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Danielsen AS, Franconeri L, Page S, Myhre AE, Tornes RA, Kacelnik O, Bjørnholt JV. Clinical outcomes of antimicrobial resistance in cancer patients: a systematic review of multivariable models. BMC Infect Dis 2023; 23:247. [PMID: 37072711 PMCID: PMC10114324 DOI: 10.1186/s12879-023-08182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/17/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Infections are major causes of disease in cancer patients and pose a major obstacle to the success of cancer care. The global rise of antimicrobial resistance threatens to make these obstacles even greater and hinder continuing progress in cancer care. To prevent and handle such infections, better models of clinical outcomes building on current knowledge are needed. This internally funded systematic review (PROSPERO registration: CRD42021282769) aimed to review multivariable models of resistant infections/colonisations and corresponding mortality, what risk factors have been investigated, and with what methodological approaches. METHODS We employed two broad searches of antimicrobial resistance in cancer patients, using terms associated with antimicrobial resistance, in MEDLINE and Embase through Ovid, in addition to Cinahl through EBSCOhost and Web of Science Core Collection. Primary, observational studies in English from January 2015 to November 2021 on human cancer patients that explicitly modelled infection/colonisation or mortality associated with antimicrobial resistance in a multivariable model were included. We extracted data on the study populations and their malignancies, risk factors, microbial aetiology, and methods for variable selection, and assessed the risk of bias using the NHLBI Study Quality Assessment Tools. RESULTS Two searches yielded a total of 27,151 unique records, of which 144 studies were included after screening and reading. Of the outcomes studied, mortality was the most common (68/144, 47%). Forty-five per cent (65/144) of the studies focused on haemato-oncological patients, and 27% (39/144) studied several bacteria or fungi. Studies included a median of 200 patients and 46 events. One-hundred-and-three (72%) studies used a p-value-based variable selection. Studies included a median of seven variables in the final (and largest) model, which yielded a median of 7 events per variable. An in-depth example of vancomycin-resistant enterococci was reported. CONCLUSIONS We found the current research to be heterogeneous in the approaches to studying this topic. Methodological choices resulting in very diverse models made it difficult or even impossible to draw statistical inferences and summarise what risk factors were of clinical relevance. The development and adherence to more standardised protocols that build on existing literature are urgent.
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Affiliation(s)
- Anders Skyrud Danielsen
- Department of Microbiology, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Léa Franconeri
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
- ECDC Fellowship Programme, Field Epidemiology Path (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Samantha Page
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ragnhild Agathe Tornes
- The Library for the Healthcare Administration, Norwegian Institute of Public Health, Oslo, Norway
| | - Oliver Kacelnik
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Jørgen Vildershøj Bjørnholt
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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2
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Recent Approaches for Downplaying Antibiotic Resistance: Molecular Mechanisms. BIOMED RESEARCH INTERNATIONAL 2023; 2023:5250040. [PMID: 36726844 PMCID: PMC9886476 DOI: 10.1155/2023/5250040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
Antimicrobial resistance (AMR) is a ubiquitous public health menace. AMR emergence causes complications in treating infections contributing to an upsurge in the mortality rate. The epidemic of AMR in sync with a high utilization rate of antimicrobial drugs signifies an alarming situation for the fleet recovery of both animals and humans. The emergence of resistant species calls for new treatments and therapeutics. Current records propose that health drug dependency, veterinary medicine, agricultural application, and vaccination reluctance are the primary etymology of AMR gene emergence and spread. Recently, several encouraging avenues have been presented to contest resistance, such as antivirulent therapy, passive immunization, antimicrobial peptides, vaccines, phage therapy, and botanical and liposomal nanoparticles. Most of these therapies are used as cutting-edge methodologies to downplay antibacterial drugs to subdue the resistance pressure, which is a featured motive of discussion in this review article. AMR can fade away through the potential use of current cutting-edge therapeutics, advancement in antimicrobial susceptibility testing, new diagnostic testing, prompt clinical response, and probing of new pharmacodynamic properties of antimicrobials. It also needs to promote future research on contemporary methods to maintain host homeostasis after infections caused by AMR. Referable to the microbial ability to break resistance, there is a great ultimatum for using not only appropriate and advanced antimicrobial drugs but also other neoteric diverse cutting-edge therapeutics.
