1
|
Heath MR, Fan W, Leu CS, Gomez-Simmonds A, Lodise T, Freedberg DE. Gut colonization with multidrug resistant organisms in the intensive care unit: a systematic review and meta-analysis. Crit Care 2024; 28:211. [PMID: 38943133 PMCID: PMC11214232 DOI: 10.1186/s13054-024-04999-9] [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: 04/29/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Gut colonization with multidrug-resistant organisms (MDRO) frequently precedes infection among patients in the intensive care unit (ICU), although the dynamics of colonization are not completely understood. We performed a systematic review and meta-analysis of ICU studies which described the cumulative incidence and rates of MDRO gut acquisition. METHODS We systematically searched PubMed, Embase, and Web of Science for studies published from 2010 to 2023 reporting on gut acquisition of MDRO in the ICU. MDRO were defined as multidrug resistant non-Pseudomonas Gram-negative bacteria (NP-GN), Pseudomonas spp., and vancomycin-resistant Enterococcus (VRE). We included observational studies which obtained perianal or rectal swabs at ICU admission (within 48 h) and at one or more subsequent timepoints. Our primary outcome was the incidence rate of gut acquisition of MDRO, defined as any MDRO newly detected after ICU admission (i.e., not present at baseline) for all patient-time at risk. The study was registered with PROSPERO, CRD42023481569. RESULTS Of 482 studies initially identified, 14 studies with 37,305 patients met criteria for inclusion. The pooled incidence of gut acquisition of MDRO during ICU hospitalization was 5% (range: 1-43%) with a pooled incidence rate of 12.2 (95% CI 8.1-18.6) per 1000 patient-days. Median time to acquisition ranged from 4 to 26 days after ICU admission. Results were similar for NP-GN and Pseudomonas spp., with insufficient data to assess VRE. Among six studies which provided sufficient data to perform curve fitting, there was a quasi-linear increase in gut MDRO colonization of 1.41% per day which was stable through 30 days of ICU hospitalization (R2 = 0.50, p < 0.01). CONCLUSIONS Acquisition of gut MDRO was common in the ICU and increases with days spent in ICU through 30 days of follow-up. These data may guide future interventions seeking to prevent gut acquisition of MDRO in the ICU.
Collapse
Affiliation(s)
- Madison R Heath
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Weijia Fan
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Cheng-Shiun Leu
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Angela Gomez-Simmonds
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA.
| |
Collapse
|
2
|
Shinde AS, Kapoor D. Infections After Liver Transplant -Timeline, Management and Prevention. J Clin Exp Hepatol 2024; 14:101316. [PMID: 38264574 PMCID: PMC10801311 DOI: 10.1016/j.jceh.2023.101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplantation (LT) is the standard treatment for end- stage liver disease. Patient and graft survival have improved significantly in the last three decades owing to improvement in surgical technique, better perioperative management and better immunosuppressive regimens. However, LT recipients are at increased risk of infections, particularly in the first year after transplantation. The risk of infection is directly proportional to immunosuppressive regimen and graft function. In this review, we will briefly discuss the timeline of infections after liver transplant, preventive strategies and management of infectious complications.
Collapse
Affiliation(s)
- Ajay S. Shinde
- Consultant Gastroenterologist and Hepatologist, Yashoda Hospitals, Secunderabad, Telangana, India
| | - Dharmesh Kapoor
- Consultant Hepatologist, Yashoda Hospitals, Secunderabad, Telangana, India
| |
Collapse
|
3
|
Mak JT, Ha S, Perloff S, Knorr JP. Perioperative daptomycin for prophylaxis of vancomycin-resistant Enterococcus infection in colonized liver transplant recipients. Transpl Infect Dis 2024; 26:e14186. [PMID: 37910593 DOI: 10.1111/tid.14186] [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: 06/06/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Infection with vancomycin-resistant Enterococcus (VRE) in liver transplant recipients (LTR) has been associated with extended hospital stays, increased readmission rates, graft failure, and death. A tailored perioperative surgical prophylaxis regimen targeting VRE may reduce postoperative infections in VRE-colonized patients. This study investigated the outcomes of perioperative daptomycin in this patient population. METHODS This retrospective, single-center cohort study included LTR ≥ 18 years old who were VRE-colonized from June 2018 to November 2022. VRE colonization was identified by a VRE rectal swab screen or a positive VRE culture prior to transplant. Two groups were analyzed: daptomycin versus no daptomycin. All LTR received perioperative piperacillin-tazobactam for 24 h. If VRE-colonized, one dose of daptomycin (6 mg/kg) was given pre- and postoperatively. Demographics, clinical characteristics, risk factors for VRE infection, and daptomycin dose were collected. The primary outcome was VRE infection at 14 days and 90 days post-transplant. RESULTS There were 36 VRE-colonized LTR; 19 received daptomycin and 17 did not. Baseline characteristics and risk factors for VRE infection were similar between groups. More VRE infections occurred in the no daptomycin group within 14 days post-transplant (24% vs. 0%, p = .04), but at 90 days posttransplant there was no significant difference (29% vs. 16%, p = .43). The average daptomycin dose was 7.1 mg/kg. CONCLUSION Perioperative daptomycin reduced the rate of VRE infections in VRE-colonized LTR within 14 days posttransplant but not at 90 days. Future studies should evaluate if higher doses and/or longer duration of perioperative daptomycin can reduce VRE infections beyond 14 days post-transplant.
Collapse
Affiliation(s)
- Jordan T Mak
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - Seung Ha
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - Sarah Perloff
- Department of Internal Medicine, Division of Infectious Diseases, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - John P Knorr
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Mascellino MT, Biswas S, Oliva A. Editorial: Enterobacteriaceae antimicrobial agents and resistance: relationship with the therapeutic approach, volume II. Front Cell Infect Microbiol 2024; 14:1356413. [PMID: 38304194 PMCID: PMC10830809 DOI: 10.3389/fcimb.2024.1356413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Affiliation(s)
| | - Silpak Biswas
- Department of Microbiology, School of Tropical Medicine, Kolkata, India
| | - Alessandra Oliva
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| |
Collapse
|
5
|
Fiore M, Corrente A, Di Franco S, Alfieri A, Pace MC, Martora F, Petrou S, Mauriello C, Leone S. Antimicrobial approach of abdominal post-surgical infections. World J Gastrointest Surg 2023; 15:2674-2692. [PMID: 38222012 PMCID: PMC10784838 DOI: 10.4240/wjgs.v15.i12.2674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/24/2023] [Accepted: 11/21/2023] [Indexed: 12/27/2023] Open
Abstract
Abdominal surgical site infections (SSIs) are infections that occur after abdominal surgery. They can be superficial, involving the skin tissue only, or more profound, involving deeper skin tissues including organs and implanted materials. Currently, SSIs are large global health problem with an incidence that varies significantly depending on the United Nations' Human Development Index. The purpose of this review is to provide a practical update on the latest available literature on SSIs, focusing on causative pathogens and treatment with an overview of the ongoing studies of new therapeutic strategies.
Collapse
Affiliation(s)
- Marco Fiore
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
| | - Antonio Corrente
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
| | - Sveva Di Franco
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
| | - Aniello Alfieri
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
| | - Maria Caterina Pace
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples 80138, Italy
| | - Francesca Martora
- Unit of Virology and Microbiology, “Umberto I” Hospital, Nocera Inferiore 84018, Italy
| | - Stephen Petrou
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA 94143, United States
| | - Claudio Mauriello
- Department of General Surgery, “Santa Maria delle Grazie” Hospital, Pozzuoli 80078, Italy
| | - Sebastiano Leone
- Division of Infectious Diseases, “San Giuseppe Moscati” Hospital, Avellino 83100, Italy
| |
Collapse
|
6
|
Shang C, Yang R, Yang Y, Zhang H, Zhang J, Xia Q, Gao Y, Deng Y. Colonization of extended-spectrum β-lactamase-producing Enterobacteriaceae does not affect subsequent infection and liver transplant outcomes: a retrospective observational cohort study. Front Public Health 2023; 11:1207889. [PMID: 37794888 PMCID: PMC10546942 DOI: 10.3389/fpubh.2023.1207889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/29/2023] [Indexed: 10/06/2023] Open
Abstract
Objective To investigate the colonization rate of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E), subsequent infections by ESBL-E and ESBL-producing gram-negative bacilli (ESBL-GNB), and the effect of ESBL-E colonization on clinical outcomes in liver transplantation (LT) recipients. Methods This is a retrospective cohort study that included patients who underwent LT at Shanghai Renji Hospital between July 2016 and December 2017. Rectal swabs from LT patients at the postoperative ICU enrollment were screened anonymously for ESBL-E carriage. Demographics data, laboratory indexes, operative complications, and clinical course information were also obtained. The extent of ESBL-E colonization, the subsequent infection rates of ESBL-E and ESBL-GNB, and the clinical outcomes were compared between ESBL-E colonized and non-colonized patients. Results In total, 496 liver transplant recipients (387 males) were included in this study. ESBL-E colonization was detected in 240 patients (48.4%). There was no significant difference between the rates of ESBL-E infection (5.8 vs. 3.1%, p = 0.143), Ischemia-reperfusion ≥ 3 (27.9 vs. 24.6%, p = 0.403), acute kidney injury (39.6 vs. 38.7%, p = 0.835), acute rejection (2.1 vs. 1.6%, p = 0.664), graft versus host reaction (1.3 vs. 1.2%, p = 0.937), duration of hospitalization (22 vs. 23 days, p = 0.568), 90-day mortality (7.1 vs. 4.7%, p = 0.262) and 1-year mortality (12.9 vs. 9.3%, p = 0.265) in patients with and without ESBL-E colonization. Though the ESBL-GNB infection rate was higher in ESBL-E colonized patients (12.1 vs. 6.6%, p = 0.037), multivariate analysis showed that ESBL-E colonization did not increase the risk of ESBL-GNB infection (Model 1: aOR 1.755, 95% CI: 0.911-3.380, p = 0.093; Model 2: aOR 1.556, 95% CI: 0.761-3.181, p = 0.226). The ESBL-producing bacteria spectrum of colonization was significantly different from that of infections occurring after LT, with only three colonization events leading to infection by the same pathogen identified. Conclusion ESBL-E colonization in liver transplant patients is not associated with ESBL-E infection, nor is it a risk factor for post-transplant ESBL-GNB infection. Additionally, ESBL-E colonization does not lead to worse prognoses when compared with non-colonized patients. Clinical trial registration Chinese Clinical Trial Registry, Identifier [ChiCTR2100043034].
