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Park SY, Baek YJ, Kim JH, Seong H, Kim B, Kim YC, Yoon JG, Heo N, Moon SM, Kim YA, Song JY, Choi JY, Park YS. Guidelines for Antibacterial Treatment of Carbapenem-Resistant Enterobacterales Infections. Infect Chemother 2024; 56:308-328. [PMID: 39231504 DOI: 10.3947/ic.2024.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/19/2024] [Indexed: 09/06/2024] Open
Abstract
This guideline aims to promote the prudent use of antibacterial agents for managing carbapenem-resistant Enterobacterales (CRE) infections in clinical practice in Korea. The general section encompasses recommendations for the management of common CRE infections and diagnostics, whereas each specific section is structured with key questions that are focused on antibacterial agents and disease-specific approaches. This guideline covers both currently available and upcoming antibacterial agents in Korea.
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Affiliation(s)
- Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Yae Jee Baek
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jung Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Seong
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Bongyoung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yong Chan Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Infectious Diseases, Yonsei University Yongin Severance Hospital, Yongin, Korea
| | - Jin Gu Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Namwoo Heo
- Department of Infectious Diseases, Yonsei University Yongin Severance Hospital, Yongin, Korea
| | - Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Ah Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Joon Young Song
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Soo Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Infectious Diseases, Yonsei University Yongin Severance Hospital, Yongin, Korea.
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Li D, Rao H, Xu Y, Zhang M, Zhang J, Luo J. Monotherapy vs combination therapy in patients with Klebsiella pneumoniae bloodstream infection: A systematic review and meta-analysis. J Infect Chemother 2024; 30:372-378. [PMID: 38369125 DOI: 10.1016/j.jiac.2024.02.007] [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: 10/22/2023] [Revised: 12/24/2023] [Accepted: 02/06/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To determine whether mortality is lower in patients with Klebsiella pneumoniae bloodstream infection (BSI) who receive combination antimicrobial therapy than in those who receive monotherapy. METHODS Two authors independently searched for relevant articles in the PubMed, Embase, Web of Science, and Cochrane Library databases through to August 10, 2023. Risk of bias was evaluated using the ROBINS-I tool. Possible sources of heterogeneity were evaluated by meta-regression using a mixed-effects model. RESULTS Among 8044 articles screened, there were 23 studies (3443 patients) that were eligible for meta-analysis. Meta-regression analysis identified the proportion of patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI to be a potential source of heterogeneity. Subgroup analysis showed that mortality on monotherapy was significantly higher when the proportion of patients with CRKP BSI was ≥50% (OR 1.75, 95% CI 1.33-2.30) and significantly lower when this proportion was <50% (OR 0.55, 95% CI 0.24-1.24). Overall mortality was significantly higher on tigecycline monotherapy (OR 2.86, 95% CI 1.46-5.59) than on combination therapy containing both these agents. There was a trend in favor of colistin/polymyxin B-containing combination therapy (OR 1.37, 95% CI 0.83-2.28). CONCLUSIONS Combination antimicrobial therapy can lower mortality in patients with CRKP but may not show a survival advantage over monotherapy when the proportion of patients with CRKP BSI is <50%. High-quality prospective observational studies are needed because of the high risk of bias and limited data in the studies performed to date.
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Affiliation(s)
- Dan Li
- Department of Laboratory Medicine, Qionglai Medical Center Hospital , Chengdu, Sichuan, China
| | - Huayun Rao
- Department of Laboratory Medicine, Qionglai Medical Center Hospital , Chengdu, Sichuan, China
| | - Yi Xu
- Department of Laboratory Medicine, Qionglai Medical Center Hospital , Chengdu, Sichuan, China
| | - Min Zhang
- Department of Laboratory Medicine, Qionglai Medical Center Hospital , Chengdu, Sichuan, China
| | - Jie Zhang
- Department of Laboratory Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Jianrong Luo
- Department of Laboratory Medicine, Qionglai Medical Center Hospital , Chengdu, Sichuan, China.
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Katip W, Rayanakorn A, Oberdorfer P, Taruangsri P, Nampuan T, Okonogi S. Comparative effectiveness and mortality of colistin monotherapy versus colistin-fosfomycin combination therapy for the treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections: A propensity score analysis. J Infect Public Health 2024; 17:727-734. [PMID: 38513335 DOI: 10.1016/j.jiph.2024.03.010] [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: 09/02/2023] [Revised: 01/21/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) infections pose a significant threat to global health due to limited treatment options and high mortality rates. Colistin-based regimens have emerged as a primary treatment approach, but the effectiveness and mortality outcomes of colistin monotherapy versus colistin-fosfomycin combination therapy remain uncertain. This study aims to compare the effectiveness and mortality of colistin monotherapy and colistin-fosfomycin combination therapy for CRE infections. Notably, our study is the first to undertake a comprehensive examination of the effectiveness and mortality outcomes between colistin monotherapy and colistin-fosfomycin combination therapy in the context of CRE infections. METHODS A retrospective cohort study was conducted using data from patients diagnosed with carbapenem-resistant Enterobacteriaceae (CRE) infections at Nakornping Hospital during 2015 to 2022. Inverse probability weighting (IPW) was employed to create balanced cohorts of patients receiving either colistin monotherapy or colistin-fosfomycin combination therapy. The primary outcome measure was treatment effectiveness, assessed by 30-day mortality. Secondary outcome measures included clinical response, mortality at the end of treatment, and microbiologic response. Univariate and multivariate logistic regression analysis were employed after applying propensity score weighting using inverse probability of weighting (IPW). RESULTS A total of 220 patients were included in the analysis, with 67 receiving colistin monotherapy and 153 receiving colistin-fosfomycin combination therapy. Propensity score weighting using IPW balanced the baseline characteristics between the two groups. The effectiveness of treatment, as measured by 30-day mortality, was not significantly different between the colistin monotherapy group and the colistin-fosfomycin combination therapy group (adjusted odds ratio [aOR] = 1.51, 95% confidence interval [CI]: 0.60-3.78, p = 0.383). Similarly, no significant difference was observed in the mortality at the end of treatment between the two groups (aOR = 1.26, 95% CI: 0.55-2.90, p = 0.576). The clinical response (aOR = 1.48, 95% CI: 0.61-3.59, p = 0.383) and microbiologic response (aOR = 0.66, 95% CI: 0.18-2.38, p = 0.527) were similar between the colistin monotherapy and colistin-fosfomycin combination therapy groups. CONCLUSION The propensity score analysis among 220 matched patients showed comparable treatment effectiveness and mortality between colistin monotherapy and colistin-fosfomycin combination therapy for CRE infections. These results suggest that colistin monotherapy may be as effective as combination therapy. More prospective randomized controlled trials are needed to confirm these findings and establish optimal CRE treatment strategies.
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Affiliation(s)
- Wasan Katip
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand; Epidemiological and Innovative Research Group of Infectious Diseases (EIRGID), Chiang Mai University, Chiang Mai 50200, Thailand; Center of Excellence in Pharmaceutical Nanotechnology, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand.
| | - Ajaree Rayanakorn
- Epidemiological and Innovative Research Group of Infectious Diseases (EIRGID), Chiang Mai University, Chiang Mai 50200, Thailand; Department of Pharmacology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Peninnah Oberdorfer
- Epidemiological and Innovative Research Group of Infectious Diseases (EIRGID), Chiang Mai University, Chiang Mai 50200, Thailand; Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | | | - Teerapong Nampuan
- Department of Pharmacy, Nakornping Hospital, Chiang Mai 50180, Thailand
| | - Siriporn Okonogi
- Center of Excellence in Pharmaceutical Nanotechnology, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand; Department of Pharmaceutical Sciences, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
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Li X, Li C, Zhou L, Wang Q, Yao J, Zhang X, Yu Y, Li R, Zhou H, Tu Y. Global phylogeography and genomic characterization of bla KPC and bla NDM-positive clinical Klebsiella aerogenes isolates from China, 2016-2022. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 923:171560. [PMID: 38458455 DOI: 10.1016/j.scitotenv.2024.171560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
Carbapenem-resistant Klebsiella aerogenes (CRKA), being one of the members of carbapenem-resistant Enterobacteriaceae (CRE), has caused great public health concern, but with fewer studies compared to other CRE members. Furthermore, studies on phylogenetic analysis based on whole genome Single-Nucleotide Polymorphism (SNP) of CRKA were limited. Here, 20 CRKA isolates (11 blaKPC-2-bearing and 9 blaNDM-1/5-harboring) were characterized by antimicrobial susceptibility testing, conjugation assay, whole genome sequencing (WGS) and bioinformatics analysis. Additionally, the phylogeographic relationships of K. aerogenes were further investigated from public databases. All isolates were multidrug-resistant (MDR) bacteria, and they demonstrated susceptibility to colistin. Most blaKPC-2 or blaNDM-1/5-carrying plasmids were found to be conjugative. Phylogenetic analysis revealed the clonal dissemination of K. aerogenes primarily occurred within clinical settings. Notably, some strains in this study showed the potential for clonal transmission, sharing few SNPs between K. aerogenes and KPC- and/or NDM-positive K. aerogenes isolated from various countries. The STs of K. aerogenes strains had significant diversity. WGS analysis showed that the IncFIIK plasmid was the most prevalent carrier of blaKPC-2, and, blaNDM-1/5 were detected on the IncX3 plasmids. The Tn6296 and Tn3000 transposons were most common vehicles for facilitating the transmission of blaKPC-2 and blaNDM-1/5, respectively. This study highlights the importance of continuous screening and surveillance by WGS for analysis of drug-resistant strains in hospital settings, and provide clinical information that supports epidemiological and public health research on human pathogens.
