. Treatment of this special type of injury, which differs in the form and extent from conventional high-energy trauma of the lower extremities, usually requires lengthy and extensive therapy algorithms in order to preserve the affected extremity. PATIENTS AND METHODS Based on the results of 34 gunshot wounds of the lower extremities which were surgically treated in this department between 2005 and 2011, this article reports on procedures used for wound management, soft tissue reconstruction and restoration of bone continuity. This group included 18 patients with a total of 20 gunshot-related fractures, 40% of which affected the lower leg and 35% the thigh. The affected extremities could be salvaged in all cases. RESULTS The therapeutic spectrum required for bone reconstruction after soft tissue coverage demonstrated in these case examples ranged from conventional osteosynthesis with or without local cancellous bone transplant with platelet-rich plasma, to healing in a fixator, bone resection and the Masquelet method, distraction osteogenesis using a fixator in order to restore continuity and definitive secondary extension using an intramedullary skeletal kinetic distractor (ISKD) nail. Out of 15 bullet fractures affecting large tubular bones 8 could be healed without any shortening, axis deviation or malrotation. In 7 cases definitive shortening by an average of 20 mm (minimum 10 mm and maximum 40 mm) was necessary. The average treatment time before full weight-bearing was achieved within tolerable pain limits was 66 weeks (minimum 4 weeks and maximum 267 weeks). Secondary osteitis and osteomyelitis following primary restoration was detected in only one case. CONCLUSION These results show that the treatment of gunshot wounds of the lower extremities is time-consuming and extensive and requires the complete spectrum of modern trauma surgery. Despite the high risk of complications during treatment it is possible and feasible to apply procedures that preserve the extremities.
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Affiliation(s)
- A Franke
- Abteilung XIV, Klinik für Unfallchirurgie und Orthopädie, Hand- und Wiederherstellungschirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstr. 170, 56072, Koblenz, Deutschland,
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Ketter PM, Guentzel MN, Schaffer B, Herzig M, Wu X, Montgomery RK, Parida BK, Fedyk CG, Yu JJ, Jorgensen J, Chambers JP, Cap AP, Arulanandam BP. Severe Acinetobacter baumannii sepsis is associated with elevation of pentraxin 3. Infect Immun 2014; 82:3910-8. [PMID: 25001601 PMCID: PMC4187799 DOI: 10.1128/iai.01958-14] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 06/27/2014] [Indexed: 12/18/2022] Open
Abstract
Multidrug-resistant Acinetobacter baumannii is among the most prevalent bacterial pathogens associated with trauma-related wound and bloodstream infections. Although septic shock and disseminated intravascular coagulation have been reported following fulminant A. baumannii sepsis, little is known about the protective host immune response to this pathogen. In this study, we examined the role of PTX3, a soluble pattern recognition receptor with reported antimicrobial properties and stored within neutrophil granules. PTX3 production by murine J774a.1 macrophages was assessed following challenge with A. baumannii strains ATCC 19606 and clinical isolates (CI) 77, 78, 79, 80, and 86. Interestingly, only CI strains 79, 80, and 86 induced PTX3 synthesis in murine J774a.1 macrophages, with greatest production observed following CI 79 and 86 challenge. Subsequently, C57BL/6 mice were challenged intraperitoneally with CI 77 and 79 to assess the role of PTX3 in vivo. A. baumannii strain CI 79 exhibited significantly (P < 0.0005) increased mortality, with an approximate 50% lethal dose (LD50) of 10(5) CFU, while an equivalent dose of CI 77 exhibited no mortality. Plasma leukocyte chemokines (KC, MCP-1, and RANTES) and myeloperoxidase activity were also significantly elevated following challenge with CI 79, indicating neutrophil recruitment/activation associated with significant elevation in serum PTX3 levels. Furthermore, 10-fold-greater PTX3 levels were observed in mouse serum 12 h postchallenge, comparing CI 79 to CI 77 (1,561 ng/ml versus 145 ng/ml), with concomitant severe pathology (liver and spleen) and coagulopathy. Together, these results suggest that elevation of PTX3 is associated with fulminant disease during A. baumannii sepsis.