Collapse
Affiliation(s)
- Chen Shang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Run Yang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ya Yang
- Department of Infection Control, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haomin Zhang
- Department of Laboratory Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuxiao Deng
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
7
|
Liu M, Li C, Liu J, Wan Q. Risk factors of early bacterial infection and analysis of bacterial composition, distribution and drug susceptibility after cadaveric liver transplantation. Ann Clin Microbiol Antimicrob 2023; 22:63. [PMID: 37525234 PMCID: PMC10391978 DOI: 10.1186/s12941-023-00616-9] [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: 04/26/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND This study provided a theoretical basis for the clinical diagnosis and treatment of bacterial infection after liver transplantation through analyzing the pathogenic distribution, drug sensitivity and risk factors of bacterial infection after liver transplantation. METHODS We collected clinical data from 207 recipients undergoing liver transplantation of graft from donation after citizens' death donors in the Third Xiangya Hospital of Central South University from January 2019 to December 2021 and analyzed the composition and distribution of bacterial pathogens, drug resistance and risk factors of infection. RESULTS A total of 90 bacterial infections occurred in 55 recipients within two months after liver transplantation, and the incidence of bacterial infection was 26.6% (55/207). The gram-negative bacteria (46/90, 51.1%) were more prevalent than gram-positive bacteria (44/90, 48.9%). Common sites of infection were the abdominal/biliary tract (26/90, 28.9%), lung (22/90, 22.4%) and urinary tract (22/90, 22.4%). Fourteen cases (6.8%) died after liver transplantation. Klebsiella pneumoniae (17/90, 18.9%) was the most frequent gram-negative bacteria causing infection in liver transplant recipients and 58.7%, 50%, 80.4% and 89.1% of gram-negative bacteria were sensitive to amikacin, minocycline, tigecycline and polymyxin B, respectively. The most common gram-positive bacteria was Enterococcus faecium (30/90, 33.3%) and 97.7%, 100%, 86.4%, 100% and 100% of gram-positive bacteria were sensitive to vancomycin, teicoplanin, daptomycin, tigecycline and linezolid, respectively. Univariate analysis revealed that bacterial infection was associated with female, age (≥ 50 years old), preoperative albumin (≤ 30 g/L), operation duration (≥ 400 min), intraoperative blood loss (≥ 3000 ml) and postoperative ventilator support. Binary Logistic regression analysis showed that female (OR = 3.149, 95% CI: 1.418-6.993, P = 0.005), operation duration (≥ 400 min) (OR = 2.393, 95% CI: 1.202-4.765, P = 0.013) and intraoperative blood loss (≥ 3000 ml) (OR = 2.052, 95% CI: 1.007-4.183, P = 0.048) were independent risk factors for bacterial infection after liver transplantation. CONCLUSION The incidence of early bacterial infection after liver transplantation was high, and the infection sites were mainly abdominal/biliary tract, respiratory tract and urinary tract. The most common pathogenic bacterium was gram-negative bacterium. Our study also identified several independent risk factors for bacterial infection after liver transplantation, including female gender, operation duration of 400 min or more, and intraoperative blood loss of 3000 ml or more. By addressing these risk factors, such as implementing strategies to optimize surgical procedures and minimize blood loss, healthcare professionals can work towards reducing the incidence of bacterial infections following liver transplantation.
Collapse
Affiliation(s)
- Min Liu
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
| | - Cuiying Li
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
| | - Jing Liu
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, the Third Xiangya Hospital, Central South University, 410013, Changsha, China
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, 410013, Changsha, China.
- Engineering and Technology Research Center for Transplantation Medicine of National Health Commission, the Third Xiangya Hospital, Central South University, 410013, Changsha, China.
| |
Collapse
|
8
|
Fernández A, Díez-Picazo C, Iglesias Sobrino C, Trueba Collado C, Romero Cristóbal M, Díaz Fontenla F, Caballero Marcos A, Valerio M, Olmedo M, Vicente Rangel T, Padilla Ortega B, Ramos R, López Baena JÁ, Muñoz P, Bañares R, Salcedo M. Implementation and impact of an antibiotic control program and multidrug-resistant bacterial colonization in a liver transplant unit. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:357-361. [PMID: 35638756 DOI: 10.17235/reed.2022.8810/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
INTRODUCTION infections by multidrug-resistant bacteria are a major cause of morbidity and mortality in transplant patients. OBJECTIVE a retrospective single-center study was performed to evaluate the implementation of an Antimicrobial Treatment Optimization Program (PROA) on multidrug-resistant bacteria colonization and infection after liver transplant (LT). METHODS colonization by multidrug-resistant bacteria and infections during the first year after a liver transplant were analyzed in a group of 76 transplanted patients in two stages, before and after PROA (2016-2019). Clinical variables related to infection, readmissions and survival one year after the liver transplant were analyzed. RESULTS there was good adherence to the PROA. Infection was the most frequent cause for readmission during the first year after the liver transplant. Incidence of infections was similar during both periods (mean of 1.25 and 1.5 episodes of bacterial infection per patient/year, respectively) with 19 bacterial infectious episodes, six by hospital-acquired multidrug-resistant and extensively drug-resistant (MDR-XDR) bacteria in the pre-PROA stage, and 18 bacterial infectious episodes, five by MDR-XDR in the post-PROA stage. A 37 % decrease of post-TH of rectal colonization by MDR-XDR after liver transplant was observed during 2019. CONCLUSIONS epidemiological surveillance policies and antibiotic optimization are key to control the increase of colonization and infection by multidrug-resistant bacteria in liver transplant units. Long-term studies are needed to better evaluate the impact of these programs.
Collapse
Affiliation(s)
- Ainhoa Fernández
- Aparato Digestivo, Hospital General Universitario Gregorio Marañón, ESPAÑA
| | | | | | | | | | | | | | - Maricela Valerio
- Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón
| | - María Olmedo
- Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón
| | - Teresa Vicente Rangel
- Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón
| | - Belén Padilla Ortega
- Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón
| | - Rafael Ramos
- Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón
| | - José Ángel López Baena
- Cirugía Biliopancreática y Trasplante Hepático, Hospital General Universitario Gregorio Marañón
| | - Patricia Muñoz
- Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón
| | - Rafael Bañares
- Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | | |
Collapse
|
9
|
Dolci G, Burastero GJ, Paglia F, Cervo A, Meschiari M, Guaraldi G, Chester J, Mussini C, Franceschini E. Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review. Microorganisms 2023; 11:1606. [PMID: 37375108 DOI: 10.3390/microorganisms11061606] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections.
Collapse
Affiliation(s)
- Giovanni Dolci
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giulia Jole Burastero
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Francesca Paglia
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Adriana Cervo
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Johanna Chester
- Department of Dermatology, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| |
Collapse
|
10
|
Willems RPJ, van Dijk K, Vehreschild MJGT, Biehl LM, Ket JCF, Remmelzwaal S, Vandenbroucke-Grauls CMJE. Incidence of infection with multidrug-resistant Gram-negative bacteria and vancomycin-resistant enterococci in carriers: a systematic review and meta-regression analysis. THE LANCET. INFECTIOUS DISEASES 2023; 23:719-731. [PMID: 36731484 DOI: 10.1016/s1473-3099(22)00811-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/17/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Carriers of multidrug-resistant bacteria are at risk of infections with these bacteria; the precise size of this risk is unclear. We aimed to quantify the effect of gut colonisation on subsequent risk of infection with multidrug-resistant bacteria. METHODS We performed a systematic review and meta-regression analysis. We searched PubMed, Embase, Web of Science Core Collection, and Google Scholar for follow-up studies published from Jan 1, 1995, to March 17, 2022, that measured the incidence of infections with multidrug-resistant Gram-negative bacteria (MDR-GNB) and from Jan 1, 1995, to March 15, 2022, that measured the incidence of infections with vancomycin-resistant enterococci (VRE). We included original cohort studies and case-control studies that used incidence-density sampling, included 50 or more patients with enteric colonisation or positive urinary samples as a surrogate marker of colonisation, or both, and analysed infections clearly preceded by colonisation. We did not use any language restrictions. We excluded studies not reporting length of follow-up. Summary data were extracted and independently cross-verified by two authors. Carriage was defined as MDR-GNB or VRE, detected in faecal or urinary cultures. Our primary outcomes were cumulative incidence and incidence density of infection in patients colonised by multidrug-resistant bacteria. To estimate pooled incidences, general linearised mixed-effects meta-regressions were used, adjusting for varying follow-up durations. This study is registered with PROSPERO, CRD42020222415. FINDINGS Of the 301 studies identified, 44 studies (26 on MDR-GNB, 14 on VRE, and four on both MDR-GNB and VRE) from 14 countries were retained for qualitative synthesis, 40 of which were analysed with meta-regression, comprising data for 14 049 patients colonised with multidrug-resistant bacteria. The pooled cumulative incidence of infection was 14% (95% CI 10-18; p<0·0001) at a median follow-up time of 30 days for MDR-GNB (845 cases of infection in 9034 patients colonised) and 8% (5-13; p<0·0001) at 30 days for VRE (229 cases of infection in 4747 patients colonised). Infection incidence density (4·26 infections per 1000 patient-days; 95% CI 1·69-6·82) and cumulative incidence of infection (19%, 95% CI 15-25; p<0·0001; 602 cases of infection in 4547 patients colonised) were highest for carbapenem-resistant Gram-negative bacteria at 30 days. Risk of bias was rated low to moderate. INTERPRETATION The risk of infection was substantial, with the highest risk for patients colonised with carbapenem-resistant Gram-negative bacteria and the lowest in patients with VRE. These data might help to guide prophylactic and treatment decisions and form a valuable resource for planning clinical trials on targeted prevention. FUNDING The Netherlands Organization for Health Research and Development.
Collapse
Affiliation(s)
- Roel P J Willems
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands.
| | - Karin van Dijk
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany
| | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sharon Remmelzwaal
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam Infection and Immunity Institute, Amsterdam, Netherlands; Department of Clinical Medicine and Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| |
Collapse
|
11
|
Rathod SN, Bardowski L, Tse I, Churyla A, Fiehler M, Malczynski M, Qi C, Tanna SD, Bulger C, Al-Qamari A, Oakley R, Zembower TR. Vancomycin-resistant Enterococcus outbreak in a pre- and post-cardiothoracic transplant population: Impact of discontinuing multidrug-resistant organism surveillance during the coronavirus disease 2019 pandemic. Transpl Infect Dis 2022; 24:e13972. [PMID: 36169219 DOI: 10.1111/tid.13972] [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: 12/17/2021] [Revised: 08/31/2022] [Accepted: 09/16/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Many institutions suspended surveillance and contact precautions for multidrug-resistant organisms (MDROs) at the outset of the coronavirus disease 2019 (COVID-19) pandemic due to a lack of resources. Once our institution reinstated surveillance in September 2020, a vancomycin-resistant Enterococcus (VRE) faecium outbreak was detected in the cardiothoracic transplant units, a population in which we had not previously detected outbreaks. METHODS An outbreak investigation was conducted using pulsed-field gel electrophoresis for strain typing and electronic medical record review to determine the clinical characteristics of involved patients. The infection prevention (IP) team convened a multidisciplinary process improvement team comprised of IP, cardiothoracic transplant nursing and medical leadership, environmental services, and the microbiology laboratory. RESULTS Between December 2020 and March 2021, the outbreak involved thirteen patients in the cardiothoracic transplant units, four index cases, and nine transmissions. Of the 13, seven (54%) were on the transplant service, including heart and lung transplant recipients, patients with ventricular assist devices, and a patient on extracorporeal membrane oxygenation as a bridge to lung transplantation. Four of 13 (31%) developed a clinical infection. DISCUSSION Cardiothoracic surgery/transplant patients may have a similar risk for VRE-associated morbidity as abdominal solid organ transplant and stem cell transplant patients, highlighting the need for aggressive outbreak management when VRE transmission is detected. Our experience demonstrates an unintended consequence of discontinuing MDRO surveillance in this population and highlights a need for education, monitoring, and reinforcement of foundational infection prevention measures to ensure optimal outcomes.