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Affiliation(s)
- Xi Li
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Changan Li
- Jiangsu Co-Innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu 225009, China
| | - Longjie Zhou
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Qiaojun Wang
- Jiangsu Co-Innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu 225009, China
| | - Jiayao Yao
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Xiaofan Zhang
- Laboratory Medicine Center, Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Yunsong Yu
- Center for General Practice Medicine, Department of Infectious Diseases, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Ruichao Li
- Jiangsu Co-Innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, College of Veterinary Medicine, Yangzhou University, Yangzhou, Jiangsu 225009, China.
| | - Hua Zhou
- Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, China.
| | - Yuexing Tu
- Department of Critical Care Medicine, Tongde Hospital of Zhejiang Province, #234 Gucui Road, Hangzhou, Zhejiang 310012, China.
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Cogliati Dezza F, Covino S, Petrucci F, Sacco F, Viscido A, Gavaruzzi F, Ceccarelli G, Raponi G, Borrazzo C, Alessandri F, Mastroianni CM, Venditti M, Oliva A. Risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections and related mortality in critically ill patients with CRAB colonization. JAC Antimicrob Resist 2023; 5:dlad096. [PMID: 37577156 PMCID: PMC10412853 DOI: 10.1093/jacamr/dlad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/21/2023] [Indexed: 08/15/2023] Open
Abstract
Background Among MDR bacteria, carbapenem-resistant Acinetobacter baumannii (CRAB) is a major concern due to the limited therapeutic options. During the COVID-19 pandemic, a worrying increase in the spread of CRAB infections was reported. Objectives The study assessed the risk factors for CRAB bloodstream infection (BSI) in patients admitted to the ICU with CRAB colonization, and the related mortality risk factors. Methods We conducted a single-centre, observational, prospective study; all consecutive patients with CRAB colonization admitted to the ICU of a tertiary hospital in Rome from January 2021 to September 2022 were included in the study. Univariate and multivariate analyses were performed to investigate BSI and mortality risk factors. Results Overall, 129 patients were included in the study; 57 (44%) out of these developed BSI. In our study population, at the multivariable analysis the Charlson comorbidity index (CCI) (P = 0.026), COVID-19 (P < 0.001), multisite colonization (P = 0.016) and the need for mechanical ventilation (P = 0.024) were risk factors independently associated with BSI development. Furthermore, age (P = 0.026), CCI (P < 0.001), septic shock (P = 0.001) and Pitt score (P < 0.001) were independently associated with mortality in the BSI patients. Instead, early appropriate therapy (P = 0.002) and clinical improvement within 72 h (P = 0.011) were shown to be protective factors. Conclusions In critically ill patients colonized by CRAB, higher CCI, multisite colonization and the need for mechanical ventilation were identified as risk factors for BSI onset. These predictors could be useful to identify patients at highest risk of BSI.
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Affiliation(s)
| | - Sara Covino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Flavia Petrucci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Sacco
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Agnese Viscido
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Gavaruzzi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Gianmarco Raponi
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristian Borrazzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | | | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Zeng M, Xia J, Zong Z, Shi Y, Ni Y, Hu F, Chen Y, Zhuo C, Hu B, Lv X, Li J, Liu Z, Zhang J, Yang W, Yang F, Yang Q, Zhou H, Li X, Wang J, Li Y, Ren J, Chen B, Chen D, Wu A, Guan X, Qu J, Wu D, Huang X, Qiu H, Xu Y, Yu Y, Wang M. Guidelines for the diagnosis, treatment, prevention and control of infections caused by carbapenem-resistant gram-negative bacilli. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:653-671. [PMID: 36868960 DOI: 10.1016/j.jmii.2023.01.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/14/2023] [Accepted: 01/26/2023] [Indexed: 02/19/2023]
Abstract
The dissemination of carbapenem-resistant Gram-negative bacilli (CRGNB) is a global public health issue. CRGNB isolates are usually extensively drug-resistant or pandrug-resistant, resulting in limited antimicrobial treatment options and high mortality. A multidisciplinary guideline development group covering clinical infectious diseases, clinical microbiology, clinical pharmacology, infection control, and guideline methodology experts jointly developed the present clinical practice guidelines based on best available scientific evidence to address the clinical issues regarding laboratory testing, antimicrobial therapy, and prevention of CRGNB infections. This guideline focuses on carbapenem-resistant Enterobacteriales (CRE), carbapenem-resistant Acinetobacter baumannii (CRAB), and carbapenem-resistant Pseudomonas aeruginosa (CRPA). Sixteen clinical questions were proposed from the perspective of current clinical practice and translated into research questions using PICO (population, intervention, comparator, and outcomes) format to collect and synthesize relevant evidence to inform corresponding recommendations. The grading of recommendations, assessment, development and evaluation (GRADE) approach was used to evaluate the quality of evidence, benefit and risk profile of corresponding interventions and formulate recommendations or suggestions. Evidence extracted from systematic reviews and randomized controlled trials (RCTs) was considered preferentially for treatment-related clinical questions. Observational studies, non-controlled studies, and expert opinions were considered as supplementary evidence in the absence of RCTs. The strength of recommendations was classified as strong or conditional (weak). The evidence informing recommendations derives from studies worldwide, while the implementation suggestions combined the Chinese experience. The target audience of this guideline is clinician and related professionals involved in management of infectious diseases.
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Affiliation(s)
- Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai 200032, China
| | - Jun Xia
- The Nottingham Ningbo GRADE Centre, University of Nottingham Ningbo China, Ningbo, China; Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhiyong Zong
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi Shi
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Yuxing Ni
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, And Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of People's Republic of China, Shanghai 200040, China
| | - Yijian Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University, And Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of People's Republic of China, Shanghai 200040, China
| | - Chao Zhuo
- Department of Infectious Diseases, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiaoju Lv
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jiabin Li
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Anhui 230022, China
| | - Zhengyin Liu
- Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, And Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of People's Republic of China, Shanghai 200040, China
| | - Wenjie Yang
- Department of Infectious Diseases, Tianjin First Center Hospital, Tianjin 300192, China
| | - Fan Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, And Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of People's Republic of China, Shanghai 200040, China
| | - Qiwen Yang
- Department and State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hua Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xin Li
- Department of Pharmacy, The Third Hospital of Changsha, Changsha 410015, China
| | - Jianhua Wang
- Pharmaceutical Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China
| | - Yimin Li
- Department of Critical Care Medicine,State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jian'an Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
| | - Baiyi Chen
- Divison of Infectious Diseases, The First Hospital of China Medical University, Shenyang 110001, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Beijing 100044, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Yingchun Xu
- Department and State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, And Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of People's Republic of China, Shanghai 200040, China.
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7
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Zhang L, Zhen S, Shen Y, Zhang T, Wang J, Li J, Lin Q, Xiao Z, Zheng Y, Jiang E, Han M, Wang J, Feng S. Bloodstream infections due to Carbapenem-Resistant Enterobacteriaceae in hematological patients: assessment of risk factors for mortality and treatment options. Ann Clin Microbiol Antimicrob 2023; 22:41. [PMID: 37202758 DOI: 10.1186/s12941-023-00586-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
PURPOSE Bloodstream infection (BSI) caused by Carbapenem-Resistant Enterobacteriaceae (CRE) are associated with poor outcomes in hematological patients. The aim of this study was to identify risk factors for mortality and evaluate the value of epidemiological feature of carbapenemases in guiding antimicrobial treatment options. METHODS Hematological patients with monomicrobial CRE BSI between January 2012 and April 2021 were included. The primary outcome was all-cause mortality 30 days after BSI onset. RESULTS A total of 94 patients were documented in the study period. Escherichia coli was the most common Enterobacteriaceae, followed by Klebsiella pneumoniae. 66 CRE strains were tested for carbapenemase genes, and 81.8% (54/66) were positive, including NDM (36/54), KPC (16/54), IMP (1/54). Besides, one E. coli isolate was found to express both NDM and OXA-48-like genes. Overall, 28 patients received an antimicrobial treatment containing ceftazidime-avibactam (CAZ-AVI), of which 21 cases were combined with aztreonam. The remaining 66 patients were treated with other active antibiotics (OAAs). The 30-day mortality rate was 28.7% (27/94) for all patients, and was only 7.1% ((2/28) for patients treated with CAZ-AVI. In multivariate analysis, the presence of septic shock at BSI onset (OR 10.526, 95% CI 1.376-76.923) and pulmonary infection (OR 6.289, 95% CI 1.351-29.412) were independently risk factors for 30-day mortality. Comparing different antimicrobial regimens, CAZ-AVI showed a significant survive benefit than OAAs (OR 0.068, 95% CI 0.007-0.651). CONCLUSION CAZ-AVI-containing regimen is superior to OAAs for CRE BSI. As the predominance of blaNDM in our center, we recommend the combination with aztreonam when choose CAZ-AVI.