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Affiliation(s)
| | | | - Beverly Schaffer
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Maryanne Herzig
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Xiaowu Wu
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Robbie K Montgomery
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Bijaya K Parida
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Chriselda G Fedyk
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Jieh-Juen Yu
- University of Texas at San Antonio, San Antonio, Texas, USA
| | - James Jorgensen
- University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Andrew P Cap
- United States Army Institute for Surgical Research, San Antonio Military Medical Center, San Antonio, Texas, USA
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Phenotypic and genotypic changes over time and across facilities of serial colonizing and infecting Escherichia coli isolates recovered from injured service members. J Clin Microbiol 2014; 52:3869-77. [PMID: 25143566 DOI: 10.1128/jcm.00821-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Escherichia coli is the most common colonizing and infecting organism isolated from U.S. service members injured during deployment. Our objective was to evaluate the phenotypic and genotypic changes of infecting and colonizing E. coli organisms over time and across facilities to better understand their transmission patterns. E. coli isolates were collected via surveillance cultures and infection workups from U.S. military personnel injured during deployment (June 2009 to May 2011). The isolates underwent antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and multiplex PCR for phylotyping to determine their resistance profiles and clonality. A total of 343 colonizing and 136 infecting E. coli isolates were analyzed, of which 197 (57%) and 109 (80%) isolates, respectively, produced extended-spectrum β-lactamases (ESBL). Phylogroup A was predominant among both colonizing (38%) and infecting isolates (43%). Although 188 unique pulsed-field types (PFTs) were identified from the colonizing isolates, and 54 PFTs were identified from the infecting isolates, there was a lack of PFT overlap between study years, combat zones, and military treatment facilities. On a per-subject basis, 26% and 32% of the patients with serial colonizing isolates and 10% and 21% with serial infecting isolates acquired changes in their phylogroup and PFT profiles, respectively, over time. The production of ESBL remained high over time and across facilities, with no substantial changes in antimicrobial susceptibilities. Overall, our results demonstrated an array of genotypic and phenotypic differences for the isolates without large clonal clusters; however, the same PFTs were occasionally observed in the colonizing and infecting isolates, suggesting that the source of infections may be endogenous host organisms.
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Cooper RA. Surgical site infections: epidemiology and microbiological aspects in trauma and orthopaedic surgery. Int Wound J 2014; 10 Suppl 1:3-8. [PMID: 24251837 DOI: 10.1111/iwj.12179] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Causative agents of wound infections and the routes by which they access surgical incision sites have been recognised for more than a century. Despite knowledge of the factors that influence the risks of surgical site infections (SSIs) and the means to prevent and/or control them, surgical patients still get infections. Traditional systems of classifying and diagnosing SSIs and the diversity of microbial flora reported in contemporary SSIs will be described. Strategies available to prevent and control SSIs will be critically reviewed and the need to develop alternative approaches will be discussed.
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Affiliation(s)
- Rose A Cooper
- Centre for Biomedical Sciences, Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff, UK
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Mathieu L, Marty A, Ramaki A, Najib A, Ahmadzai W, Fugazzotto DJ, Rigal S, Shirzai N. Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul. Eur J Trauma Emerg Surg 2014; 40:387-93. [PMID: 26816076 DOI: 10.1007/s00068-013-0334-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 09/19/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed. METHODS This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation. RESULTS Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1-28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4-45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up. CONCLUSION This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.