Collapse
Affiliation(s)
- Shardul N Rathod
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Laura Bardowski
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Isabella Tse
- Cardiac, Vascular, and Thoracic Stepdown, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Monica Fiehler
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA
| | - Michael Malczynski
- Department of Pathology, Northwestern University Feinberg School of Medicine, Clinical Microbiology Laboratory, Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Chao Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Clinical Microbiology Laboratory, Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sajal D Tanna
- Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christine Bulger
- Department of Environmental Services and Patient Escort, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Abbas Al-Qamari
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine and Northwestern Medicine, Chicago, Illinois, USA.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robin Oakley
- Cardiac Transplant Intensive Care Unit, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Teresa R Zembower
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, Illinois, USA.,Department of Pathology, Northwestern University Feinberg School of Medicine, Clinical Microbiology Laboratory, Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
12
|
Prevalence, mortality, and resource utilization of Staphylococcus aureus bacteremia in liver transplant recipients: A 2012–2016 nationwide analysis. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022. [DOI: 10.1016/j.cegh.2022.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
13
|
Impact of Intensive Care Unit Discharge Delay on Liver Transplantation Outcomes. J Clin Med 2022; 11:jcm11092561. [PMID: 35566687 PMCID: PMC9101850 DOI: 10.3390/jcm11092561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background: For general intensive care unit (ICU) patients, ICU discharge delay (ICUDD) has been associated with an increased hospital length of stay (LOS) and the acquisition of multi-resistant organism (MRO) infections. The impact of ICUDD on liver transplant (LT) recipients is unknown. Methods: We retrospectively studied consecutive adult LT between 2011 and 2019. ICUDD was defined as >8 h between a patient being cleared for discharge to ward and the patient leaving the ICU. Results: 550 patients received LT and the majority (68.5%) experienced ICUDD. The median time between clearance for ward and the patient leaving the ICU was 25.6 h. No donor or recipient variables were associated with ICUDD. Patients cleared for discharge early in the week (Sunday-Tuesday) and those discharged outside routine work hours were more likely to experience ICUDD (p = 0.001 and p < 0.001, respectively). The median hospital LOS was identical (18 days, p = 0.96) and there were no differences in other patient outcomes. Patients who became colonized with MRO in the ICU spent a longer time there compared to those who remained MRO-free (9 vs. 6 days, p < 0.001); however, this was not due to ICUDD. Conclusion: ICUDD post-LT is common and does not prolong hospital LOS. ICUDD is not associated with adverse patient outcomes or MRO colonization.
Collapse
|
14
|
Cao S, Tennakoon L, Brubaker AL, Forrester JD. Infection with Two Multi-Drug-Resistant Organisms in Solid Organ Transplant Patients Is Associated with Increased Mortality and Prolonged Hospitalization. Surg Infect (Larchmt) 2022; 23:394-399. [PMID: 35357980 DOI: 10.1089/sur.2021.300] [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: 10/18/2022] Open
Abstract
Background: Solid organ transplant recipients have several risk factors for peri-operative multi-drug-resistant infection: their immune system is dampened as a result of critical illness and surgical stress that may be further impaired by induction immunotherapy and broad-spectrum antibiotic prophylaxis promotes selection for resistant pathogens. Infection with multi-drug-resistant organisms (MDRO) results in morbidity and mortality for solid organ transplant recipients. Patients and Methods: To assess in-hospital mortality and hospitalization duration associated with these infections, we analyzed cross-sectional, retrospective data from the 2016 Agency for Healthcare and Quality, Healthcare Cost and Utilization Project's National Inpatient Sample. Our analysis included 31,105 index admissions records for liver, kidney, heart, lung, and pancreas transplant recipients in the United States. Outcomes were assessed by multivariable regression analysis adjusting for covariables. Results: One percent (355/29,451) of patients with diagnosis of no MDRO infections died, 3% (40/1491) with diagnosis of one MDRO infection died, and 15% (25/166) with diagnosis of two MDRO infections died. Diagnosis of one MDRO infection was associated with a 20-day increase in hospitalization duration (95% confidence interval [CI], 17-22) but not increased odds of death (odds ratio [OR], 1.2; 95% CI, 0.5-2.5). Diagnosis of two MDRO infections was associated with an increased odds of death (OR, 9.6' 95% CI, 3.3-27.9) and a 41-day increase in hospitalization duration (95% CI, 34-49). Conclusions: Strategies to decrease peri-operative MDRO infection may improve survival and decrease duration of hospitalization for solid organ transplant patients.
Collapse
Affiliation(s)
- Siqi Cao
- School of Medicine, Department of Surgery, Stanford University, Stanford, California, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Aleah L Brubaker
- Division of Transplant Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Joseph D Forrester
- School of Medicine, Department of Surgery, Stanford University, Stanford, California, USA
| |
Collapse
|
15
|
Verma A, Vimalesvaran S, Dhawan A. Epidemiology, Risk Factors and Outcome Due to Multidrug Resistant Organisms in Paediatric Liver Transplant Patients in the Era of Antimicrobial Stewardship and Screening. Antibiotics (Basel) 2022; 11:antibiotics11030387. [PMID: 35326850 PMCID: PMC8944546 DOI: 10.3390/antibiotics11030387] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/06/2022] [Accepted: 03/11/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Background: Multidrug-resistant organisms (MDRO) are a growing problem in liver transplant recipients (LTR), associated with high morbidity and mortality. We reviewed the impact of antimicrobial stewardship (AMS) and active screening of MDRO on the epidemiology and outcomes in paediatric LTR. (2) Methods: Single-centre retrospective review of paediatric LTR from January 2017 to December 2018. (3) Results: Ninety-six children were included; 32 (33%) patients were colonised with ≥1 MDRO and 22 (23%) patients had MDRO infections. Median (IQR) duration for start of infection was 9.5 (1.8−16.0) days. Colonisation rate with Gram-positive MDRO was 15.6%, with infection rate of 6.2%; majority due to Vancomycin-Resistant Enterococcus faecium (VRE). Colonisation with Gram-negative MDRO was 27.0%, with infection rate of 16.6%; majority due to extended-spectrum β-lactamase producing Enterobacteriaceae. Colonisation and infection rate due to Carbapenem-resistant Enterobacteriaceae was 6% and 3%, respectively, during screening and AMS, compared to historical control of 25% and 30%, respectively, without screening and AMS. There was significant reduction in VRE and CRE infection during AMS period in comparison to historical control. Pre-transplant risk factors including bacterial infections pre-transplant (p < 0.01), diagnosis of biliary atresia (p = 0.03), exposure to antibiotics (p < 0.01), EBV viraemia (p = 0.01), and auxiliary transplantation (p < 0.01) were associated with post-transplant MDRO infections. Patients with MDRO infections had longer length of hospital and paediatric intensive care unit stay days (p < 0.01) but associated with no mortality. (4) Conclusions: Our results demonstrate low incidence of colonisation and infections with MDRO, which were associated with high morbidity but no mortality in paediatric LTR. There was significant reduction in MRSA, VRE, and CRE during AMS period compared to pre-AMS era. Some risk factors are unavoidable but antibiotic overuse, early initiation of appropriate antibiotic therapy and effective infection prevention strategies can be monitored with multifaceted approach of AMS and screening of MDRO. With limited therapeutic options for MDRO and efficacy data of newer antibiotics in paediatric LTR, robust infection control practices are of paramount importance.
Collapse
Affiliation(s)
- Anita Verma
- Department of Infection Sciences, King’s College Hospital, London SE5 9RS, UK
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, King’s College Hospital, London SE5 9RS, UK; (S.V.); (A.D.)
- Correspondence:
| | - Sunitha Vimalesvaran
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, King’s College Hospital, London SE5 9RS, UK; (S.V.); (A.D.)
| | - Anil Dhawan
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, King’s College Hospital, London SE5 9RS, UK; (S.V.); (A.D.)
| |
Collapse
|
16
|
Chiang D, Dingle TC, Belga S, Kabbani D, Bhanji RA, Walter J, Abraldes JG, Cervera C. Association between Gut Colonization of Vancomycin-resistant Enterococci and Liver Transplant Outcomes. Transpl Infect Dis 2022; 24:e13821. [PMID: 35247208 DOI: 10.1111/tid.13821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/11/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) colonization is common in liver transplant recipients and has been associated with worse post-transplant outcomes. METHODS We conducted a retrospective cohort study at the University of Alberta Hospital including patients who underwent a liver transplant between September 2014 and December 2017. RESULTS Of 343 patients, 68 (19.8%) had pre-transplant VRE colonization and 27 (27/275, 9.8%) acquired VRE post-transplant, 67% were males and the median age was 56.5 years. VRE colonized patients at baseline had higher MELD scores and required longer post-transplant hospitalization. VRE colonization was associated with increased risk of early acute kidney injury (AKI) (64% vs 52%, p = 0. 044), clinically significant bacterial/fungal infection (29% vs 17%, p = 0. 012) and invasive VRE infection (5% vs 1%, p = 0. 017). Mortality at 2-years was 13% in VRE-colonized versus 7% in non-colonized (p = 0.085). On multivariate analysis, VRE colonization increased the risk of post-transplant AKI (HR 1.504, 95% CI: 1.077-2.100, p = 0.017) and clinically significant bacterial or fungal infection at 6 months (HR 2.038, 95%CI: 1.222-3.399, p = 0.006), and was associated with non-significant trend towards increased risk of mortality at 2-years post-transplant (HR 1.974 95% CI 0.890-4.378; p = 0.094). CONCLUSIONS VRE colonization in liver transplant patients is associated with increased risk of early AKI, clinically significant infections, and a trend towards increased mortality at 2-years. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Diana Chiang
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tanis C Dingle
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada.,Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Sara Belga
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rahima A Bhanji
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jens Walter
- Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Alberta, Canada.,Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine and APC Microbiome Ireland, University College Cork, Cork, Ireland.,School of Microbiology, University College Cork, Cork, Ireland
| | - Juan G Abraldes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
17
|
Shafiekhani M, Shekari Z, Boorboor A, Zare Z, Arabsheybani S, Azadeh N. Bacterial and fungal co-infections with SARS-CoV-2 in solid organ recipients: a retrospective study. Virol J 2022; 19:35. [PMID: 35246169 PMCID: PMC8894563 DOI: 10.1186/s12985-022-01763-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/21/2022] [Indexed: 01/08/2023] Open
Abstract
Background SARS-CoV-2, a novel corona virus, has caused clusters of fatal pneumonia worldwide. Immune compromised patients are among the high risk groups with poor prognosis of the disease. The presence of bacterial or fungal co-infections with SARS-CoV-2 is associated with increased mortality. Methods The electronic data of the liver and kidney recipients, hospitalized in COVID-19 intensive care unit in an 8-month period in 2020 were retrospectively assessed. The documented bacterial or fungal infections alongside with outcome and risk factors were recorded and analyzed by binary logistic regression model and multivariate analyses. Results Sixty-Six liver and kidney recipients with positive RT-PCR for SARS-CoV-2 were included this study. Twenty one percent of the patients had at least one episode of co-infection during their COVID-19 course. Bacterial and fungal co-infections contributed to a significantly higher mortality. Urine and sputum were the most common sites of pathogen isolation (45.45% and 36.36%; respectively). The majority of infections were caused by vancomycin- resistant Enterococci (30%). Escherichia coli stood in the next position with 23.3%. Prior hospitalization and high doses of corticosteroids were associated with co-infections (p < 0.001 and p = 0.02; respectively.) Conclusions Bacterial and fungal co-infections with COVID-19 are more prevalent in solid organ recipients compared to the general population. Prior hospitalizations and use of broad-spectrum antimicrobial agents lead to emergence of multi-drug resistant pathogens in this susceptible patient population. Early detection and treatment of co-infections as well as antibiotic stewardship is recommended in solid organ recipients.