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3
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Lactobacillus supports Clostridiales to restrict gut colonization by multidrug-resistant Enterobacteriaceae. Nat Commun 2022; 13:5617. [PMID: 36153315 PMCID: PMC9509339 DOI: 10.1038/s41467-022-33313-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
Infections by multidrug-resistant Enterobacteriaceae (MRE) are life-threatening to patients. The intestinal microbiome protects against MRE colonization, but antibiotics cause collateral damage to commensals and open the way to colonization and subsequent infection. Despite the significance of this problem, the specific commensals and mechanisms that restrict MRE colonization remain largely unknown. Here, by performing a multi-omic prospective study of hospitalized patients combined with mice experiments, we find that Lactobacillus is key, though not sufficient, to restrict MRE gut colonization. Lactobacillus rhamnosus and murinus increase the levels of Clostridiales bacteria, which induces a hostile environment for MRE growth through increased butyrate levels and reduced nutrient sources. This mechanism of colonization resistance, an interaction between Lactobacillus spp. and Clostridiales involving cooperation between microbiota members, is conserved in mice and patients. These results stress the importance of exploiting microbiome interactions for developing effective probiotics that prevent infections in hospitalized patients. Multidrug-resistant Enterobacteriaceae (MRE) represent a major threat for patients’ health. Here, the authors describe how cooperation between gut commensal bacteria (Lactobacillus spp. And Clostridiales) restrict MRE colonization in mice and patients
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4
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Szychowiak P, Villageois-Tran K, Patrier J, Timsit JF, Ruppé É. The role of the microbiota in the management of intensive care patients. Ann Intensive Care 2022; 12:3. [PMID: 34985651 PMCID: PMC8728486 DOI: 10.1186/s13613-021-00976-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.
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Affiliation(s)
- Piotr Szychowiak
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, 37000, Tours, France
| | - Khanh Villageois-Tran
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Laboratoire de Bactériologie, AP-HP, Hôpital Beaujon, 92110, Paris, France
| | - Juliette Patrier
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Jean-François Timsit
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Étienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.
- Laboratoire de Bactériologie, AP-HP, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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5
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Zahar JR, Blot S, Nordmann P, Martischang R, Timsit JF, Harbarth S, Barbier F. Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies. Clin Infect Dis 2020; 68:2125-2130. [PMID: 30312366 DOI: 10.1093/cid/ciy864] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022] Open
Abstract
The rising burden of intensive care unit (ICU)-acquired infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) strengthens the requirement for efficient prevention strategies. The detection of intestinal carriage of ESBL-E through active surveillance cultures (ASC) and the implementation of contact precautions (CP) in carriers are currently advocated in most high-income countries, to prevent cross-transmission and subsequent ESBL-E infections in critically-ill patients. Yet, recent studies have challenged the benefit of ASC and CP in controlling the spread of ESBL-E in ICUs with high compliance to standard hygiene precautions and no ongoing outbreak of ESBL-producing Klebsiella pneumoniae or Enterobacter spp. Besides, given their debated performance to positively predict which patients are at risk of ESBL-E infections, ASC results appear of limited value to rationalize the empirical use of carbapenems in the ICU, emphasizing the urgent need for novel anticipatory and diagnostic approaches. This Viewpoint article summarizes the available evidence on these issues.