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Affiliation(s)
- Lining Zhang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Sisi Zhen
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Yuyan Shen
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Tingting Zhang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jieru Wang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jia Li
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Qingsong Lin
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
| | - Zhijian Xiao
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Yizhou Zheng
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Erlie Jiang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Mingzhe Han
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jianxiang Wang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Sizhou Feng
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
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8
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Syed B, Ishaque S, Imran A, Muslim O, Khalid S, Siddiqui AB. Emergence of colistin-resistant gram-negative rods in intensive care units: A cross-sectional study from a developing country. SAGE Open Med 2022; 10:20503121221132358. [PMID: 36277441 PMCID: PMC9583228 DOI: 10.1177/20503121221132358] [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: 12/10/2021] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives To determine the clinical features, outcomes, and factors associated with the emergence of colistin-resistant gram-negative rods isolated from patients admitted to intensive care units. Methods This cross-sectional study was conducted at the intensive care units of Liaquat National Hospital, from April 2019 to February 2020. Gram-negative rods resistant to colistin with minimum inhibitory concentrations ⩾ 4 mcg/mL according to Clinical and Laboratory Standards Institute criteria as reported in cultures were included. Clinical, demographical data and treatment given were recorded and analyzed using SPSS version 25. Results A total of 93 patients were included; 58.1% were males. The mean age of patients was 59.48 ± 18.36 years. The most common organism isolated was Klebsiella pneumoniae (91.4%). The most common specimen was the tracheal (62.4%). Ventilator-acquired pneumonia was seen in 38.7%. The most common co-morbid disease seen in patients was diabetes (41%); 77% had a symptomatic infection and were treated with a combination of 2 or more antibiotics, most commonly meropenem plus fosfomycin. The most common susceptible antibiotics were fosfomycin (72%) and tigecycline (50.5%). Mean intensive care unit stay and total duration of hospital stay were prolonged (16.83 ± 12.93 and 23.34 ± 17.52 days, respectively). Forty-eight (62.3%) patients with symptomatic infection with colistin-resistant isolates were treated and discharged, and mortality was seen in 23 (29.9%). A significant association was found between mortality and symptomatic infection, endotracheal intubation with mechanical ventilation (p = 0.003), and a prolonged hospital stay of >20 days (p = 0.041). Conclusion Colistin-resistant gram-negative rods pose a significant problem especially in developing countries because of limited therapeutic options. Stringent infection control and comprehensive antimicrobial stewardship programs are needed to overcome this challenge.
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Affiliation(s)
- Beenish Syed
- Sindh Infectious Diseases Hospital and
Research Center, Dow University of Health Sciences, Karachi, Pakistan,Beenish Syed, Sindh Infectious Diseases
Hospital and Research Center, Dow University of Health Sciences, Gulshan-e-Iqbal
Block 10, Karachi, 75300, Pakistan.
| | - Sadia Ishaque
- Shaheed Mohtarma Benazir Bhutto Trauma
Center, Karachi, Pakistan
| | - Abira Imran
- Department of Biostatistics, Liaquat
National Hospital and Medical College, Karachi, Pakistan
| | - Osaid Muslim
- Department of Medicine, Agha Khan
University Hospital, Karachi, Pakistan
| | - Seema Khalid
- Department of Medicine, Liaquat
National Hospital and Medical College, Karachi, Pakistan
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9
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Vidal-Cortés P, Martin-Loeches I, Rodríguez A, Bou G, Cantón R, Diaz E, De la Fuente C, Torre-Cisneros J, Nuvials FX, Salavert M, Aguilar G, Nieto M, Ramírez P, Borges M, Soriano C, Ferrer R, Maseda E, Zaragoza R. Current Positioning against Severe Infections Due to Klebsiella pneumoniae in Hospitalized Adults. Antibiotics (Basel) 2022; 11:antibiotics11091160. [PMID: 36139940 PMCID: PMC9495006 DOI: 10.3390/antibiotics11091160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Infections due to Klebsiella pneumoniae have been increasing in intensive care units (ICUs) in the last decade. Such infections pose a serious problem, especially when antimicrobial resistance is present. We created a task force of experts, including specialists in intensive care medicine, anaesthesia, microbiology and infectious diseases, selected on the basis of their varied experience in the field of nosocomial infections, who conducted a comprehensive review of the recently published literature on the management of carbapenemase-producing Enterobacterales (CPE) infections in the intensive care setting from 2012 to 2022 to summarize the best available treatment. The group established priorities regarding management, based on both the risk of developing infections caused by K. pneumoniae and the risk of poor outcome. Moreover, we reviewed and updated the most important clinical entities and the new antibiotic treatments recently developed. After analysis of the priorities outlined, this group of experts established a series of recommendations and designed a management algorithm.
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Affiliation(s)
| | - Ignacio Martin-Loeches
- ICU, Trinity Centre for Health Science HRB-Welcome Trust, St. James’s Hospital Dublin, D08 NHY1 Dublin, Ireland
| | - Alejandro Rodríguez
- ICU, Hospital Universitari Joan XXIII, 43005 Tarragona, Spain
- Institut d’Investigació Sanitària Pere Virgil, 43007 Tarragona, Spain
- Departament Medicina I Ciruurgia, Universitat Rovira i Virgili, 43003 Tarragona, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Germán Bou
- Microbiology Department, Complejo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Rafael Cantón
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Microbiology Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Emili Diaz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Critical Care Department, Corporació Sanitària Parc Taulí, 08208 Sabadell, Spain
- Department of Medicine, Universitat Autonoma de Barcelona (UAB), 08193 Barcelona, Spain
| | | | - Julián Torre-Cisneros
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Service, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14004 Córdoba, Spain
| | | | - Miguel Salavert
- Infectious Diseases Department, Hospital Universitari I Politecnic La Fe, 46026 Valencia, Spain
| | - Gerardo Aguilar
- SICU, Department of Anesthesiology and Critical Care, Hospital Clínico Universitario Valencia, 46014 Valencia, Spain
- School of Medicine, Universitat de Valencia, 46010 Valencia, Spain
| | - Mercedes Nieto
- ICU, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Paula Ramírez
- ICU, Hospital Universitari I Politecnic La Fe, 46026 Valencia, Spain
| | - Marcio Borges
- ICU, Hospital Universitario Son Llázter, 07198 Palma de Mallorca, Spain
- Fundación Micellium, 46183 Valencia, Spain
| | - Cruz Soriano
- ICU, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | | | - Emilio Maseda
- Fundación Micellium, 46183 Valencia, Spain
- SICU, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Zaragoza
- Fundación Micellium, 46183 Valencia, Spain
- ICU, Hospital Universitario Dr. Peset, 46017 Valencia, Spain
- Correspondence:
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10
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Cogliati Dezza F, Arcari G, Alessi F, Valeri S, Curtolo A, Sacco F, Ceccarelli G, Raponi G, Alessandri F, Mastroianni CM, Venditti M, Oliva A. Clinical Impact of COVID-19 on Multi-Drug-Resistant Gram-Negative Bacilli Bloodstream Infections in an Intensive Care Unit Setting: Two Pandemics Compared. Antibiotics (Basel) 2022; 11:926. [PMID: 35884179 PMCID: PMC9312122 DOI: 10.3390/antibiotics11070926] [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: 05/31/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Two mutually related pandemics are ongoing worldwide: the COVID-19 and antimicrobial resistance pandemics. This study aims to evaluate the impact of COVID-19 on multi-drug-resistant Gram-negative bacteria (MDR-GN) bloodstream infections (BSIs) in a single intensive care unit (ICU). We conducted a retrospective study including patients admitted to the ICU, reorganized for COVID-19 patients' healthcare, with at least one confirmed MDR-GN BSI during 2019-2020. We compared clinical and microbiological features, incidence density, antibiotic therapy and mortality rate in pre- and during-COVID-19 pandemic periods. We estimated the impact of COVID-19 on mortality by means of univariate Cox regression analyses. A total of 46 patients were included in the study (28 non-COVID-19/18 COVID-19). Overall, 63 BSI episodes occurred (44/19), and non-COVID-19 patients had a higher incidence of MDR-GN BSIs and were more likely to present K. pneumoniae BSIs, while the COVID-19 group showed more A. baumannii BSIs with higher per pathogen incidence. COVID-19 patients presented more critical conditions at the BSI onset, a shorter hospitalization time from BSI to death and higher 30-day mortality rate from BSI onset. COVID-19 and septic shock were associated with 30-day mortality from MDR-GN BSIs, while early active therapy was a protective factor. In conclusion, COVID-19 showed a negative impact on patients with MDR-GN BSIs admitted to the ICU.