Collapse
Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shekari
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Boorboor
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Zare
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Arabsheybani
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nazanin Azadeh
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
18
|
Lee IK, Sng YP, Li WF, Chen CL, Wang CC, Lin CC, Chen IL. Importance of daptomycin dosage on the clinical outcome in liver transplant recipients with vancomycin-resistant enterococci infection. J Chemother 2022; 34:367-374. [PMID: 35075978 DOI: 10.1080/1120009x.2022.2031470] [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: 10/19/2022]
Abstract
We retrospectively studied 16 (3 colonization and 13 infections) early post-liver transplant (≤60-day after transplantation) patients with vancomycin-resistant enterococci (VRE) colonization/infection from 2016 to 2019. All VRE isolates were Enterococcus faecium. Of 13 patients with VRE infection, 12 (92.3%) underwent living-donor liver transplantation and 1 underwent deceased donor liver transplantation. Among these 13 patients, the median time from transplant to emergence of VRE infection was 12 days. The median interval from VRE infection to death was 27 days. Of these 13 patients, eleven patients (8 survived; 3 died) received daptomycin therapy for VRE. Among them, 4 (36.3%) received daptomycin doses <8 mg/kg. Non-survivors (n = 3) received significantly lower daptomycin dose than survivors (n = 8; p = .040). Daptomycin doses <8mg/kg were more frequently associated with non-survivors (n = 3) than with survivors (n = 8; p = .024). In summary, the suboptimal dosage of daptomycin may have contributed to a higher rate of in-hospital mortality. Doses ≥8 mg/kg may be needed to adequately treat VRE infection in liver transplant recipients.
Collapse
Affiliation(s)
- Ing-Kit Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ping Sng
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Feng Li
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chao-Long Chen
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Che Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| |
Collapse
|
19
|
Lee RA, Goldman J, Haidar G, Lewis J, Arif S, Hand J, La Hoz RM, Pouch S, Holaday E, Clauss H, Kaye KS, Nellore A. Daptomycin-Resistant Enterococcus Bacteremia Is Associated with Prior Daptomycin Use and Increased Mortality after Liver Transplantation. Open Forum Infect Dis 2022; 9:ofab659. [PMID: 35146044 PMCID: PMC8826376 DOI: 10.1093/ofid/ofab659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Risk factors for acquisition of vancomycin-resistant Enterococcus (VRE) include immunosuppression, antibiotic exposure, indwelling catheters, and manipulation of the gastrointestinal tract, all of which occur in liver transplant recipients. VRE infections are documented in liver transplantation (LT); however, only one single center study has assessed the impact of daptomycin-resistant Enterococcus (DRE) in this patient population. Methods We conducted a retrospective multicenter cohort study comparing liver transplant recipients with either VRE or DRE bacteremia. The primary outcome was death within 1 year of transplantation. Multivariable logistic regression analyses were performed to calculate adjusted odds ratios for outcomes of interest. Results We identified 139 cases of Enterococcus bacteremia following LT, of which 78% were VRE and 22% were DRE. When adjusted for total intensive care unit days in the first transplant year, liver-kidney transplantation, and calcineurin inhibitor use, patients with DRE bacteremia were 2.65 times more likely to die within 1 year of transplantation (adjusted odds ratio [aOR], 2.648; 95% CI, 1.025–6.840; P = .044). Prior daptomycin exposure was found to be an independent predictor of DRE bacteremia (aOR, 30.62; 95% CI, 10.087–92.955; P < .001). Conclusions In this multicenter study of LT recipients with Enterococcus bacteremia, DRE bacteremia was associated with higher 1-year mortality rates when compared with VRE bacteremia. Our data provide strong support for dedicated infection prevention and antimicrobial stewardship efforts for transplant patients. Further research is needed to support the development of better antibiotics for DRE and practical guidance focusing on identification and prevention of colonization and subsequent infection in liver transplant recipients at high risk for DRE bacteremia.
Collapse
Affiliation(s)
- Rachael A Lee
- University of Alabama at Birmingham, Birmingham AL, USA
| | | | - Ghady Haidar
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jessica Lewis
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Ricardo M La Hoz
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | | | - Anoma Nellore
- University of Alabama at Birmingham, Birmingham AL, USA
| |
Collapse
|
20
|
Joshi S, Shallal A, Zervos M. Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control. Infect Dis Clin North Am 2021; 35:953-968. [PMID: 34752227 DOI: 10.1016/j.idc.2021.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Vancomycin-resistant enterococcus (VRE) is a pathogen of growing concern due to increasing development of antibiotic resistance, increasing length of hospitalizations and excess mortality. The utility of some infection control practices are debatable, as newer developments in infection prevention strategies continued to be discovered. This article summarizes the significance of VRE and VRE transmission, along with highlighting key changes in infection control practices within the past 5 years.
Collapse
Affiliation(s)
- Seema Joshi
- Division of Infectious Diseases, Henry Ford Hospital, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA.
| | - Anita Shallal
- Division of Infectious Diseases, Henry Ford Hospital, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA
| | - Marcus Zervos
- Wayne State University, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA
| |
Collapse
|
21
|
McFarlane AC, Kabbani D, Bakal JA, Smith SW. Clinical impact of vancomycin-resistant enterococci colonization in nonliver solid organ transplantation and its implications for infection control strategies: A single-center, 10-year retrospective study. Transpl Infect Dis 2021; 23:e13747. [PMID: 34674357 DOI: 10.1111/tid.13747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) colonization in nonliver solid organ transplantation (SOT) is poorly defined. Infection control management of these patients is influenced by the association of VRE with adverse outcomes in liver transplantation. This study examines the frequency and clinical impact of VRE colonization specifically on nonliver SOT patients and discusses implications for nosocomial VRE control. METHODS We retrospectively reviewed all nonliver SOT patients at a single transplant center from 2005 to 2015. We determined colonization rates in the peritransplant period and the rate of VRE infections. The association between VRE colonization with 90-day mortality and other clinical outcomes was examined. RESULTS There were 1786 nonliver SOTs from 2005 to 2015, with 81 (4.6%) colonized with VRE in the peritransplantation period. The colonization prevalence varied by organ type: 45 of 423 lung (10.6%), 12 of 352 heart (3.4%), one of 18 heart-lung (5.6%), 20 of 884 kidney (2.3%), three of 63 kidney-pancreas (4.8%), zero of 11 pancreas, zero of five small bowel, and zero of 11 multivisceral. Peritransplant VRE colonization was not associated with 90-day mortality odds ratio = 2.35 (95% CI = 0.53, 10.29) and adjusted odds ratio = 1.52 (95% CI = 0.34, 6.88). In the multivariable logistic regression, there was no association with mortality at 1 year or 5 years, hospital length of stay, rehospitalization, or days alive out of hospital. There were 14 inpatient VRE infections up to 1 year after transplantation. CONCLUSION Nonliver SOT patients have lower rates of VRE colonization than liver SOT, and colonization was not associated with increased adverse clinical outcomes. Although infection control strategies for VRE in hospital remain controversial, nonliver SOT should be considered among typical hospitalized patients when designing strategies for prevention.
Collapse
Affiliation(s)
- Alexandra C McFarlane
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada.,Alberta SPOR SUPPORT Unit Data Platform, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie W Smith
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
22
|
Li H, Yu X, Shi B, Zhang K, Yuan L, Liu X, Wang P, Lv J, Meng G, Xuan Q, Wu W, Li B, Peng X, Qin X, Liu W, Zhong L, Peng Z. Reduced pannexin 1-IL-33 axis function in donor livers increases risk of MRSA infection in liver transplant recipients. Sci Transl Med 2021; 13:13/606/eaaz6169. [PMID: 34380770 DOI: 10.1126/scitranslmed.aaz6169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/28/2020] [Accepted: 07/12/2021] [Indexed: 12/28/2022]
Abstract
Liver transplantation patients are at increased risk for methicillin-resistant Staphylococcus aureus (MRSA) infection, but the molecular mechanism remains unclear. We found that genetic predisposition to low pannexin 1 (PANX1) expression in donor livers was associated with MRSA infection in human liver transplantation recipients. Using Panx1 and Il-33-knockout mice for liver transplantation models with MRSA tail vein injection, we demonstrated that Panx1 deficiency increased MRSA-induced liver injury and animal death. We found that decreased PANX1 expression in the liver led to reduced release of adenosine triphosphate (ATP) from hepatocytes, which further reduced the activation of P2X2, an ATP-activating P2X receptor. Reduced P2X2 function further decreased the NLRP3-mediated release of interleukin-33 (IL-33), reducing hepatic recruitment of macrophages and neutrophils. Administration of mouse IL-33 to Panx1-/- mice significantly (P = 0.011) ameliorated MRSA infection and animal death. Reduced human hepatic IL-33 protein abundance also associated with increased predisposition to MRSA infection. Our findings reveal that genetic predisposition to reduced PANX1 function increases risk for MRSA infection after liver transplantation by decreasing hepatic host innate immune defense, which can be attenuated by IL-33 treatment.