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Affiliation(s)
- Jean-Ralph Zahar
- Infection Control Unit, Avicenne University Hospital, Assistance Publique - Hôpitaux de Paris, Bobigny.,INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France
| | - Stijn Blot
- Department of Internal Medicine, Ghent University, Belgium.,Burns, Trauma and Critical Care Research Centre, Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Patrice Nordmann
- Medical and Molecular Microbiology Unit, Department of Medicine, Faculty of Science, INSERM European Unit.,Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg.,Institute for Microbiology, University of Lausanne and University Hospital Centre
| | - Romain Martischang
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Jean-François Timsit
- INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France.,Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, APHP, Paris
| | - Stephan Harbarth
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, Orléans, France
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6
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Lalaoui R, Javelle E, Bakour S, Ubeda C, Rolain JM. Infections Due to Carbapenem-Resistant Bacteria in Patients With Hematologic Malignancies. Front Microbiol 2020; 11:1422. [PMID: 32765433 PMCID: PMC7379235 DOI: 10.3389/fmicb.2020.01422] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022] Open
Abstract
In developed countries, hematological malignancies (HM) account for 8 to 10% of cancers diagnosed annually and one-third of patients with HM (HMP) are expected to die from their disease. The former wide spectrum “magic bullet,” imipenem, has been ousted by the emergence of carbapenem resistant (CR) pathogens. In endemic areas, infections with CR-bacteria occur in vulnerable patients, notably in HMP, who suffer from high mortality related to infectious complications. In this work, we reviewed epidemiologic and clinical factors associated with CR-infections in adult HMP and data on CR-related mortality and antibiotic treatments in this population. We found that resistance profile of strains involved in HMP infections, mainly bacteremia, reflect local epidemiology. Significant risk factors for infections with CR-bacteria include sex male, age around 50 years old, acute leukemia, selvage chemotherapy, neutropenia, and digestive colonization by CR-bacteria. Mortality rate is high in HMP infected with CR-Enterobacteriaceae, more particularly in case of acute myeloid leukemia and unresolved neutropenia, due to inappropriate empiric management and delayed administration of targeted antibiotics, such as tigecycline, colistin, or new associations of active drugs. Thus, we developed an algorithm for clinicians, assessing the incremental risk for CR-bacterial infection occurrence and mortality in febrile HMP, to guide decisions related to empirical therapeutic strategies.
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Affiliation(s)
- Rym Lalaoui
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Emilie Javelle
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France.,Laveran Military Teaching Hospital, Marseille, France
| | - Sofiane Bakour
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Carles Ubeda
- Centro Superior de Investigación en Salud Pública, FISABIO, Valencia, Spain.,Centers of Biomedical Research Network (CIBER), Epidemiology and Public Health, Madrid, Spain
| | - Jean-Marc Rolain
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
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7
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Niehus R, van Kleef E, Mo Y, Turlej-Rogacka A, Lammens C, Carmeli Y, Goossens H, Tacconelli E, Carevic B, Preotescu L, Malhotra-Kumar S, Cooper BS. Quantifying antibiotic impact on within-patient dynamics of extended-spectrum beta-lactamase resistance. eLife 2020; 9:e49206. [PMID: 32379042 PMCID: PMC7205461 DOI: 10.7554/elife.49206] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 03/22/2020] [Indexed: 12/22/2022] Open
Abstract
Antibiotic-induced perturbation of the human gut flora is expected to play an important role in mediating the relationship between antibiotic use and the population prevalence of antibiotic resistance in bacteria, but little is known about how antibiotics affect within-host resistance dynamics. Here we develop a data-driven model of the within-host dynamics of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae. We use blaCTX-M (the most widespread ESBL gene family) and 16S rRNA (a proxy for bacterial load) abundance data from 833 rectal swabs from 133 ESBL-positive patients followed up in a prospective cohort study in three European hospitals. We find that cefuroxime and ceftriaxone are associated with increased blaCTX-M abundance during treatment (21% and 10% daily increase, respectively), while treatment with meropenem, piperacillin-tazobactam, and oral ciprofloxacin is associated with decreased blaCTX-M (8% daily decrease for all). The model predicts that typical antibiotic exposures can have substantial long-term effects on blaCTX-M carriage duration.