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Affiliation(s)
- Francesco Cogliati Dezza
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Gabriele Arcari
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (G.A.); (F.S.); (G.R.)
| | - Federica Alessi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Serena Valeri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Ambrogio Curtolo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Federica Sacco
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (G.A.); (F.S.); (G.R.)
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Giammarco Raponi
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy; (G.A.); (F.S.); (G.R.)
| | - Francesco Alessandri
- Department of Anesthesia and Critical Care Medicine, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy;
| | - Claudio Maria Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (F.C.D.); (F.A.); (S.V.); (A.C.); (G.C.); (C.M.M.); (M.V.)
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11
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Performance Evaluation of the VITEK2 and Sensititre Systems to Determine Colistin Resistance and MIC for Acinetobacter baumannii. Diagnostics (Basel) 2022; 12:diagnostics12061487. [PMID: 35741297 PMCID: PMC9221671 DOI: 10.3390/diagnostics12061487] [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: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022] Open
Abstract
Performances of the colistin antimicrobial susceptibility testing (AST) systems of Acinetobacter baumannii vary depending on the manufacturer, and data on colistin-resistant A. baumannii are limited. We evaluated the VITEK2 and Sensititre systems to determine colistin resistance and minimum inhibitory concentration (MIC) for A. baumannii isolated from a clinical microbiology laboratory. A total of 213 clinical A. baumannii isolates were tested, including 81 colistin-resistant A. baumannii. ASTs were performed using the VITEK2 and Sensititre systems according to the manufacturer’s instructions. Reference MICs for colistin were determined using the manual broth microdilution method (BMD). The results of the two AST methods were compared with the BMD results. VITEK2 and Sensititre systems showed category agreements of 95.3% and 99.1%, respectively. VITEK2 had a relatively high very major error (VME) rate (9.9%). Sensititre reported higher MICs than the reference method for the susceptible isolates and showed low essential agreement. In conclusion, the automated systems investigated in this study showed good category agreements for colistin AST of A. baumannii. However, VITEK2 had a high VME rate, and Sensititre had differences in MIC results. Colistin AST remains a challenging task in the clinical laboratory.
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12
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A meta-analysis for the role of aminoglycosides and tigecyclines in combined regimens against colistin- and carbapenem-resistant Klebsiella pneumoniae bloodstream infections. Eur J Clin Microbiol Infect Dis 2022; 41:761-769. [PMID: 35303195 DOI: 10.1007/s10096-022-04429-0] [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: 11/30/2021] [Accepted: 03/04/2022] [Indexed: 12/28/2022]
Abstract
We aimed to describe the effect of aminoglycosides and tigecycline to reduce the mortality in colistin- and carbapenem-resistant Klebsiella pneumoniae (ColR-CR-Kp) infections. We included the studies with defined outcomes after active or non-active antibiotic treatment of ColR-CR-Kp infections. The active treatment was defined as adequate antibiotic use for at least 3 days (72 h) after the diagnosis of ColR-CR-Kp infection by culture. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and the checklist of PRISMA 2020 was applied. Crude and adjusted odds ratios (OR) with 95% confidence interval (CI) were calculated and pooled in the random effects model. Adding aminoglycosides to the existing treatment regimen reduced overall mortality significantly (OR 0.34, 95% CI 0.20-0.58). Overall mortality was 34% in patients treated with aminoglycoside-combined regimens and was 60% in patients treated with non-aminoglycoside regimens. Treatment with tigecycline is not found to reduce mortality (OR: 0.76, 95% CI: 0.47-1.23). Our results suggest that aminoglycoside addition to the existing regimen of colistin- and carbapenem-resistant Klebsiella pneumoniae infections reduces mortality significantly.
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13
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Shein AMS, Hongsing P, Abe S, Luk-In S, Ragupathi NKD, Wannigama DL, Chatsuwan T. Will There Ever Be Cure for Chronic, Life-Changing Colistin-Resistant Klebsiella pneumoniae in Urinary Tract Infection? Front Med (Lausanne) 2022; 8:806849. [PMID: 35004783 PMCID: PMC8740227 DOI: 10.3389/fmed.2021.806849] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Aye Mya Sithu Shein
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Interdisciplinary Program of Medical Microbiology, Graduate School, Chulalongkorn University, Bangkok, Thailand
| | - Parichart Hongsing
- Mae Fah Luang University Hospital, Chiang Rai, Thailand.,School of Integrative Medicine, Mae Fah Luang University, Chiang Rai, Thailand
| | - Shuichi Abe
- Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Sirirat Luk-In
- Department of Clinical Microbiology and Applied Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Naveen Kumar Devanga Ragupathi
- Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, United Kingdom.,Department of Chemical and Biological Engineering, The University of Sheffield, Sheffield, United Kingdom.,Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | - Dhammika Leshan Wannigama
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, United Kingdom.,School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, WA, Australia
| | - Tanittha Chatsuwan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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14
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Íñigo M, Pozo JLD. Treatment of infections caused by carbapenemase-producing Enterobacterales. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35 Suppl 3:46-50. [PMID: 36285858 PMCID: PMC9717464 DOI: 10.37201/req/s03.11.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antibiotic resistance is one of the main menaces to public and individual health worldwide. In the last two decades, an increase in the detection of carbapenem-resistant Enterobacterales has been reported. The treatment of infections caused by these strains is a therapeutic challenge. The use of carbapenems may be beneficial depending on MIC value and source of infection. New drugs, with different activity against the different classes of carbapenemases, are developed showing significant benefits.
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Affiliation(s)
- Melania Íñigo
- Department of Clinical Microbiology, Clínica Universidad de Navarra, Madrid, Spain
| | - José Luís Del Pozo
- Department of Clinical Microbiology, Clínica Universidad de Navarra, Madrid, Spain,Infectious Diseases Division, Clínica Universidad de Navarra, Pamplona, Spain,Department of Clinical Microbiology, Clínica Universidad de Navarra, Pamplona, Spain,Instituto de Investigación Sanitaria de Navarra (IdiSNA),Correspondence: José Luís Del Pozo Department of Clinical Microbiology & Infectious Diseases Division, Clínica Universidad de Navarra, Pamplona, Spain E-mail:
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15
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Paul M, Carrara E, Retamar P, Tängdén T, Bitterman R, Bonomo RA, de Waele J, Daikos GL, Akova M, Harbarth S, Pulcini C, Garnacho-Montero J, Seme K, Tumbarello M, Lindemann PC, Gandra S, Yu Y, Bassetti M, Mouton JW, Tacconelli E, Baño JR. European Society of clinical microbiology and infectious diseases (ESCMID) guidelines for the treatment of infections caused by Multidrug-resistant Gram-negative bacilli (endorsed by ESICM -European Society of intensive care Medicine). Clin Microbiol Infect 2021; 28:521-547. [PMID: 34923128 DOI: 10.1016/j.cmi.2021.11.025] [Citation(s) in RCA: 379] [Impact Index Per Article: 126.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
SCOPE These ESCMID guidelines address the targeted antibiotic treatment of 3rd generation cephalosporin-resistant Enterobacterales (3GCephRE) and carbapenem-resistant Gram-negative bacteria, focusing on the effectiveness of individual antibiotics and on combination vs. monotherapy. METHODS An expert panel was convened by ESCMID. A systematic review was performed including randomized controlled trials and observational studies, examining different antibiotic treatment regimens for the targeted treatment of infections caused by the 3GCephRE, carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumanni (CRAB). Treatments were classified as head-to-head comparisons between individual antibiotics and monotherapy vs. combination therapy regimens, including defined monotherapy and combination regimens only. The primary outcome was all-cause mortality, preferably at 30 days and secondary outcomes included clinical failure, microbiological failure, development of resistance, relapse/recurrence, adverse events and length of hospital stay. The last search of all databases was conducted in December 2019, followed by a focused search for relevant studies up until ECCMID 2021. Data were summarized narratively. The certainty of the evidence for each comparison between antibiotics and between monotherapy vs. combination therapy regimens was classified by the GRADE recommendations. The strength of the recommendations for or against treatments was classified as strong or conditional (weak). RECOMMENDATIONS The guideline panel reviewed the evidence per pathogen, preferably per site of infection, critically appraising the existing studies. Many of the comparisons were addressed in small observational studies at high risk of bias only. Notably, there was very little evidence on the effects of the new, recently approved, beta-lactam beta-lactamase inhibitors on infections caused by carbapenem-resistant Gram-negative bacteria. Most recommendations are based on very-low and low certainty evidence. A high value was placed on antibiotic stewardship considerations in all recommendations, searching for carbapenem-sparing options for 3GCephRE and limiting the recommendations of the new antibiotics for severe infections, as defined by the sepsis-3 criteria. Research needs are addressed.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Pilar Retamar
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Robert A Bonomo
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Medical Service, Research Service, and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA;; VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - George L Daikos
- First Department of Medicine, National and Kapodistrian University of Athens
| | - Murat Akova
- Hacettepe University School of Medicine, Department Of Infectious Diseases, Ankara, Turkey
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Celine Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | | | - Katja Seme
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Italy
| | | | - Sumanth Gandra
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China; Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy; Clinica Malattie Infettive, San Martino Policlinico Hospital, Genoa, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany; German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany.