Collapse
Affiliation(s)
- Hao Li
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Xiaoyu Yu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Baojie Shi
- Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
| | - Kun Zhang
- Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
| | - Liyun Yuan
- Bio-Med Big Data Center, CAS-MPG Partner Institute for Computational Biology, Shanghai Institutes of Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China
| | - Xueni Liu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Pusen Wang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Junwei Lv
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Guangxun Meng
- Institut Pasteur of Shanghai, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai 200031, China
| | - Qiankun Xuan
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Wenjuan Wu
- Department of Laboratory Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200085, China
| | - Bin Li
- Shanghai Institute of Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiao Peng
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 10140, USA
| | - Xuebin Qin
- Department of Neuroscience, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 10140, USA.,Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA 70112, USA.,Department of Pathology, Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Wanqing Liu
- Department of Pharmaceutical Sciences and Department of Pharmacy, Wayne State University, Detroit, MI 48201, USA.
| | - Lin Zhong
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China.
| | - Zhihai Peng
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China. .,Department of General Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen 361000, China.,Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen 361000, China
| |
Collapse
|
23
|
Oñate J, Pallares Gutiérrez CJ, Esparza G, Jimenez A, Berrio Medina I, Osorio-Pinzón J, Cataño J, Alvarez- Moreno C, Rodriguez J, Guevara F, Mercado M, Zuluaga M, Becerra JS, Alvarez M, Coronel W, Ordonez K, Villegas M. Consensus Recommendations Based on Evidence for Abdominal Sepsis in the Pediatric and Adult Population of Colombia. INFECTIO 2021. [DOI: 10.22354/in.v25i4.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
24
|
Sansotta N, De Luca E, Nicastro E, Tebaldi A, Ferrari A, D’Antiga L. Incidence of Cholangitis and Sepsis Associated with Percutaneous Transhepatic Cholangiography in Pediatric Liver Transplant Recipients. Antibiotics (Basel) 2021; 10:antibiotics10030282. [PMID: 33801816 PMCID: PMC8001276 DOI: 10.3390/antibiotics10030282] [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: 02/01/2021] [Revised: 02/28/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background. Percutaneous transhepatic cholangiography (PTC) is an established treatment in the management of biliary strictures. The aim of our study was to determine the incidence of PTC-related infectious complications in transplanted children, and identify their precise aetiol-ogy. Methods. We retrospectively reviewed all PTC performed from January 2017 to October 2020 in our center. Before the procedure, all patients received antibiotic prophylaxis defined as first line, while second line was used in case of previously microbiological isolation. Cholangitis was defined as fever (>38.5°) and elevated inflammatory markers after PTC, while sepsis included hemodynamic instability in addition to cholangitis. Results. One hundred and fifty-seven PTCs from 50 pediatric recipients were included. The overall incidence of cholangitis and sepsis after PTC was 44.6% (70/157) and 3.2% (5/157), respectively, with no fatal events. Blood cultures yielded positive results in 15/70 cases (21.4%). Enterococcus faecium and Pseudomonas aeruginosa were the most common isolated pathogens. Multidrug-resistant (MDR) pathogens were found in 11/50 patients (22%). Conclusion. PTC is associated with a relatively high rate of post-procedural cholangitis, although with low rate of sepsis and no fatal events. Blood cultures allowed to find a precise aetiology in roughly a quarter of the cases, showing prevalence of Enterococcus faecium and Pseudomonas aeruginosa.
Collapse
Affiliation(s)
- Naire Sansotta
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
- Correspondence:
| | - Ester De Luca
- Department of Pediatrics, University of Milano Bicocca, 20126 Milan, Italy;
| | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Alessandra Tebaldi
- Infectious Diseases Unit, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Alberto Ferrari
- FROM Research Foundation, Statistics, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Lorenzo D’Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| |
Collapse
|
25
|
Ejtehadi F, Zare E, Shamsaeefar A, Nikeghbalian S, Kazemi K, Nikoupour H, Eghlimi H, Motazedian N, Moghadami M, Malekhosseini SA. Clinical Outcome of Vancomycin-Resistant Enterococcus Colonization Among Liver Transplant Recipients at Shiraz Organ Transplant Center. EXP CLIN TRANSPLANT 2021; 19:806-810. [PMID: 33663359 DOI: 10.6002/ect.2020.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant recipients are more susceptible to vancomycin-resistant enterococci colonization than healthy individuals. We investigated the prevalence of vancomycin-resistant enterococci colonization and its effect on the outcomes of liver transplant recipients. MATERIALS AND METHODS Patients who had undergone primary liver transplant at the Shiraz Organ Transplant Center from 2015 to 2017 were enrolled in this study. Demographic characteristics, laboratory test results, duration of stay in the intensive care unit, total duration of hospital stay, and clinical outcome data were extracted from the Shiraz Organ Transplant Center database. Posttransplant outcomes such as graft rejection, mortality, hospital stay, and kidney function tests were included for the first 90 days after transplant. RESULTS A total of 753 liver transplant recipients (470 males and 283 females) were included in this study. Vancomycin-resistant enterococci colonization was identified in 51 patients (6.8%) after transplant at the time of intensive care unit admission. Our study found no significant difference between outcomes for patients with vancomycin-resistant enterococci colonization and outcomes for patients without colonization, including graft rejection, mortality, hospital stay, and kidney function tests. CONCLUSIONS Our study revealed that asymptomatic vancomycin-resistant enterococci colonization in liver transplant patients has no adverse effect on the duration of posttransplant hospital stay, early mortality rate, graft rejection rate, or kidney function compared with noncolonized patients.
Collapse
Affiliation(s)
- Fardad Ejtehadi
- From the Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Ferstl PG, Filmann N, Heilgenthal EM, Schnitzbauer AA, Bechstein WO, Kempf VAJ, Villinger D, Schultze TG, Hogardt M, Stephan C, Mutlak H, Weiler N, Mücke MM, Trebicka J, Zeuzem S, Waidmann O, Welker MW. Colonization with multidrug-resistant organisms is associated with in increased mortality in liver transplant candidates. PLoS One 2021; 16:e0245091. [PMID: 33481811 PMCID: PMC7822319 DOI: 10.1371/journal.pone.0245091] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023] Open
Abstract
Objectives Rising prevalence of multidrug-resistant organisms (MDRO) is a major health problem in patients with liver cirrhosis. The impact of MDRO colonization in liver transplantation (LT) candidates and recipients on mortality has not been determined in detail. Methods Patients consecutively evaluated and listed for LT in a tertiary German liver transplant center from 2008 to 2018 underwent screening for MDRO colonization including methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant gram-negative bacteria (MDRGN), and vancomycin-resistant enterococci (VRE). MDRO colonization and infection status were obtained at LT evaluation, planned and unplanned hospitalization, three months upon graft allocation, or at last follow-up on the waiting list. Results In total, 351 patients were listed for LT, of whom 164 (47%) underwent LT after a median of 249 (range 0–1662) days. Incidence of MDRO colonization increased during waiting time for LT, and MRDO colonization was associated with increased mortality on the waiting list (HR = 2.57, p<0.0001. One patients was colonized with a carbapenem-resistant strain at listing, 9 patients acquired carbapenem-resistant gram-negative bacteria (CRGN) on the waiting list, and 4 more after LT. In total, 10 of these 14 patients died. Conclusions Colonization with MDRO is associated with increased mortality on the waiting list, but not in short-term follow-up after LT. Moreover, colonization with CRGN seems associated with high mortality in liver transplant candidates and recipients.
Collapse
Affiliation(s)
- Philip G. Ferstl
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
- * E-mail:
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt am Main, Frankfurt, Germany
| | - Eva-Maria Heilgenthal
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Andreas A. Schnitzbauer
- Department of General and Visceral Surgery, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Wolf O. Bechstein
- Department of General and Visceral Surgery, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Volkhard A. J. Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - David Villinger
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Tilman G. Schultze
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Michael Hogardt
- Institute for Medical Microbiology and Infection Control, University Hospital, Goethe University, Frankfurt am Main, Germany
- University Center for Infectious Diseases (UCI), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt Main, Germany
| | - Christoph Stephan
- Department for Internal Medicine II / Infectious Diseases, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Haitham Mutlak
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Nina Weiler
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Marcus M. Mücke
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Jonel Trebicka
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Oliver Waidmann
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Martin-Walter Welker
- Department for Internal Medicine I / Gastroenterology and Hepatology, University Hospital, Goethe University, Frankfurt am Main, Germany
| |
Collapse
|
27
|
Kaur J, Cao X, Abutaleb NS, Elkashif A, Graboski AL, Krabill AD, AbdelKhalek AH, An W, Bhardwaj A, Seleem MN, Flaherty DP. Optimization of Acetazolamide-Based Scaffold as Potent Inhibitors of Vancomycin-Resistant Enterococcus. J Med Chem 2020; 63:9540-9562. [PMID: 32787141 DOI: 10.1021/acs.jmedchem.0c00734] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Vancomycin-resistant enterococci (VRE) are the second leading cause of hospital-acquired infections (HAIs) attributed to a drug-resistant bacterium in the United States, and resistance to the frontline treatments is well documented. To combat VRE, we have repurposed the FDA-approved carbonic anhydrase drug acetazolamide to design potent antienterococcal agents. Through structure-activity relationship optimization we have arrived at two leads possessing improved potency against clinical VRE strains from MIC = 2 μg/mL (acetazolamide) to MIC = 0.007 μg/mL (22) and 1 μg/mL (26). Physicochemical properties were modified to design leads that have either high oral bioavailability to treat systemic infections or low intestinal permeability to treat VRE infections in the gastrointestinal tract. Our data suggest the intracellular targets for the molecules are putative α-carbonic and γ-carbonic anhydrases, and homology modeling and molecular dynamics simulations were performed. Together, this study presents potential anti-VRE therapeutic options to provide alternatives for problematic VRE infections.
Collapse
Affiliation(s)
- Jatinder Kaur
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Xufeng Cao
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Nader S Abutaleb
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, Indiana 47907, United States
| | - Ahmed Elkashif
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, Indiana 47907, United States
| | - Amanda L Graboski
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Aaron D Krabill
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Ahmed Hassan AbdelKhalek
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, Indiana 47907, United States
| | - Weiwei An
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Atul Bhardwaj
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States
| | - Mohamed N Seleem
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, 625 Harrison Street, West Lafayette, Indiana 47907, United States.,Purdue Institute for Drug Discovery, 720 Clinic Drive, West Lafayette, Indiana 47907, United States.,Purdue Institute of Inflammation, Immunology and Infectious Disease, 207 South Martin Jischke Drive, West Lafayette, Indiana 47907, United States
| | - Daniel P Flaherty
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana 47907, United States.,Purdue Institute for Drug Discovery, 720 Clinic Drive, West Lafayette, Indiana 47907, United States.,Purdue Institute of Inflammation, Immunology and Infectious Disease, 207 South Martin Jischke Drive, West Lafayette, Indiana 47907, United States
| |
Collapse
|
28
|
Chan S, Ng S, Chan HP, Pascoe EM, Playford EG, Wong G, Chapman JR, Lim WH, Francis RS, Isbel NM, Campbell SB, Hawley CM, Johnson DW. Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients. Cochrane Database Syst Rev 2020; 8:CD013209. [PMID: 32799356 PMCID: PMC7437398 DOI: 10.1002/14651858.cd013209.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Solid organ transplant recipients are at high risk for infections due to the complexity of surgical procedures combined with the impact of immunosuppression. No consensus exists on the role of antibiotics for surgical site infections in solid organ transplant recipients. OBJECTIVES To assess the benefits and harms of prophylactic antimicrobial agents for preventing surgical site infections in solid organ transplant recipients. SEARCH METHODS The Cochrane Kidney and Transplant Register of Studies was searched up to 21 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing prophylactic antibiotics in preventing surgical site infections in solid organ transplant recipients at any time point after transplantation. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality, and extracted data. Primary outcomes were surgical site infections and antimicrobial resistance. Other outcomes included urinary tract infections, pneumonias and septicaemia, death (any cause), graft loss, graft rejection, graft function, adverse reactions to antimicrobial agents, and outcomes identified by the Standardised Outcomes of Nephrology Group (SONG), specifically graft health, cardiovascular disease, cancer and life participation. Summary effect estimates were obtained using a random-effects model and results were expressed as risk ratios (RR) and 95% confidence intervals (CI). The quality of the evidence was assessed using the risk of bias and the GRADE approach. MAIN RESULTS We identified eight eligible studies (718 randomised participants). Overall, five studies (248 randomised participants) compared antibiotics versus no antibiotics, and three studies (470 randomised participants) compared extended duration versus short duration antibiotics. Risk of bias was assessed as high for performance bias (eight studies), detection bias (eight studies) and attrition bias (two studies). It is uncertain whether antibiotics reduce the incidence of surgical site infections as the certainty of the evidence has been assessed as very low (RR 0.42, 95% CI 0.21 to 0.85; 5 studies, 226 participants; I2 = 25%). The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). It is uncertain whether extended duration antibiotics reduces the incidence of surgical site infections in either solid organ transplant recipients (RR 1.19, 95% CI 0.58 to 2.48; 2 studies, 302 participants; I2 = 0%) or kidney-only transplant recipients (RR 0.50, 95% CI 0.05 to 5.48; 1 study, 205 participants) as the certainty of the evidence has been assessed as very low. The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). None of the eight included studies evaluated antimicrobial agent adverse reactions, graft health, cardiovascular disease, cancer, life participation, biochemical and haematological parameters, intervention cost, hospitalisation length, or overall hospitalisation costs. AUTHORS' CONCLUSIONS Due to methodological limitations, risk of bias and significant heterogeneity, the current evidence for the use of prophylactic perioperative antibiotics in transplantation is of very low quality. Further high quality, adequately powered RCTs would help better inform clinical practice.