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Affiliation(s)
| | - Esther van Kleef
- National Institute for Public Health and theEnvironmentBilthovenNetherlands
| | - Yin Mo
- University of OxfordOxfordUnited Kingdom
| | | | | | | | | | - Evelina Tacconelli
- University of TuebingenTuebingenGermany
- Infectious Diseases, University of VeronaVeronaItaly
| | | | - Liliana Preotescu
- Matei Balş National Institute for Infectious DiseasesBucharestRomania
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8
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Andremont O, Armand-Lefevre L, Dupuis C, de Montmollin E, Ruckly S, Lucet JC, Smonig R, Magalhaes E, Ruppé E, Mourvillier B, Lebut J, Lermuzeaux M, Sonneville R, Bouadma L, Timsit JF. Semi-quantitative cultures of throat and rectal swabs are efficient tests to predict ESBL-Enterobacterales ventilator-associated pneumonia in mechanically ventilated ESBL carriers. Intensive Care Med 2020; 46:1232-1242. [PMID: 32313993 PMCID: PMC7222166 DOI: 10.1007/s00134-020-06029-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/26/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE In ICU patients with carriage of extended spectrum beta-lactamase producing Enterobacterales (ESBL-E) and suspected Gram-negative bacilli ventilator-associated pneumonia (GNB-VAP), the quantification of the rectal and throat ESBL-E carriage might predict the ESBL-E involvement in GNB-VAP. Our aim was to evaluate whether a semi-quantitative assessment of rectal/throat ESBL-E carriage can predict ESBL-E-associated VAP in medical ICU patients. METHODS From May 2014 to May 2017, all ESBL-E carriers had a semi-quantitative assessment of ESBL-E density in swabs cultures. For those who developed GNB-VAP (diagnosed using bronchoalveolar lavage or plugged telescopic catheter with significant quantitative culture), the last positive swab collected at least 48 h before GNB-VAP onset was selected. Clinical data were extracted from a prospectively collected database. RESULTS Among 365 ESBL-E carriers, 82 developed 107 episodes of GNB-VAP (ESBL-E VAP, n = 50; and non-ESBL-E GNB-VAP, n = 57) after 13 days of mechanical ventilation in median. Antimicrobials use before VAP onset was similar between groups. The last swabs were collected 5 days in median before VAP onset. ESBL-E. coli carriers developed ESBL-E VAP less frequently (n = 13, 34%) than others (n = 32, 67.3%, p < .01). Throat swab positivity (39 (78%) vs. 12 (23%), p < .01) was more frequent for ESBL-E VAP. ESBL-E VAP was associated with significantly higher ESBL-E density in rectal swabs. In multivariate models, non-E. coli ESBL-E carriage and rectal ESBL-E carriage density, or throat carriage, remained associated with ESBL-E VAP. CONCLUSION In carriers of ESBL-E other than E. coli, ESBL-E throat carriage or a high-density ESBL-E rectal carriage are risk factors of ESBL-E VAP in case of GNB-VAP.