| | - Jesus Rodriguez Baño
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
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16
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Effah CY, Drokow EK, Agboyibor C, Liu S, Nuamah E, Sun T, Miao L, Wang J, Xu Z, Wu Y, Zhang X. Evaluation of the Therapeutic Outcomes of Antibiotic Regimen Against Carbapenemase-Producing Klebsiella pneumoniae: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:597907. [PMID: 34803661 PMCID: PMC8599800 DOI: 10.3389/fphar.2021.597907] [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: 08/24/2020] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Carbapenemase-producing Klebsiella pneumoniae (CpKP) has been implicated as an increasing threat to public health. CpKP is a ubiquitous, opportunistic pathogen that causes both hospital and community acquired infections. This organism hydrolyzes carbapenems and other β-lactams and thus, leading to multiple resistance to these antibiotics. Despite the difficult to treat nature of infections caused by CpKP, little has been discussed on the mortality, clinical response and microbiological success rates associated with various antibiotic regimen against CpKP. This meta-analysis was designed to fill the paucity of information on the clinical impact of various antibiotic therapeutic regimens among patients infected with CpKP. Materials and Methods: Literature in most English databases such as Medline through PubMed, Google Scholar, Web of Science, Cochrane Library and EMBASE, were searched for most studies published between the years 2015–2020. Data were analyzed using the R studio 2.15.2 statistical software program (metaphor and meta Package, Version 2) by random-effects (DerSimonian and Laird) model. Results: Twenty-one (21) studies including 2841 patients who had been infected with CpKP were analysed. The overall mortality rate was 32.2% (95%CI = 26.23–38.87; I2 = 89%; p-value ≤ 0.01, Number of patients = 2716). Pooled clinical and microbiological success rates were 67.6% (95%CI = 58.35–75.64, I2 = 22%, p-value = 0.25, Number of patients = 171) and 74.9% (95%CI = 59.02–86.09, I2 = 53%, p-value = 0.05, Number of patients = 121), respectively. CpKP infected patients treated with combination therapy are less likely to die as compared to those treated with monotherapy (OR = 0.55, 95%CI = 0.35–0.87, p-value = 0.01, Number of patients = 1,475). No significant difference existed between the mortality rate among 60years and above patients vs below 60years (OR = 0.84, 95%CI = 0.28–2.57, p-value = 0.76, 6 studies, Number of patients = 1,688), and among patients treated with triple therapy vs. double therapy (OR = 0.50, 95%CI = 0.21–1.22, p-value = 0.13, 2 studies, Number of patients = 102). When compared with aminoglycoside-sparing therapies, aminoglycoside-containing therapies had positive significant outcomes on both mortality and microbiological success rates. Conclusion: New effective therapies are urgently needed to help fight infections caused by this organism. The effective use of various therapeutic options and the strict implementation of infection control measures are of utmost importance in order to prevent infections caused by CpKP. Strict national or international implementation of infection control measures and treatment guidelines will help improve healthcare, and equip governments and communities to respond to and prevent the spread of infectious diseases caused by CpKP.
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Affiliation(s)
| | - Emmanuel Kwateng Drokow
- Department of Radiation Oncology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Clement Agboyibor
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Shaohua Liu
- General ICU, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Emmanuel Nuamah
- College of Agriculture and Natural Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Tongwen Sun
- General ICU, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijun Miao
- General ICU, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Wang
- General ICU, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhiwei Xu
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital & People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongjun Wu
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Xiaoju Zhang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital & People's Hospital of Zhengzhou University, Zhengzhou, China
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Association between rectal colonization by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae and mortality: a prospective, observational study. J Glob Antimicrob Resist 2021; 29:476-482. [PMID: 34788693 DOI: 10.1016/j.jgar.2021.10.024] [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: 09/09/2021] [Revised: 10/15/2021] [Accepted: 10/24/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We evaluated the association of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) rectal colonization with crude mortality and whether this association is independent of the risk of KPC-Kp infection.. METHODS Prospective cohort study of patients followed up 90 days after a study of rectal colonization. Cox-regression was used to study the variables associated with crude mortality. Sensitivity analyses for crude 90-day mortality in different subcohorts were performed. RESULTS A total of 1244 patients (1078 non-colonized and 166 colonized) were included. None of the non-colonized patients and 78 (47.0%) of the colonized patients developed KPC-Kp infection. Crude 90-day mortality was 18% (194/1078) in non-colonized patients and 41.6% (69/166) in colonized patients. Rectal colonization was not associated with crude mortality (Hazard Ratio [HR] 1.03; 95% CI 0.69-1.54; p = 0.85) when the model was adjusted for severe KPC-Kp infection (INCREMENT-CPE score [ICS] > 7). KPC-Kp infection with ICS > 7 was associated with an increased risk of all-cause mortality (HR 2.21; 95% CI 1.35-3.63; p = 0.002). In the sensitivity analyses, KPC-Kp colonization was not associated with mortality in any of the analyzed subcohorts, including patients who did not develop KPC-Kp infection (HR 0.93; 95%CI: 0.60-1.43; p=0.74). CONCLUSIONS KPC-Kp rectal colonization was not associated with crude mortality. Mortality increased when colonized patients developed severe KPC-Kp infection (ICS > 7). Rectal colonization was a necessary although insufficient condition to die from a KPC-Kp infection.
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Rezk AR, Bawady SA, Omar NN. Incidence of emerging multidrug-resistant organisms and its impact on the outcome in the pediatric intensive care. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2021. [PMCID: PMC8557963 DOI: 10.1186/s43054-021-00071-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Healthcare-associated infections (HCAI) are a worldwide threat in intensive care units particularly in the pediatric intensive care units with a major cause of morbidity and mortality among this age group. The aim of the study is to determine the prevalence and risk factors predisposing to multidrug-resistant organisms (MDROs) infections among pediatric intensive care unit (PICU) patients at Ain Shams Pediatric University Hospitals as well as determining mortality and morbidity rates along with the length of stay at PICU.
Results
Culture results revealed that of the 282 patients evaluated, only 26 (9.2%) were MDROs (half of the affected patients had Acinetobacter species (50%) and the rest of them were free, 256 (90.8%). Our study revealed that the majority of MDROs were isolated from sputum in more than half of the patients 19/32 (59.3%) followed by whole blood in 10/32 (31.2%) and urine in 3/32 (9.4%). Pulmonary system was the most common affected site and was mainly colonized by MDR Acinetobacter (71.4%) followed by MDR Klebsiella (41.6%). Regarding MDR risk factors in our PICU, multivariate logistic regression analyses showed significant relationship between MDROs and age under 1 year (odds ratio [OR] 2.4554; 95% confidence interval [95% CI] (1.072–5.625); p = 0.043) and underlying pulmonary disease (OR 2.417; 95% CI (1.014–5.761); p = 0.592). A statistically significant higher mortality was detected in patients colonized with MDROs 9/26 (34.6%) versus MDROs non-colonized patients 32/256 (12.5%) [P=0.002]. Moreover, MDROs infection has negative significant risk with discharged patients ([OR] 0.269; [95% CI] (0.111–0.656); p = 0.002). Additionally, patients infected with MDROs did have significantly greater PICU stay than those non-infected [median (IQR), 16.5 (10.7–22), 5 (4–8), P=0.00] and have longer ventilation [median (IQR), 15.5 (10–18), 3 (2–10), P=0.00].
Conclusion
Prevalence of MDROs (9.2%) was low among PICU cases at Ain Shams University Hospitals. Most common MDROs were Acinetobacter and Klebsiella followed by pseudomonas species. The frequency of gram-negative organisms is much more common than gram-positive organisms. An increasing rate of antimicrobial resistance with increasing mortality and morbidity among PICU patients is observed worldwide; even for new categories, so, strict infection control programs should be implemented.