Collapse
Affiliation(s)
- Samuel Chan
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Hooi P Chan
- General Practice Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Department of Biostatistics, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Department of Nephrology, Westmead Clinical School, Sydney, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gardiner Hospital, Perth, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| |
Collapse
|
29
|
Sarwar S, Koff A, Malinis M, Azar MM. Daptomycin perioperative prophylaxis for the prevention of vancomycin-resistant Enterococcus infection in colonized liver transplant recipients. Transpl Infect Dis 2020; 22:e13280. [PMID: 32216015 DOI: 10.1111/tid.13280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/18/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Vancomycin-resistant Enterococcus (VRE)-colonized liver transplantation (LT) recipients have increased post-LT morbidity, mortality, and higher rates of VRE infections compared with their non-colonized counterparts. Pre-LT screening for VRE colonization and inclusion of daptomycin in the perioperative antibiotic prophylaxis regimen may mitigate this risk. METHODS We performed a retrospective chart review of liver transplant recipients aged ≥ 18 years between 2013 and August 2019 to identify pre-LT VRE-colonized recipients and whether they received daptomycin perioperative prophylaxis (DPP). Demographic and clinical characteristics, including risk factors for VRE infection, were collected. Outcomes measured were VRE-related infection and all-cause mortality within 90 days of LT. RESULTS Of the 27 VRE-colonized liver transplant recipients within the study period, 25 received DPP. All recipients were admitted to the intensive care unit postoperatively, six (24%) required reoperation, fifteen (60%) required renal replacement therapy, and eight (32%) experienced postoperative hemorrhage within 90 days post-transplant. Two recipients (8%) experienced acute cellular rejection, but no primary graft failure was seen within 90 days. Among those who received DPP, no infections related to VRE or death was seen within 90 days of LT. The two VRE-colonized recipients who did not receive DPP both developed VRE bacteremia in the early post-LT period. CONCLUSION Despite having multiple risk factors for post-LT VRE infection, VRE-colonized recipients who received DPP did not develop VRE-related infections in the first 90 days post-LT. Our experience demonstrates that pre-LT VRE screening and DPP may be associated with a reduction in VRE infection in the early post-LT period, but this strategy warrants further evaluation in prospective studies.
Collapse
Affiliation(s)
- Sajed Sarwar
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alan Koff
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Maricar Malinis
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marwan M Azar
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
30
|
Jafarpour Z, Pouladfar G, Malek Hosseini SA, Firoozifar M, Jafari P. Bacterial infections in the early period after liver transplantation in adults: A prospective single-center cohort study. Microbiol Immunol 2020; 64:407-415. [PMID: 32112581 DOI: 10.1111/1348-0421.12785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 01/16/2023]
Abstract
Liver transplantation (LT) is a potentially curative treatment for terminal stage hepatic diseases. Bacterial infections are the main causes of mortality and morbidity in the early period after LT. Identifying the risk factors could help in minimizing their development. We prospectively investigated the incidence, characteristics, and risk factors of bacterial infections among the recipients during hospitalization after LT and assigned a predictive score. All 389 consecutive adults who underwent LT at the main referral hospital of LT in Iran during 1 year were enrolled prospectively in a cohort study. Infection group consisted of 143 recipients (36.8%). Urinary tract and surgical site infections were the most frequent ones. Gram-negative bacteria were more prevalent than Gram-positive ones. Independent risk factors were female sex (relative risks = 2.13), age ≤ 43.5 years (3.70), hospital stay ≥ 9.5 days (5.22), abdominal reoperation (3.03), vancomycin-resistant Enterococci colonization (5.52), hospitalization 3 months prior to LT (3.25), mechanical ventilation ≥48 hr (4.93), and renal replacement therapies (13.40). We developed a risk score for the prediction of bacterial infections with an area under the receiver operating characteristic curve of 0.85 (95% CI, 0.81-0.89) with sensitivity of 88% and specificity of 64%. In the infection group, mortality was higher than in controls (18.9% vs. 2.0%) with longer hospitalization (16 vs. 10 days; P < 0.001). We detected a high rate of bacterial infections leading to longer hospital stay and higher mortality rate. The formulated risk score can help predict bacterial infections; however, it requires clinical validation in further studies.
Collapse
Affiliation(s)
- Zahra Jafarpour
- Alborzi Clinical Microbiology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholamreza Pouladfar
- Alborzi Clinical Microbiology Research Center, Nemazee Teaching Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Malek Hosseini
- Shiraz Organ Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Firoozifar
- Shiraz Organ Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Jafari
- Department of Biostatistics, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
31
|
Takemura Y, Hibi T, Shinoda M, Obara H, Minagawa T, Kitago M, Yagi H, Abe Y, Matsubara K, Oshima G, Hori S, Hoshino K, Yamada Y, Itano O, Takano Y, Kuroda T, Hasegawa N, Kitagawa Y. Methicillin-resistant Staphylococcus aureus carriers are vulnerable to bloodstream infection after living donor liver transplantation. Clin Transplant 2019; 33:e13753. [PMID: 31692105 DOI: 10.1111/ctr.13753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/03/2019] [Accepted: 10/25/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) is a life-threatening complication after living donor liver transplantation (LDLT). We aimed to explore the incidence and predisposing factors of BSI at our institution. METHODS We conducted a retrospective cohort analysis on all consecutive adults with BSI within 6 months after LDLT performed between 2005 and 2016. For antimicrobial prophylaxis, ampicillin/sulbactam, cefotaxime, and micafungin were administered. From 2011, methicillin-resistant Staphylococcus aureus (MRSA) carriers were decolonized using mupirocin ointment and chlorhexidine gluconate soap. Risk factors for BSI were identified by uni- and multivariate logistic regression. RESULTS Of a total of 106 LDLTs, 42 recipients (40%) suffered BSI. The BSI group demonstrated significantly higher in-hospital mortality rates compared with the non-BSI group (24% vs. 7%, P = .01). We identified MRSA carrier (odds ratio [OR], 19.1; P < .001), ABO incompatibility (OR, 2.9; P = .03), and estimated glomerular filtration rate <30 mL/min/1.73m2 (OR, 15.8; P = .02) as independent risk factors for BSI. Decolonization treatment for MRSA carriers did not reduce the incidence of all-cause BSI but reduced the frequency of BSI caused by MRSA. CONCLUSION To our knowledge, for the first time, MRSA carriers were revealed to be highly vulnerable to BSI after LDLT.
Collapse
Affiliation(s)
- Yusuke Takemura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takuya Minagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Yaoko Takano
- Center for Infectious Disease and Infection Control, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hasegawa
- Center for Infectious Disease and Infection Control, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
32
|
Martin Mateos R, Albillos A. Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management. Liver Transpl 2019; 25:1700-1709. [PMID: 31408581 DOI: 10.1002/lt.25621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.
Collapse
Affiliation(s)
- Rosa Martin Mateos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
33
|
Pereira MR, Rana MM. Methicillin-resistant Staphylococcus aureus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13611. [PMID: 31120612 DOI: 10.1111/ctr.13611] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 12/25/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the epidemiology, diagnosis, prevention, and management of methicillin-resistant Staphylococcus aureus (MRSA) infections in solid organ transplantation. Despite an increasing armamentarium of antimicrobials active against MRSA, improved diagnostic tools, and overall declining rates of infection, MRSA infections remain a substantial cause of morbidity and mortality in solid organ transplant recipients. Pre- and post-transplant MRSA colonization is a significant risk factor for post-transplant MRSA infection. The preferred initial treatment of MRSA bacteremia remains vancomycin. Hand hygiene, chlorhexidine bathing in the ICU, central-line bundles that focus on reducing unnecessary catheter use, disinfection of patient equipment, and the environment along with antimicrobial stewardship are all aspects of an infection prevention approach to prevent MRSA transmission and decrease healthcare-associated infections.
Collapse
|
34
|
Haidar G, Green M. Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13595. [PMID: 31102546 DOI: 10.1111/ctr.13595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 02/06/2023]
Abstract
This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.
Collapse
Affiliation(s)
- Ghady Haidar
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Green
- Departments of Pediatrics, Surgery & Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Division of Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | |
Collapse
|
35
|
Mechergui A, Achour W, Mathlouthi S, Hassen AB. Prevalence of infectious multi-drug resistant bacteria isolated from immunocompromised patients in Tunisia. Afr Health Sci 2019; 19:2021-2025. [PMID: 31656485 PMCID: PMC6794499 DOI: 10.4314/ahs.v19i2.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES A retrospective study was conducted in the Bone Marrow Transplant Center of Tunisia during a period of 10 years (from 2002 to 2011) in order to report the prevalence of infectious multi-drug resistant bacteria. METHODS Bacterial identification was carried on the basis of biochemical characteristics and API identification systems. Antibiotic susceptibility was tested by disc diffusion method on Muller-Hinton agar. RESULTS During the study period, 34.5% of 142 Klebsiella pneumoniae strains and 11.46% of 218 Escherichia coli strains were extended-spectrum beta-lactamase (ESBL) producers. Also, 32.8% of 210 strains of Pseudomonas aeruginosa were imipenem and/or ceftazidime resistant and 20.75% of 106 strains of Staphylococcus aureus were methicillin resistant. A rising trend was observed for the prevalence of the selected multidrug resistant bacteria. CONCLUSION These findings may have important clinical implications in prophylaxis and selection of antibiotic treatment. Continuous surveillance is needed, especially for onco-hematological patients.
Collapse
Affiliation(s)
- Arij Mechergui
- The National Bone Marrow Transplant Center, 1006, Tunis, Tunisia
- Faculty of Medicine of Tunis, UR12ES02, 1007, Tunis, Tunisia
| | - Wafa Achour
- The National Bone Marrow Transplant Center, 1006, Tunis, Tunisia
- Faculty of Medicine of Tunis, UR12ES02, 1007, Tunis, Tunisia
| | - Sondos Mathlouthi
- The National Bone Marrow Transplant Center, 1006, Tunis, Tunisia
- Faculty of Medicine of Tunis, UR12ES02, 1007, Tunis, Tunisia
| | - Assia Ben Hassen
- The National Bone Marrow Transplant Center, 1006, Tunis, Tunisia
- Faculty of Medicine of Tunis, UR12ES02, 1007, Tunis, Tunisia
| |
Collapse
|
36
|
Abbo LM, Grossi PA. Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13589. [PMID: 31077619 DOI: 10.1111/ctr.13589] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.