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Affiliation(s)
- Olivier Andremont
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Laurence Armand-Lefevre
- UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Bacteriological Department, Bichat-Claude Bernard university hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Claire Dupuis
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Etienne de Montmollin
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | - Roland Smonig
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eric Magalhaes
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Etienne Ruppé
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Bacteriological Department, Bichat-Claude Bernard university hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bruno Mourvillier
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jordane Lebut
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mathilde Lermuzeaux
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Sonneville
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1148, Laboratory for Vascular and Translational Science, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France. .,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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9
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High Heterogeneity of Multidrug-Resistant Enterobacteriaceae Fecal Levels in Hospitalized Patients Is Partially Driven by Intravenous β-Lactams. Antimicrob Agents Chemother 2020; 64:AAC.01415-19. [PMID: 31767720 DOI: 10.1128/aac.01415-19] [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: 07/15/2019] [Accepted: 11/12/2019] [Indexed: 11/20/2022] Open
Abstract
Multidrug-resistant Enterobacteriaceae (MRE) colonize the intestine asymptomatically from where they can breach into the bloodstream and cause life-threatening infections, especially in heavily colonized patients. Despite the clinical relevance of MRE colonization levels, we know little about how they vary in hospitalized patients and the clinical factors that determine those levels. Here, we conducted one of the largest studies of MRE fecal levels by tracking longitudinally 133 acute leukemia patients and monitoring their MRE levels over time through extensive culturing. MRE were defined as Enterobacteriaceae species that acquired nonsusceptibility to ≥1 agent in ≥3 antimicrobial categories. In addition, due to the selective media used, the MRE had to be resistant to third-generation cephalosporins. MRE were detected in 60% of the patients, but their fecal levels varied considerably among patients and within the same patient (>6 and 4 orders of magnitude, respectively). Multivariate analysis of clinical metadata revealed an impact of intravenous beta-lactams (i.e., meropenem and piperacillin-tazobactam), which significantly diminished the fecal MRE levels in hospitalized patients. Consistent with a direct action of beta-lactams, we found an effect only when the patient was colonized with strains sensitive to the administered beta-lactam (P < 0.001) but not with nonsusceptible strains. We report previously unobserved inter- and intraindividual heterogeneity in MRE fecal levels, suggesting that quantitative surveillance is more informative than qualitative surveillance of hospitalized patients. In addition, our study highlights the relevance of incorporating antibiotic treatment and susceptibility data of gut-colonizing pathogens for future clinical studies and in clinical decision-making.
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10
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Bassetti M, Poulakou G, Ruppe E, Bouza E, Van Hal SJ, Brink A. Antimicrobial resistance in the next 30 years, humankind, bugs and drugs: a visionary approach. Intensive Care Med 2017; 43:1464-1475. [PMID: 28733718 DOI: 10.1007/s00134-017-4878-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/24/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To describe the current standards of care and major recent advances with regard to antimicrobial resistance (AMR) and to give a prospective overview for the next 30 years in this field. METHODS Review of medical literature and expert opinion were used in the development of this review. RESULTS There is undoubtedly a large clinical and public health burden associated with AMR in ICU, but it is challenging to quantify the associated excess morbidity and mortality. In the last decade, antibiotic stewardship and infection prevention and control have been unable to prevent the rapid spread of resistant Gram-negative bacteria (GNB), in particular carbapenem-resistant Pseudomonas aeruginosa (and other non-fermenting GNB), extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacteriaceae (CRE). The situation appears more optimistic currently for Gram-positive, where Staphylococcus aureus, and particularly methicillin-resistant S. aureus (MRSA), remains a cardinal cause of healthcare-associated infections worldwide. Recent advancements in laboratory techniques allow for a rapid identification of the infecting pathogen and antibiotic susceptibility testing. Their impact can be particularly relevant in settings with prevalence of MDR, since they may guide fine-tuning of empirically selected regimen, facilitate de-escalation of unnecessary antimicrobials, and support infection control decisions. Currently, antibiotics are the primary anti-infective solution for patients with known or suspected MDR bacteria in intensive care. Numerous incentives have been provided to encourage researchers to work on alternative strategies to reverse this trend and to provide a means to treat these pathogens. Although some promising antibiotics currently in phase 2 and 3 of development will soon be licensed and utilized in ICU, the continuous development of an alternative generation of compounds is extremely important. There are currently several promising avenues available to fight antibiotic resistance, such as faecal microbiota, and phage therapy.
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Affiliation(s)
- Matteo Bassetti
- Department of Medicine, Infectious Diseases Clinic, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale S. Maria Della Misericordia 15, 33100, Udine, Italy.
| | - Garyphallia Poulakou
- Fourth Department of Internal Medicine, School of Medicine, Attikon University General Hospital, Athens National and Kapodistrian University, 1 Rimini St, 12462, Athens, Greece
| | - Etienne Ruppe
- Genomic Research Laboratory, Division of Infectious Diseases, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Sebastian J Van Hal
- Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Adrian Brink
- Ampath National Laboratory Services, Department of Clinical Microbiology, Milpark Hospital, Johannesburg, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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