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Souza GHDAD, Rossato L, Brito GT, Bet GMDS, Simionatto S. Carbapenem-resistant Pseudomonas aeruginosa strains: a worrying health problem in intensive care units. Rev Inst Med Trop Sao Paulo 2021; 63:e71. [PMID: 34586305 PMCID: PMC8494492 DOI: 10.1590/s1678-9946202163071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/12/2021] [Indexed: 11/22/2022] Open
Abstract
Pseudomonas aeruginosa is one of the most common bacterium with a broad spectrum of human-associated infections. It is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. The emergence and dissemination of carbapenemases among P. aeruginosa clinical isolates is a serious public health concern as it limits the options for the treatment of bacterial infections. Here, we described the molecular and epidemiological characteristics of 28 carbapenem-resistant P. aeruginosa strains isolated from patients hospitalized in an intensive care unit (ICU). The antimicrobial susceptibility of carbapenem-resistant P. aeruginosa strains was determined by broth microdilution. The presence of resistance genes was evaluated by PCR and DNA sequencing. Additionally, alterations in genes encoding P. aeruginosa outer membrane proteins were analyzed by PCR as well as SDS-PAGE. Clinical characteristics of the patients and the economic impact of hospitalization on the public health system were evaluated. PCR amplification showed that the blaKPC-2 and blaTEM genes were identified in three isolates (11%) and blaSHV gene in two isolates (7%). Outer membrane profiles obtained by SDS-PAGE indicated that the OprD porin was either absent or was produced at very low levels. A PCR assay using oprD-specific primers failed to show the presence of mutations in this gene. P. aeruginosa strains were isolated from 28 patients, among whom 43% (12/28) had sepsis, 31% (9/28) had respiratory failure, and 31% (9/28) had systemic arterial hypertension. A high mortality rate (39%) was observed in these patients, with an average duration of hospitalization of 34.6 days and a median cost of 3.275 dollars per patient. The production of carbapenemase was not the main mechanism of resistance in these strains. All carbapenem-resistant P. aeruginosa were isolated from patients hospitalized in the ICU. Besides the high mortality rate, many patients remained hospitalized for several days, resulting in a high cost of hospitalization for the public health system. Therefore, the evolution of this resistance and its dissemination should be actively monitored among critically ill patients to improve their health conditions.
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Affiliation(s)
| | - Luana Rossato
- Universidade Federal da Grande Dourados, Laboratório de Pesquisa em Ciências da Saúde, Dourados, Mato Grosso do Sul, Brazil
| | - Gabriel Teixeira Brito
- Universidade Federal da Grande Dourados, Laboratório de Pesquisa em Ciências da Saúde, Dourados, Mato Grosso do Sul, Brazil
| | - Graciela Mendonça Dos Santos Bet
- Universidade Federal da Grande Dourados, Laboratório de Pesquisa em Ciências da Saúde, Dourados, Mato Grosso do Sul, Brazil.,Universidade Federal da Grande Dourados, Hospital Universitário, Comissão de Controle das Infecções Hospitalares, Dourados, Mato Grosso do Sul, Brazil
| | - Simone Simionatto
- Universidade Federal da Grande Dourados, Laboratório de Pesquisa em Ciências da Saúde, Dourados, Mato Grosso do Sul, Brazil
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Evolutionary Trajectories toward Ceftazidime-Avibactam Resistance in Klebsiella pneumoniae Clinical Isolates. Antimicrob Agents Chemother 2021; 65:e0057421. [PMID: 34339281 DOI: 10.1128/aac.00574-21] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
From January 2019 to April 2020, 32 KPC-producing, ceftazidime-avibactam (CZA) resistant Klebsiella pneumoniae strains were isolated in a university hospital in Rome, Italy. These strains belonged to the ST512, ST101 and ST307 high-risk clones. Nine different CZA-resistant KPC-3 protein variants were identified, five of them never previously reported (KPC-66 to KPC-70). Among them, KPC-31, KPC-39, KPC-49, KPC-66, KP-68, KPC-69 and KPC-70 showed amino acid substitutions, insertions and deletions in the Ω loop of the protein. KPC-29 has the duplication, while the novel KPC-67 has the triplication of the KDD triplet in the 270-loop of the protein. Genomics performed on contemporary resistant and susceptible clones underlined that those novel mutations emerged in blaKPC-3 genes located on conserved plasmids: in ST512, all blaKPC-3 mutant genes were located in pKpQIL plasmids, while the three novel blaKPC-3 mutants identified in ST101 were on FIIk-FIA(HI1)-R plasmids. Selection also promoted multiplication of the carbapenemase gene copy number by transposition, recombination, and fusion of resident plasmids. When expressed in Escherichia coli recipient cells cloned in the high-copy number pTOPO vector, the Ω loop mutated variants showed CZA-resistant phenotype associated with susceptibility to carbapenems, while KPC variants with insertions in the 270-loop showed residual activity on carbapenems. The investigation of CZA-resistance mechanisms offered the unique opportunity to study vertical, horizontal, and oblique evolutionary trajectories of K. pneumoniae high-risk clones.
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López-Viñau T, Peñalva G, García-Martínez L, Castón JJ, Muñoz-Rosa M, Cano Á, Recio M, Cisneros JM, Pérez-Nadales E, Rumbao Aguirre J, García-Martínez E, Salcedo I, del Prado JR, de la Fuente C, Martínez-Martínez L, Gracia-Ahufinger I, Torre-Cisneros J. Impact of an Antimicrobial Stewardship Program on the Incidence of Carbapenem Resistant Gram-Negative Bacilli: An Interrupted Time-Series Analysis. Antibiotics (Basel) 2021; 10:586. [PMID: 34065645 PMCID: PMC8190633 DOI: 10.3390/antibiotics10050586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/10/2021] [Accepted: 05/14/2021] [Indexed: 12/31/2022] Open
Abstract
Carbapenem-resistant Gram-negative bacilli (CR-GNB) are a critical public health threat, and carbapenem use contributes to their spread. Antimicrobial stewardship programs (ASPs) have proven successful in reducing antimicrobial use. However, evidence on the impact of carbapenem resistance remains unclear. We evaluated the impact of a multifaceted ASP on carbapenem use and incidence of CR-GNB in a high-endemic hospital. An interrupted time-series analysis was conducted one year before and two years after starting the ASP to assess carbapenem consumption, CR-GNB incidence, death rates of sentinel events, and other variables potentially related to CR-GNB incidence. An intense reduction in carbapenem consumption occurred after starting the intervention and was sustained two years later (relative effect -83.51%; 95% CI -87.23 to -79.79). The incidence density of CR-GNB decreased by -0.915 cases per 1000 occupied bed days (95% CI -1.743 to -0.087). This effect was especially marked in CR-Klebsiella pneumoniae and CR-Escherichia coli, reversing the pre-intervention upward trend and leading to a relative reduction of -91.15% (95% CI -105.53 to -76.76) and -89.93% (95% CI -107.03 to -72.83), respectively, two years after starting the program. Death rates did not change. This ASP contributed to decreasing CR-GNB incidence through a sustained reduction in antibiotic use without increasing mortality rates.
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Affiliation(s)
- Teresa López-Viñau
- Pharmacy Unit, Reina Sofia University Hospital, 14004 Cordoba, Spain; (T.L.-V.); (L.G.-M.); (J.R.d.P.)
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
| | - Germán Peñalva
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Virgen del Rocio University Hospital, 41013 Seville, Spain; (G.P.); (J.M.C.)
| | - Lucrecia García-Martínez
- Pharmacy Unit, Reina Sofia University Hospital, 14004 Cordoba, Spain; (T.L.-V.); (L.G.-M.); (J.R.d.P.)
| | - Juan José Castón
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
| | - Montserrat Muñoz-Rosa
- Microbiology Unit, Reina Sofia University Hospital, IMIBIC, Department of Agricultural Chemistry, Edafology and Microbiology, University of Cordoba, 14004 Cordoba, Spain; montserrat.munoz.sspa@xn--juntadeandaluca-ipb.es (M.M.-R.); (L.M.-M.)
| | - Ángela Cano
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
| | - Manuel Recio
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
| | - José Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Virgen del Rocio University Hospital, 41013 Seville, Spain; (G.P.); (J.M.C.)
| | - Elena Pérez-Nadales
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
| | - José Rumbao Aguirre
- Hospital Management, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.R.A.); (E.G.-M.)
| | - Elena García-Martínez
- Hospital Management, Reina Sofia University Hospital, 14004 Cordoba, Spain; (J.R.A.); (E.G.-M.)
| | - Inmaculada Salcedo
- Preventive Medicine Unit, Reina Sofia University Hospital, 14004 Cordoba, Spain;
| | - José Ramón del Prado
- Pharmacy Unit, Reina Sofia University Hospital, 14004 Cordoba, Spain; (T.L.-V.); (L.G.-M.); (J.R.d.P.)
| | | | - Luis Martínez-Martínez
- Microbiology Unit, Reina Sofia University Hospital, IMIBIC, Department of Agricultural Chemistry, Edafology and Microbiology, University of Cordoba, 14004 Cordoba, Spain; montserrat.munoz.sspa@xn--juntadeandaluca-ipb.es (M.M.-R.); (L.M.-M.)
| | - Irene Gracia-Ahufinger
- Microbiology Unit, Reina Sofia University Hospital, IMIBIC, Department of Agricultural Chemistry, Edafology and Microbiology, University of Cordoba, 14004 Cordoba, Spain; montserrat.munoz.sspa@xn--juntadeandaluca-ipb.es (M.M.-R.); (L.M.-M.)
| | - Julián Torre-Cisneros
- Infectious Diseases Unit, Reina Sofia University Hospital, Maimonides, Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba (UCO), 14004 Cordoba, Spain; (J.J.C.); (Á.C.); (M.R.); (E.P.-N.); (J.T.-C.)