Collapse
Affiliation(s)
- Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine and Jackson Health System, Miami, Florida
| | - Paolo Antonio Grossi
- Infectious Diseases Section, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | |
Collapse
|
37
|
Nellore A, Huprikar S. Vancomycin-resistant Enterococcus in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13549. [PMID: 30913322 DOI: 10.1111/ctr.13549] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/19/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation address vancomycin-resistant enterococci (VRE) infections in SOT candidates and recipients. VRE are an important cause of infection and have been named by the CDC as a serious public threat. Typically, a commensal of the gastrointestinal tract, VRE may become pathogenic after abdominal organ manipulation like transplantation. This guideline reviews the microbiology, antimicrobial resistance mechanisms, epidemiology, and clinical manifestations of VRE infection in the context of solid organ transplantation. Treatment regimens including combination therapies and novel investigational agents are also reviewed. Finally, an updated appraisal of infection control measures relevant to VRE infection and colonization is presented.
Collapse
Affiliation(s)
- Anoma Nellore
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shirish Huprikar
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | |
Collapse
|
38
|
Abstract
Liver transplantation (LTPL) is the only curative option for patients with end stage liver disease (ESLD) or with hepatocellular carcinoma (HCC). Eurotransplant in Leiden, the Netherlands, is responsible for organ allocation. The model of end stage liver disease (MELD) score, which describes the severity of the liver disease, is decisive for organ allocation. The heterogeneous patient collective and hepatic-related comorbidities and their dynamics represent challenges. The anesthesiologist is responsible for evaluating the overall prognosis, whereby cardiac, pulmonary, renal and neurological comorbidities must be taken into consideration. During LTPL surgery is divided into several stages. Besides volume management, heat preservation and coagulation management, major challenges for the anesthesiologist are hemodynamic stabilization and regulation of the acid-base balance.
Collapse
|
39
|
Belga S, Chiang D, Kabbani D, Abraldes JG, Cervera C. The direct and indirect effects of vancomycin-resistant enterococci colonization in liver transplant candidates and recipients. Expert Rev Anti Infect Ther 2019; 17:363-373. [PMID: 30977692 DOI: 10.1080/14787210.2019.1607297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Vancomycin-resistant enterococci (VRE) colonization and subsequent infection results in increased morbidity, mortality and use of health-care resources. The burden of VRE colonization in liver transplant candidates and recipients is significant. VRE colonization is a marker of gut dysbiosis and its impact on the microbiota-liver axis, may negatively affect graft function and result in negative outcomes pre- and post-transplantation. Areas covered: In this article we describe the epidemiology of VRE colonization, risk factors for VRE infection, health-care costs associated with VRE, with a focus on the impact of VRE colonization on liver transplant recipients' fecal microbiota, the therapeutic strategies for VRE decolonization and proposed pathophysiologic mechanisms of VRE colonization in liver transplant recipients. Expert opinion: VRE colonization results in a significant loss of bacterial microbiome diversity. This may have metabolic consequences, with low production of short-chain fatty acids which may, in turn, result in immune dysregulation. As antibiotics have failed to decolonize the gut, alternative strategies such as fecal microbiota transplantation (FMT), stimulation of intestinal antimicrobial peptides and phage therapy warrants future studies.
Collapse
Affiliation(s)
- Sara Belga
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Diana Chiang
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Dima Kabbani
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Juan G Abraldes
- b Department of Medicine, Division of Gastroenterology and Hepatology , University of Alberta , Edmonton , Alberta , Canada
| | - Carlos Cervera
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| |
Collapse
|
40
|
Simkins J, Morillas-Rodriguez JA, Morris MI, Abbo LM, Camargo JF, Selvaggi G, Beduschi T, Tekin A, Vianna R. Bloodstream infection caused by enteric organisms during the first 6 months after intestinal transplant. Transpl Infect Dis 2019; 21:e13064. [PMID: 30865328 DOI: 10.1111/tid.13064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/08/2019] [Accepted: 03/04/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Data on bloodstream infection (BSI) due to enteric organisms are scarce. METHODS This retrospective study (1/2009-5/2017) was aimed to evaluate the incidence of BSI episodes due to enteric organisms during the first 6 months after intestinal transplant (ITx). Differences between the first (2009-2012) and second period (2013-2017) were evaluated as they differed from each other in the perioperative fungal prophylaxis and immunosuppressive regimen. RESULTS Fifty-five adult patients were analyzed. Twenty-eight (51%) patients developed a total of 51 episodes of BSI. Mean time from transplant to BSI was 85.5 ± 58.8 days. The most common organisms were Klebsiella pneumoniae (33%), Enterococcus spp (31%), and Candida spp (18%). Twenty-three (45%) were multidrug resistant. The most common sources were gut translocation (35%), central line infection (20%), and intra-abdominal abscess (14%). Biopsy-proven rejection was associated with 16 (31%) of the BSI episodes. Patients during the first period were more likely to develop BSI (79% vs 41%, P = 0.03). There were more episodes of rejection associated with BSI in the first period (45% vs 14%, P = 0.03). The rate of reoperation into the abdominal cavity within 2 weeks after ITx was higher and the transplant hospital stay was longer among those who developed BSI (P = 0.04 for both). CONCLUSIONS Half of our patients developed BSI (typically during the first 3 months). Gut translocation was the most common source of BSI. Patients with rejection and/or enteritis should be monitored closely for BSI.
Collapse
Affiliation(s)
- Jacques Simkins
- Department of Medicine/Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Jose A Morillas-Rodriguez
- Department of Medicine/Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Michele I Morris
- Department of Medicine/Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Lilian M Abbo
- Department of Medicine/Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Jose F Camargo
- Department of Medicine/Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Gennaro Selvaggi
- Department of Surgery/Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Thiago Beduschi
- Department of Surgery/Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Akin Tekin
- Department of Surgery/Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery/Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida
| |
Collapse
|
41
|
Updates on urinary tract infections in kidney transplantation. J Nephrol 2019; 32:751-761. [PMID: 30689126 DOI: 10.1007/s40620-019-00585-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/09/2019] [Indexed: 01/20/2023]
Abstract
Urinary tract infection (UTI) represents the most common infection after kidney transplantation; it is associated with an increased risk for acute kidney rejection and impaired graft function in the early post-transplant period. Kidney transplant recipients with UTIs are often clinically asymptomatic due to the immunosuppressive therapy; however, asymptomatic bacteriuria may progress to acute pyelonephritis, bacteremia and urosepsis, particularly in the early post-transplant period, that are independent risk factors for short and long-term graft and patient survival. This article reviews the definitions, incidence, risk factors and the management of UTI in kidney transplant recipients; furthermore, the main controversial and still unanswered questions, regarding the causes of recurrent UTIs, adequate use of antibiotics to avoid antibiotic resistance, dosing and timing for prophylaxis and treatment of symptomatic infections, are also discussed. The emerging definition of urinary microbiota introduces new concepts in understanding the complexity of the disease and might represent the future target for therapeutic interventions.
Collapse
|
42
|
McNeil JC, Campbell JR, Crews JD. The Role of the Environment and Colonization in Healthcare-Associated Infections. HEALTHCARE-ASSOCIATED INFECTIONS IN CHILDREN 2019. [PMCID: PMC7120697 DOI: 10.1007/978-3-319-98122-2_2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Healthcare-associated infections (HAIs) can be caused by endogenous host microbial flora or by exogenous microbes, including those found in the hospital environment. Efforts to decrease endogenous pathogens via decolonization and skin antisepsis may decrease the risk of infection in some settings. Controlling the spread of potential pathogens from the environment requires meticulous attention to cleaning and disinfection practices. In addition to selection of the appropriate cleaning agent, use of tools that assess the adequacy of cleaning and addition of no-touch cleaning technology may decrease environmental contamination. Hand hygiene is also a critical component of preventing transmission of pathogens from the environment to patients via healthcare worker hands.
Collapse
Affiliation(s)
- J. Chase McNeil
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Judith R. Campbell
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX USA
| | - Jonathan D. Crews
- Department of Pediatrics, Baylor College of Medicine and The Children’s Hospital of San Antonio, San Antonio, TX USA
| |
Collapse
|
43
|
Kramer TS, Remschmidt C, Werner S, Behnke M, Schwab F, Werner G, Gastmeier P, Leistner R. The importance of adjusting for enterococcus species when assessing the burden of vancomycin resistance: a cohort study including over 1000 cases of enterococcal bloodstream infections. Antimicrob Resist Infect Control 2018; 7:133. [PMID: 30459945 PMCID: PMC6234683 DOI: 10.1186/s13756-018-0419-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 10/11/2018] [Indexed: 01/27/2023] Open
Abstract
Background Infections caused by vancomycin-resistant enterococci (VRE) are on the rise worldwide. Few studies have tried to estimate the mortality burden as well as the financial burden of those infections and found that VRE are associated with increased mortality and higher hospital costs. However, it is unclear whether these worse outcomes are attributable to vancomycin resistance only or whether the enterococcal species (Enterococcus faecium or Enterococcus faecalis) play an important role. We therefore aimed to determine the burden of enterococci infections attributable to vancomycin resistance and pathogen species (E. faecium and E. faecalis) in cases of bloodstream infection (BSI). Methods We conducted a retrospective cohort study on patients with BSI caused by Enterococcus faecium or Enterococcus faecalis between 2008 and 2015 in three tertiary care hospitals. Data was collected on true hospital costs (in €), length of stay (LOS), basic demographic parameters, and underlying diseases including the results of the Charlson comorbidity index (CCI). We used univariate and multivariable regression analyses to compare risk factors for in-hospital mortality and length of stay (i) between vancomycin-susceptible E. faecium- (VSEm) and vancomycin-susceptible E. faecalis- (VSEf) cases and (ii) between vancomycin-susceptible E. faecium- (VSEm) and vancomycin-resistant E. faecium-cases (VREm). We calculated total hospital costs for VSEm, VSEf and VREm. Results Overall, we identified 1160 consecutive cases of BSI caused by enterococci: 596 (51.4%) cases of E. faecium BSI and 564 (48.6%) cases of E. faecalis BSI. 103 cases of E. faecium BSI (17.3%) and 1 case of E. faecalis BSI (0.2%) were infected by vancomycin-resistant isolates. Multivariable analyses revealed (i) that in addition to different underlying diseases E. faecium was an independent risk factor for in-hospital mortality and prolonged hospital stay and (ii) that vancomycin-resistance did not further increase the risk for the described outcomes among E. faecium-isolates. However, the overall hospital costs were significantly higher in VREm-BSI cases as compared to VSEm- and VSEf-BSI cases (80,465€ vs. 51,365€ vs. 31,122€ p < 0.001). Conclusion Our data indicates that in-hospital mortality and infection-attributed hospital stay in enterococci BSI might rather be influenced by Enterococcus species and underlying diseases than by vancomycin resistance. Therefore, future studies should consider adjusting for Enterococcus species in addition to vancomycin resistance in order to provide a conservative estimate for the burden of VRE infections. Electronic supplementary material The online version of this article (10.1186/s13756-018-0419-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tobias Siegfried Kramer
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Cornelius Remschmidt
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Sven Werner
- 3Department of Medical and Financial Controlling, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Behnke
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Frank Schwab
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Guido Werner
- 4Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany.,National Reference Centre for Staphylococci and Enterococci, Berlin, Germany
| | - Petra Gastmeier
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Rasmus Leistner
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| |
Collapse
|
44
|
Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
Collapse
Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
| |
Collapse
|
45
|
Practical methods for effective vancomycin-resistant enterococci (VRE) surveillance: experience in a liver transplant surgical intensive care unit. Infect Control Hosp Epidemiol 2018; 39:1178-1182. [PMID: 30178725 DOI: 10.1017/ice.2018.178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We evaluated the utility of vancomycin-resistant Enterococcus (VRE) surveillance by varying 2 parameters: admission versus weekly surveillance and perirectal swabbing versus stool sampling. DESIGN Prospective, patient-level surveillance program of incident VRE colonization. SETTING Liver transplant surgical intensive care unit (SICU) of a tertiary-care referral medical center with a high prevalence of VRE.PatientsAll patients admitted to the SICU from June to August 2015. METHODS We conducted a point-prevalence estimate followed by admission and weekly surveillance by perirectal swabbing and/or stool sampling. Incident colonization was defined as a negative screen followed by positive surveillance. VRE was detected by culture on Remel Spectra VRE chromogenic agar. Microbiologically-confirmed VRE bloodstream infections (BSIs) were tracked for 2 months. Statistical analyses were calculated using the McNemar test, the Fisher exact test, the t test, and the χ2 test. RESULTS In total, 91 patients underwent VRE surveillance testing. The point prevalence of VRE colonization was 60.9%; VRE prevalence on admission was 30.1%. Weekly surveillance identified an additional 7 of 28 patients (25.0%) with incident colonization. VRE BSIs were more common in VRE-colonized patients than in noncolonized patients (8 of 43 vs 2 of 48; P=.028). In a direct comparison, perirectal swabs were more sensitive than stool samples in detecting VRE (64 of 67 vs 56 of 67; P=.023). Compliance with perirectal swabbing was 89% (201 of 226) compared to 56% (127 of 226) for stool collection (P≤0.001). CONCLUSIONS We recommend weekly VRE surveillance over admission-only screening in high-burden units such as liver transplant SICUs. Perirectal swabs had greater collection compliance and sensitivity than stool samples, making them the preferred methodology. Further work may have implications for antimicrobial stewardship and infection control.