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Affiliation(s)
- L Mathieu
- Department of Orthopaedic and Trauma Surgery, Desgenettes Military Hospital, Lyon, France.
| | - A Marty
- Department of Orthopaedic and Trauma Surgery, Legouest Military Hospital, Metz, France
| | - A Ramaki
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - A Najib
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - W Ahmadzai
- Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan
| | - D J Fugazzotto
- Afghan National Security Forces, Health System Development, ISAF Joint Command, Kabul, Afghanistan
| | - S Rigal
- Department of Orthopaedic and Trauma Surgery, Percy Military Hospital, Clamart, France
- Department of Surgery, French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France
| | - N Shirzai
- National Military Hospital, Kabul, Afghanistan
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Genome Sequences of Four Acinetobacter baumannii-A. calcoaceticus Complex Isolates from Combat-Related Infections Sustained in the Middle East. GENOME ANNOUNCEMENTS 2014; 2:2/1/e00026-14. [PMID: 24503987 PMCID: PMC3916481 DOI: 10.1128/genomea.00026-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Acinetobacter baumannii is among the most prevalent bacterial causes of combat-related infections on the battlefield. Antibiotic resistance and a poor understanding of the protective host immune responses make treatment difficult. Here, we report the genome sequences of four clinical Acinetobacter baumannii-A. calcoaceticus complex isolates exhibiting significant differences in virulence in a mouse sepsis model.
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Sabir R, Danish Alvi SF, Fawwad A. Antimicrobial susceptibility pattern of aerobic microbial isolates in a clinical laboratory in Karachi - Pakistan. Pak J Med Sci 2013; 29:851-5. [PMID: 24353642 PMCID: PMC3809306 DOI: 10.12669/pjms.293.3187] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/28/2013] [Accepted: 03/20/2013] [Indexed: 11/15/2022] Open
Abstract
Backgroun and Objective: Resistance to multiple antimicrobials is the major cause of debility and death due to infectious diseases around the world. Our objective was to determine the frequency and antimicrobial susceptibility pattern of aerobic microbial isolates in a clinical laboratory. Methodology: All culture specimens of tissue, pus, urine, bone, blood, fluid, stool, sputum, and high vaginal swab received in the Microbiology Department of Clinical & Research Laboratory, Baqai Institute of Diabetology and Endocrinology from May 2010 to January 2011 were included in the present study. Bacterial isolates were identified and their antimicrobial susceptibility pattern was determined. Results: Out of 312 cultured specimens, 272 (87.17%) were found infected with 437 microbial organisms (412 bacteria and 25 Candida isolates). A total of 90 (20.59%) multi-drug resistant (MDR) isolates were found. MDR Escherichia coli was isolated in 40 (34.19%) out of 117 culture specimens which showed the growth of Escherichia coli, Pseudomonas aeruginosa in 17 (22.08%), Methicillin-resistant Staphylococcus aureus in 13 (11.50%), Klebsiella pneumoniae in 7 (22.58%), Proteus species in 6 (31.58%), Acinetobacter species in 3 (33.33%), Enterobacter species in 2 (28.57%), Coliform (Escherichia coli) in 1 (16.67%) and Enterococcus species were isolated in 1 (50%) culture specimen. Conclusions: High prevalence of multi-drug resistant bacteria was found in the present study. Emergence of antimicrobial resistance has become a major challenge in infectious disease medicine. Antimicrobial resistance may be due to misuse of antimicrobials by physicians and self medication in Pakistan. Further large scale studies are needed to validate our findings.