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Gabrielyan NI, Sharapchenko SО, Kisil ОV, Kormilitsina VG, Drabkina IV, Safonova ТB, Petrukhina МI, Saitgareev RS, Zakharevich VМ. [The problem of global development of antibiotic resistant nosocomial pathogens]. TERAPEVT ARKH 2020; 92:110-116. [PMID: 33720615 DOI: 10.26442/00403660.2020.11.000783] [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: 12/26/2020] [Accepted: 12/26/2020] [Indexed: 11/22/2022]
Abstract
The problem of global expansion of multidrug-resistant nosocomial infections pathogens is under special attention at the moment. Antibiotic resistance increasing give us the limited treatment options. This problem is particularly acute for transplant clinics, because of patients need lifelong immunosuppressive therapy. From the one hand this ensures stable allograft functioning, but from the other increases the risk of severe infectious complications in the postoperative period. The purpose of this article is analysis carbapenem resistance dynamics of Klebsiella spp., Acinetobacter spp., Pseudomonas spp. and Staphylococcus spp. isolated from the blood of recipients of donor organs from 2009 to 2019 in the Shumakov National Medical Research Center of Transplantology and Artificial Organs. A significant annual decrease of carbapenem-sensitive strains of Klebsiella spp. and Acinetobacter spp. are shown. The study of a distinctive pathogen resistance profile specific to each institution can help one in selecting an adequate antimicrobial strategy and is an effective predictive tool for controlling the growth of multidrug-resistant microorganisms.
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Affiliation(s)
- N I Gabrielyan
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S О Sharapchenko
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | | | - V G Kormilitsina
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - I V Drabkina
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - Т B Safonova
- Russian Medical Academy of Continuous Professional Education
| | - М I Petrukhina
- Russian Medical Academy of Continuous Professional Education
| | - R S Saitgareev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - V М Zakharevich
- Shumakov National Medical Research Center of Transplantology and Artificial Organs.,Sechenov First Moscow State Medical University (Sechenov University)
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Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
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Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
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Khurana S, Malhotra R, Mathur P. Evaluation of Vitek®2 performance for colistin susceptibility testing for Gram-negative isolates. JAC Antimicrob Resist 2020; 2:dlaa101. [PMID: 34223053 PMCID: PMC8210208 DOI: 10.1093/jacamr/dlaa101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 10/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background The emerging resistance to the last-resort antimicrobial colistin is being reported globally. Underestimation of the burden of colistin resistance and misinterpretation of colistin susceptibility test results, using suboptimal testing methods, may be causing unexplained treatment failures and even mortality among critically ill patients. Thus, this study was conducted at an apex trauma centre to assess the performance of Vitek®2 for colistin susceptibility testing. Methods A total of 910 clinical isolates of Gram-negative bacteria (GNB), including Enterobacterales, Acinetobacter baumannii and Pseudomonas aeruginosa, were tested and analysed for colistin resistance using Vitek®2. Broth microdilution (BMD) was taken as the reference method. The essential (EA) and categorical (CA) agreements and very major error (VME) and major error (ME) rates were calculated. An MIC correlation was taken to be positive with EA ≥ 90%, CA ≥ 90%, VME ≤ 1.5% and ME ≤ 3.0% rates. Spearman's coefficient was calculated and P < 0.05 was considered statistically significant. Results A total of 64% of isolates were MDR. Overall, 196 (21.5%) and 110 (12%) of isolates were resistant to colistin by BMD and Vitek®2, respectively. The automated Vitek®2 method failed to detect the resistance in up to 48.5% of GNB tested. When comparing Vitek®2 colistin interpretive results with reference BMD for all 910 isolates, the CA was 88% (798/910) with 10% (95/910) VMEs and 1% (9/910) MEs. Conclusions The Vitek®2 method for colistin susceptibility testing, still in use in some settings; is a suboptimal and unreliable method.
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Affiliation(s)
- Surbhi Khurana
- Department of Laboratory of Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopedics, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Purva Mathur
- Department of Laboratory of Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Hasani A, Soltani E, Ahangarzadeh Rezaee M, Pirzadeh T, Ahangar Oskouee M, Hasani A, Gholizadeh P, Noie Oskouie A, Binesh E. Serotyping of Klebsiella pneumoniae and Its Relation with Capsule-Associated Virulence Genes, Antimicrobial Resistance Pattern, and Clinical Infections: A Descriptive Study in Medical Practice. Infect Drug Resist 2020; 13:1971-1980. [PMID: 32606843 PMCID: PMC7321687 DOI: 10.2147/idr.s243984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 06/11/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Klebsiella pneumoniae, one of the clinical superbugs, causes diverse infections because of its variable capsular antigens. This study focused on K. pneumoniae and aimed to assess any correlation between capsular serotype, capsule-associated virulence genes, and evaluate its resistance to conventional antibiotics in order to gain insight into any regional differences. Materials and Methods A total of 61 K. pneumoniae collected from various clinical specimens were confirmed genotypically. Clinical and demographic data for all patients were reviewed. All isolates were subjected to antimicrobial susceptibility tests. Capsular serotyping and capsule-associated virulence genes were studied using the molecular method. Results All typeable isolates were typed into K5, K20, and K54 serotypes, and among them, K54 was observed to be predominant. The most common capsule-associated virulence genes comprised uge (93.4%), ycfM (91.8%), and wabG (88.5%), while wcaG (29.5%) and rmpA (21.3%) were noted at much lower prevalence rates. The gene wcaG was significantly associated with K54 positive isolates (p = 0.001), while rmpA was associated with K20 positive isolates (p = 0.01). Conclusion Serotype K54 had a high frequency in isolates collected from patients with pulmonary diseases, while serotype K20 was associated with burn patients. Carbapenems and levofloxacin were the best therapeutic options for the treatment of infections with serotypes K20 and K54.
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Affiliation(s)
- Alka Hasani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran.,Sina Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elghar Soltani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Mohammad Ahangarzadeh Rezaee
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Tahereh Pirzadeh
- Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Mahin Ahangar Oskouee
- Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Akbar Hasani
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Pourya Gholizadeh
- Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Arezoo Noie Oskouie
- Department of Bacteriology and Virology, Faculty of Medicine, Tabriz University of Medical, Sciences, Tabriz, Iran
| | - Ehsan Binesh
- Department of Infectious Disease, School of Medicine, Shahroud University of Medical Science, Shahroud, Iran
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Impact of KPC Production and High-Level Meropenem Resistance on All-Cause Mortality of Ventilator-Associated Pneumonia in Association with Klebsiella pneumoniae. Antimicrob Agents Chemother 2020; 64:AAC.02164-19. [PMID: 32205347 DOI: 10.1128/aac.02164-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/08/2020] [Indexed: 12/18/2022] Open
Abstract
Carbapenemase-producing Enterobacterales and specifically Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) are rapidly spreading worldwide. The prognosis of ventilator-associated pneumonia (VAP) caused by KPC-Kp is not well known. Our study tries to assess whether ventilator-associated pneumonia caused by a KPC-Kp strain is associated with higher all-cause mortality than that caused by carbapenem-susceptible isolates. This is a retrospective cohort study of patients with VAP due to K. pneumoniae from a 35-bed polyvalent intensive care unit in a university hospital (>40,000 annual admissions) between January 2012 and December 2016. Adjusted multivariate analysis was used to study the association of KPC-Kp with 30-day all-cause mortality (Cox regression). We analyze 69 cases of K. pneumoniae VAP, of which 39 were produced by a KPC-Kp strain with high-level resistance to meropenem (MIC > 16 mg/ml). All-cause mortality at 30 days was 41% in the KPC-Kp group (16/39) and 33.3% in the carbapenem-susceptible cases (10/30). KPC-Kp etiology was not associated with higher mortality when controlled for confounders (adjusted hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.46 to 3.41). Adequate targeted therapy (HR, 0.03; 95% CI, <0.01 to 0.23) was associated with all-cause mortality. Assuming the limitations due to the available sample size, the prognosis of VAP caused by KPC-Kp is similar to VAPs caused by carbapenem-susceptible K. pneumoniae when appropriate treatment is used.