Collapse
|
46
|
Multidrug-Resistant Bacterial Infections in Solid Organ Transplant Candidates and Recipients. Infect Dis Clin North Am 2018; 32:551-580. [DOI: 10.1016/j.idc.2018.04.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
47
|
Tschelaut L, Assadian O, Strauss R, Matiasek J, Beer M, Angerler G, Berger-Grabner D, Presterl E. A survey on current knowledge, practice and beliefs related to preoperative antimicrobial decolonization regimens for prevention of surgical site infections among Austrian surgeons. J Hosp Infect 2018; 100:386-392. [PMID: 30031167 DOI: 10.1016/j.jhin.2018.07.019] [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: 05/15/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Various measures are considered to reduce the risk of surgical site infection (SSI), including preoperative decolonization. Details of preoperative decolonization practices in surgical departments have not been investigated in Austria. AIM To analyse the current situation of pre-surgical patient decolonization in national hospitals and to assess the current knowledge on this procedure among surgeons of different surgical disciplines. METHODS A 12-point structured questionnaire was distributed to all Austrian hospitals with at least one surgical department. FINDINGS Two-thirds (103/158; 65%) of responding surgeons stated that any type of preoperative decolonization is implemented in their surgical department. There was heterogeneity of different protocols, ranging from decolonization of only known S. aureus carriers, of a subgroup of patients, or universal decolonization of all patients before elective surgery. Octenidine was the most frequently used antimicrobial compound (60.2%), followed by mupirocin (38.8%), triclosan (14.6%), polyhexanide (12.6%), chlorhexidine (11.7%), and didecyldimonium chloride (7.8%). CONCLUSION Preoperative decolonization seems to be performed in Austrian hospitals on a routine basis. However, this measure is implemented using a variety of modalities, antimicrobial compounds, and staff. Since our survey also demonstrated that those who are better informed about preoperative decolonization are also those who are more convinced of the usefulness of the preventive measure, future activities should not only focus on generating more comparable studies in this field, but should also include targeted education.
Collapse
Affiliation(s)
- L Tschelaut
- Department of Business, IMC University of Applied Science, Krems, Austria
| | - O Assadian
- Department for Hospital Epidemiology & Infection Control, Medical University of Vienna, Vienna, Austria; Austrian Society for Infection Control, Vienna, Austria
| | - R Strauss
- Federal Ministry of Health and Women's Affairs, Department III/1, Vienna, Austria
| | - J Matiasek
- Department of Plastic and Reconstructive Surgery, St Josef Hospital Vienna, Austria
| | - M Beer
- University of Veterinary Medicine, Vienna, Austria
| | - G Angerler
- Unit for Hospital Hygiene, Orthopaedic Hospital Speising, Vienna, Austria
| | - D Berger-Grabner
- Department of Business, IMC University of Applied Science, Krems, Austria.
| | - E Presterl
- Department for Hospital Epidemiology & Infection Control, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
48
|
Paulsen G, Blum S, Danziger-Isakov L. Epidemiology and outcomes of pretransplant methicillin-resistant Staphylococcus Aureus screening in pediatric solid organ transplant candidates. Pediatr Transplant 2018; 22:e13246. [PMID: 29888518 DOI: 10.1111/petr.13246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2018] [Indexed: 11/28/2022]
Abstract
MRSA infection following SOT is an important cause of morbidity and mortality, but epidemiology and risk factors for colonization prior to pediatric SOT remain unclear. A retrospective cohort of SOT patients ≤21 years of age from 2009 to 2014 was evaluated. Demographics, MRSA screens, timing of transplantation, and MRSA infection were abstracted. From 2013 to 2014, 130 SOT candidates were screened or had known prior MRSA infection. Seventeen patients (13%) were MRSA colonized. Liver transplant candidates were least likely to be colonized (OR 0.22, CI:0.06-0.81, P = .02); greatest risk of colonization was in lung (OR 18.7, CI:1.9-182.3, P = .03), abdominal multivisceral (OR 7.5, CI:1.5-38.6, P = .02), and cardiac patients with history of cardiothoracic surgery (OR 8.0, CI:1.7-36.0, P = .007). In univariable analysis, African American patients were more likely to be colonized (OR 7.1, CI:2.49-19.41, P = .0005). There were 3 early MRSA infections in screened patients, incidence of 3.9%; only one in a colonized patient. Thirteen percent of screened pediatric SOT candidates were MRSA colonized, with greatest risk in lung, multivisceral and cardiac patients with prior cardiothoracic surgery. Early MRSA infection occurred in 3.9% of transplanted patients. Cardiothoracic and multivisceral organ transplant candidates may benefit the most from targeted MRSA screening.
Collapse
Affiliation(s)
- Grant Paulsen
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samantha Blum
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
49
|
Liu T, Zhang Y, Wan Q. Methicillin-resistant Staphylococcus aureus bacteremia among liver transplant recipients: epidemiology and associated risk factors for morbidity and mortality. Infect Drug Resist 2018; 11:647-658. [PMID: 29765236 PMCID: PMC5939879 DOI: 10.2147/idr.s161180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bacteremia due to Staphylococcus aureus, especially methicillin-resistant S. aureus (MRSA), complicates the clinical course of liver transplantation and is associated with high morbidity and mortality. Intravascular catheters had been reported to be the most frequent source of MRSA bacteremia. Among bacteremic liver recipients, 26.3%-100% of S. aureus were MRSA. Previous studies identified pre-transplant and post-transplant acquired S. aureus carriage, greater severity of liver disease, hepatocellular carcinoma and infection with immuno-modulatory viruses as predictors of S. aureus bacteremia in liver recipients. MRSA bacteremia accompanied by pneumonia and abdominal infections was related to mortality. Vancomycin, as well as daptomycin, is a first-line antibiotic for MRSA bacteremia. The purpose of this review is to better understand the characteristics of MRSA bacteremia by summarizing the epidemiology and antimicrobial resistance of S. aureus, the primary source, and related risk factors for morbidity and mortality of MRSA bacteremia. We have also explored the diagnostic, therapeutic and preventive measures for MRSA bacteremia to improve the outcomes of liver recipients.
Collapse
Affiliation(s)
- Taohua Liu
- Department of Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, People’s Republic of China
| | - Yuezhong Zhang
- Department of Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, People’s Republic of China
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| |
Collapse
|
50
|
Lewis JD, Barros AJ, Sifri CD. Comparison of risk factors and outcomes of daptomycin-susceptible and -nonsusceptible vancomycin-resistant Enterococcus faecium infections in liver transplant recipients. Transpl Infect Dis 2018; 20:e12856. [PMID: 29427322 DOI: 10.1111/tid.12856] [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: 07/10/2017] [Revised: 10/11/2017] [Accepted: 11/20/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vancomycin-resistant Enterococcus faecium (VRE) infections are common in liver transplant recipients (LTRs). Daptomycin (DAP) is an important treatment for such infections; however, DAP-nonsusceptible VRE (DNS-VRE) are increasingly frequent. The purpose of this study was to compare clinical characteristics and outcomes of LTRs with infections due to DNS-VRE and DAP-susceptible VRE (DS-VRE). METHODS A single center, retrospective review of patients who underwent liver transplantation between January 1, 2010 and December 31, 2015 and developed infections due to DS-VRE or DNS-VRE post transplant was performed. Patients with DNS-VRE and DS-VRE infections were compared using univariate and logistic regression analysis. RESULTS Fourteen LTRs developed DNS-VRE and 20 LTRs developed DS-VRE infection post-transplantation. No significant differences were observed in demographics, model for end-stage liver disease (MELD) scores, causes of end-stage liver disease, or rate of pre-transplant perirectal VRE colonization between groups. Bleeding complications and renal replacement therapy were more common in the DNS-VRE group than in the DS-VRE group. The duration of transplant hospitalization and post-transplant intensive care unit (ICU) admission was longer in the DNS-VRE group than in the DS-VRE group. The 30-day and 6-month mortality rate associated with DNS-VRE infection was similar to that associated with DS-VRE infection. CONCLUSIONS Liver transplant recipients who develop DNS-VRE infection have higher bleeding complications and longer, more complex hospitalizations compared to those who develop DS-VRE infection post transplantation; however, mortality at 30 days and 6 months is not significantly worse. Further study is needed to determine optimal strategies for the prevention and treatment of DNS-VRE infections in LTRs.
Collapse
Affiliation(s)
- J D Lewis
- Division of Infectious Diseases & International Health, University of Virginia Health System, Charlottesville, VA, USA.,Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - A J Barros
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - C D Sifri
- Division of Infectious Diseases & International Health, University of Virginia Health System, Charlottesville, VA, USA.,Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA.,Office of Hospital Epidemiology/Infection Prevention & Control, University of Virginia Health System, Charlottesville, VA, USA
| |
Collapse
|