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Affiliation(s)
- Rubina Sabir
- Rubina Sabir, Laboratory Manager, Clinical and Research Laboratory, Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
| | - S Faraz Danish Alvi
- S. Faraz Danish Alvi, MBBS, Research Officer, Research Department, Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
| | - Asher Fawwad
- Asher Fawwad, MBBS, M.Phil, Assistant Professor, Research Department, Baqai Institute of Diabetology & Endocrinology, Baqai Medical University, Karachi, Pakistan
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Antimicrobial resistance determinants in Acinetobacter baumannii isolates taken from military treatment facilities. Antimicrob Agents Chemother 2013; 58:767-81. [PMID: 24247131 DOI: 10.1128/aac.01897-13] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Multidrug-resistant (MDR) Acinetobacter baumannii infections are of particular concern within medical treatment facilities, yet the gene assemblages that give rise to this phenotype remain poorly characterized. In this study, we tested 97 clinical A. baumannii isolates collected from military treatment facilities (MTFs) from 2003 to 2009 by using a molecular epidemiological approach that enabled for the simultaneous screening of 236 antimicrobial resistance genes. Overall, 80% of the isolates were found to be MDR, each strain harbored between one and 17 resistant determinants, and a total of 52 unique resistance determinants or gene families were detected which are known to confer resistance to β-lactam (e.g., blaGES-11, blaTEM, blaOXA-58), aminoglycoside (e.g., aphA1, aacC1, armA), macrolide (msrA, msrB), tetracycline [e.g., tet(A), tet(B), tet(39)], phenicol (e.g., cmlA4, catA1, cat4), quaternary amine (qacE, qacEΔ1), streptothricin (sat2), sulfonamide (sul1, sul2), and diaminopyrimidine (dfrA1, dfrA7, dfrA19) antimicrobial compounds. Importantly, 91% of the isolates harbored blaOXA-51-like carbapenemase genes (including six new variants), 40% harbored the blaOXA-23 carbapenemase gene, and 89% contained a variety of aminoglycoside resistance determinants with up to six unique determinants identified per strain. Many of the resistance determinants were found in potentially mobile gene cassettes; 45% and 7% of the isolates contained class 1 and class 2 integrons, respectively. Combined, the results demonstrate a facile approach that supports a more complete understanding of the genetic underpinnings of antimicrobial resistance to better assess the load, transmission, and evolution of MDR in MTF-associated A. baumannii.
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Hawley CA, Watson CA, Orth K, Krachler AM. A MAM7 peptide-based inhibitor of Staphylococcus aureus adhesion does not interfere with in vitro host cell function. PLoS One 2013; 8:e81216. [PMID: 24265842 PMCID: PMC3827224 DOI: 10.1371/journal.pone.0081216] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/09/2013] [Indexed: 11/18/2022] Open
Abstract
Adhesion inhibitors that block the attachment of pathogens to host tissues may be used synergistically with or as an alternative to antibiotics. The wide-spread bacterial adhesin Multivalent Adhesion Molecule (MAM) 7 has recently emerged as a candidate molecule for a broad-spectrum adhesion inhibitor which may be used to prevent bacterial colonization of wounds. Here we have tested if the antibacterial properties of a MAM-based inhibitor could be used to competitively inhibit adhesion of methicillin-resistant Staphylococcus aureus (MRSA) to host cells. Additionally, we analyzed its effect on host cellular functions linked to the host receptor fibronectin, such as migration, adhesion and matrix formation in vitro, to evaluate potential side effects prior to advancing our studies to in vivo infection models. As controls, we used inhibitors based on well-characterized bacterial adhesin-derived peptides from F1 and FnBPA, which are known to affect host cellular functions. Inhibitors based on F1 or FnBPA blocked MRSA attachment but at the same time abrogated important cellular functions. A MAM7-based inhibitor did not interfere with host cell function while showing good efficacy against MRSA adhesion in a tissue culture model. These observations provide a possible candidate for a bacterial adhesion inhibitor that does not cause adverse effects on host cells while preventing bacterial infection.
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Affiliation(s)
- Catherine Alice Hawley
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Charlie Anne Watson
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Kim Orth
- Department of Molecular Biology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Anne Marie Krachler
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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Advances in battlefield combat casualty care. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e3182845663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Koole K, Ellerbroek PM, Lagendijk R, Leenen LPH, Ekkelenkamp MB. Colonization of Libyan civil war casualties with multidrug-resistant bacteria. Clin Microbiol Infect 2013; 19:E285-7. [PMID: 23413838 DOI: 10.1111/1469-0691.12135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/07/2012] [Accepted: 12/17/2012] [Indexed: 11/28/2022]
Abstract
In November 2011 51 Libyan war casualties were admitted to the Major Incident Hospital in Utrecht and from there were transferred to 26 other Dutch hospitals. Cultures and clinical data were collected to establish the prevalence of multidrug-resistant (MDR) bacteria in this patient group and to identify the associated risk factors. The prevalence of MDR bacteria was 59% (30/51 patients); extended spectrum β-lactamase-producing enterobacteriaceae were most common (26/51 patients: 51%). The major risk factor for carriage of MDR bacteria was the presence of open wounds at admission to the Major Incident Hospital.
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Affiliation(s)
- K Koole
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
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44
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Maslow JN. The International Threat of Antimicrobial Resistance The Perils of Paradise. Infect Control Hosp Epidemiol 2013; 34:125-6. [DOI: 10.1086/669079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Infections nosocomiales (2). MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Multidrug-resistant bacteria from personnel with combat injury at a French military medical center. J Trauma Acute Care Surg 2012; 72:1723-4. [DOI: 10.1097/ta.0b013e318256de8e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Franka EA, Shembesh MK, Zaied AA, El-Turki E, Zorgani A, Elahmer OR, Ghenghesh KS. Multidrug resistant bacteria in wounds of combatants of the Libyan uprising. J Infect 2012; 65:279-81. [PMID: 22490615 DOI: 10.1016/j.jinf.2012.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/12/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
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O'Shea MK. Acinetobacter in modern warfare. Int J Antimicrob Agents 2012; 39:363-75. [PMID: 22459899 DOI: 10.1016/j.ijantimicag.2012.01.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 01/24/2012] [Indexed: 10/28/2022]
Abstract
Increasing appreciation of the role of Acinetobacter baumannii in the aetiology of severe nosocomial infections, together with its ability to employ several mechanisms to rapidly develop resistance to multiple classes of antimicrobial agents, has led to growing interest in this organism over recent years. Recognition and subsequent investigation of the significance of pathogenic Acinetobacter infections in military personnel sustaining injuries during the conflicts in Afghanistan and Iraq has provided an important contribution to the epidemiology of infections with Acinetobacter spp. The following review examines this recent military experience.
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Affiliation(s)
- M K O'Shea
- Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
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Sutter DE, Bradshaw LU, Simkins LH, Summers AM, Atha M, Elwood RL, Robertson JL, Murray CK, Wortmann GW, Hospenthal DR. High incidence of multidrug-resistant gram-negative bacteria recovered from Afghan patients at a deployed US military hospital. Infect Control Hosp Epidemiol 2012; 32:854-60. [PMID: 21828965 DOI: 10.1086/661284] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate potential sources and risks associated with multidrug-resistant (MDR) bacteria in a deployed US military hospital. DESIGN Retrospective analysis of factors associated with recovery of MDR bacteria, supplemented by environmental sampling. SETTING The largest US military hospital in Afghanistan. PATIENTS US and Afghan patients with positive bacterial culture results, from September 2007 through August 2008. METHODS Microbiologic, demographic, and clinical data were analyzed. Potential risk factors included admission diagnosis or mechanism of injury, length of stay, gender, age, and nationality (US or Afghan). Environmental sampling of selected hospital high-touch surfaces and equipment was performed to help elucidate whether environmental MDR bacteria were contributing to nosocomial spread. RESULTS A total of 266 patients had 411 bacterial isolates that were identified during the study period, including 211 MDR bacteria (51%). Gram-negative bacteria were common among Afghan patients (241 [76%] of 319), and 70% of these were classified as MDR. This included 58% of bacteria recovered from Afghan patients within 48 hours of hospital admission. The most common gram-negative bacteria were Escherichia coli (53% were MDR), Acinetobacter (90% were MDR), and Klebsiella (63% were MDR). Almost one-half of potential extended-spectrum β-lactamase (ESBL) producers were community acquired. Of 100 environmental swab samples, 18 yielded MDR bacteria, including 10 that were Acinetobacter, but no potential ESBL-producing bacteria. CONCLUSIONS Gram-negative bacteria from Afghan patients had high rates of antimicrobial resistance. Patients experiencing complex trauma and prolonged hospital stays likely contribute to the presence of MDR bacteria in this facility. However, many of these patients had community-acquired cases, which implies high rates of colonization prior to hospital admission.
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Affiliation(s)
- Deena E Sutter
- Department of Pediatrics, Wilford Hall Medical Center, Lackland Air Force Base, TX, USA.
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