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27
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D'Onofrio V, Conzemius R, Varda-Brkić D, Bogdan M, Grisold A, Gyssens IC, Bedenić B, Barišić I. Epidemiology of colistin-resistant, carbapenemase-producing Enterobacteriaceae and Acinetobacter baumannii in Croatia. INFECTION GENETICS AND EVOLUTION 2020; 81:104263. [PMID: 32105865 DOI: 10.1016/j.meegid.2020.104263] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
Colistin is a last-resort antibiotic for the treatment of infections caused by multidrug and carbapenem-resistant Gram-negative bacteria. Colistin resistance has been emerging and multiple outbreaks have been reported in Europe and elsewhere. It has been most frequently reported in carbapenem-resistant K. pneumoniae. In this study, 24 multidrug and colistin-resistant clinical isolates (14 K. pneumoniae, one E. aerogenes, one E. cloacae, and eight A. baumannii) were collected from four hospitals in Croatia from 2013 to 2018, in order to analyse the molecular epidemiology and mechanisms of antibiotic resistance. β-lactamase and carbapenemase genes were detected by PCR. Genotyping was done on selected isolates by rep-PCR. Whole genome sequencing (WGS) was performed to discover possible molecular mechanisms for the observed colistin resistance. All isolates, except two K. pneumoniae isolates, were extensively drug resistant. Ten out of 16 (63%) K. pneumoniae isolates possessed blaOXA-48, which is the most common carbapenem resistance gene in Croatia and in other parts of Europe. All A. baumannii isolates possessed the OXA-23-like carbapenem hydrolysing oxacillinase and five turned out to be pandrug-resistant. Colistin resistance was most likely chromosomally mediated. After sequence analysis, none of the isolates were found to possess any of the mcr gene variants. Several previously reported mutations were found in PmrB, PhoP, PhoQ, and MgrB, which are associated with colistin resistance. In the global phylogenetic analysis, DNA mutations causing mutations in the MgrB protein were present mostly in lineages comprising colistin resistant isolates, and the second most prevalent mutation (K3X) was also encountered in our isolates. In addition, based on genotyping by rep-PCR, the spread of colistin resistance is most likely to be clonal. Most importantly, the presence of colistin resistance together with carbapenemase genes in extensively drug resistant isolates poses real threats in the use of carbapenems and colistin to fight infections.
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Affiliation(s)
- Valentino D'Onofrio
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium.; Department of Infectious Diseases and Immunity, Jessa Hospital, 3500 Hasselt, Belgium; Department of Internal Medicine and Center for Infectious Diseases, Radboud University Medical Center, 6663 Nijmegen, The Netherlands
| | - Rick Conzemius
- AIT, Austrian Institute for Technology, 1210 Vienna, Austria
| | | | - Maja Bogdan
- Public Health Institute of Osijek-Baranja County, 31000 Osijek, Croatia; School of Medicine, University of Osijek, 31000 Osijek, Croatia
| | - Andrea Grisold
- Institute for Hygiene, Microbiology and Environmental Medicine, Medical University of Graz, Graz, Austria
| | - Inge C Gyssens
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium.; Department of Internal Medicine and Center for Infectious Diseases, Radboud University Medical Center, 6663 Nijmegen, The Netherlands
| | - Branka Bedenić
- University Hospital Center Zagreb, 10000 Zagreb, Croatia; School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Ivan Barišić
- AIT, Austrian Institute for Technology, 1210 Vienna, Austria.
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28
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Agyeman AA, Bergen PJ, Rao GG, Nation RL, Landersdorfer CB. Mortality, clinical and microbiological response following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae infections (a meta-analysis dataset). Data Brief 2020; 28:104907. [PMID: 31886351 PMCID: PMC6921139 DOI: 10.1016/j.dib.2019.104907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/21/2019] [Indexed: 12/03/2022] Open
Abstract
This meta-analysis was conducted to assess mortality, clinical and microbiological response following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) infections. Fifty-four observational studies involving 3195 CRKP-infected patients who received antibiotic treatment were included. We found combination therapy to be associated with lower mortality than monotherapy, but no differences in clinical and microbiological response. Among the various combination therapies, no significant differences in mortality, clinical and microbiological response were found. Moreover, clinical outcomes did not differ significantly among various monotherapies. This report describes the data related to the article entitled: "A systematic review and meta-analysis of treatment outcomes following antibiotic therapy among patients with carbapenem-resistant Klebsiella pneumoniae infections".
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Affiliation(s)
- Akosua A. Agyeman
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Melbourne, Australia
| | - Phillip J. Bergen
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Melbourne, Australia
| | - Gauri G. Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Melbourne, Australia
| | - Cornelia B. Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Melbourne, Australia
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29
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Wang L, Tong X, Huang J, Zhang L, Wang D, Wu M, Liu T, Fan H. Triple Versus Double Therapy for the Treatment of Severe Infections Caused by Carbapenem-Resistant Enterobacteriaceae: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 10:1673. [PMID: 32082166 PMCID: PMC7005522 DOI: 10.3389/fphar.2019.01673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 12/23/2019] [Indexed: 02/05/2023] Open
Abstract
Introduction The role of combination treatment in the management of carbapenem-resistant Enterobacteriaceae infections (CRE) is still unclear. There have been no meta-analysis comparing the efficiency of triple therapy in treating CRE infections with that of double therapy. In this perspective, we conducted a meta-analysis to clarify whether triple therapy is superior to double therapy in treating patients with CRE infections. Methods We performed a systematic review, using PubMed and Embase without any restrictions until October 2019. Risk ratio (RR) with 95% CI were pooled to evaluate the effect of intervention. Results A total of 33 studies with 1,441 subjects were identified. Pooled analysis showed that triple therapy was not associated with a reduced mortality compared with double therapy (HR 0.99 95% CI 0.85-1.14, P = 0.85). Conclusions This meta-analysis suggests that triple therapy is not superior to double therapy in the treatment of patients with CRE infections, although the quality of evidence is generally low based on current literatures. Future well-defined, randomized controlled trials will be required to elucidate the role of triple therapy in the treatment of CRE infections.
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Affiliation(s)
- Lei Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiang Tong
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Jizhen Huang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Dongguang Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Man Wu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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30
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Falcone M, Bassetti M, Tiseo G, Giordano C, Nencini E, Russo A, Graziano E, Tagliaferri E, Leonildi A, Barnini S, Farcomeni A, Menichetti F. Time to appropriate antibiotic therapy is a predictor of outcome in patients with bloodstream infection caused by KPC-producing Klebsiella pneumoniae. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:29. [PMID: 32000834 PMCID: PMC6993311 DOI: 10.1186/s13054-020-2742-9] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/14/2020] [Indexed: 12/15/2022]
Abstract
Background Bloodstream infections (BSIs) by Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (Kp) are associated with high mortality. The aim of this study is to assess the relationship between time to administration of appropriate antibiotic therapy and the outcome of patients with BSI due to KPC-Kp hospitalized in intensive care unit (ICU). Methods An observational study was conducted in the ICUs of two academic centers in Italy. Patients with KPC-Kp bacteremia hospitalized between January 2015 to December 2018 were included. The primary outcome was the relationship between time from blood cultures (BC) collection to appropriate antibiotic therapy and 30-day mortality. The secondary outcome was to evaluate the association of different treatment regimens with 30-day mortality and a composite endpoint (30-day mortality or nephrotoxicity). A Cox regression analysis to identify factors independently associated with 30-day mortality was performed. Hazard ratio (HR) and 95% confidence interval (CI) were calculated. Results A total of 102 patients with KPC-Kp BSI were included. The most common sources of infection were intra-abdominal (23.5%), urinary tract (20.6%), and skin and skin structure (17.6%). The 30-day mortality was 45%. Median time to appropriate antibiotic therapy was shorter in patients who survived (8.5 h [IQR 1–36]) versus those who died (48 h [IQR 5–108], p = 0.014). A propensity score matching showed that receipt of an in vitro active therapy within 24 h from BC collection was associated with lower 30-day mortality (HR = 0.36, 95% CI: 0.188–0.690, p = 0.0021). At Cox regression analysis, factors associated with 30-day mortality were primary bacteremia (HR 2.662 [95% CI 1.118–6.336], p = 0.027), cardiovascular disease (HR 2.196 [95% CI 1.082–4.457], p = 0.029), time (24-h increments) from BC collection to appropriate therapy (HR 1.382 [95% CI 1.132–1.687], p = 0.001), SOFA score (HR 1.122 [95% CI 1.036–1.216], p = 0.005), and age (HR 1.030 [95% CI 1.006–1.054], p = 0.012). Ceftazidime-avibactam-containing regimens were associated with reduced risk of composite endpoint (30-day mortality OR nephrotoxicity) (HR 0.231 [95% CI 0.071–0.745], p = 0.014) compared to colistin-containing regimens. Conclusions Time to appropriate antibiotic therapy is an independent predictor of 30-day mortality in patients with KPC-Kp BSI. Appropriate antibiotic therapy should begin within 24 h from the collection of BC. Electronic supplementary material The online version of this article (10.1186/s13054-020-2742-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy.
| | - Matteo Bassetti
- Infectious Diseases Clinic Department of Health Science, University of Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | - Cesira Giordano
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Elia Nencini
- Emergency Medicine Department, University of Pisa, Pisa, Italy
| | - Alessandro Russo
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | - Elena Graziano
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Enrico Tagliaferri
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
| | | | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome "Tor Vergata", Rome, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa, 2, 56124, Pisa, PI, Italy
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31
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Hirsch R, Wiesner J, Marker A, Pfeifer Y, Bauer A, Hammann PE, Vilcinskas A. Profiling antimicrobial peptides from the medical maggot Lucilia sericata as potential antibiotics for MDR Gram-negative bacteria. J Antimicrob Chemother 2020; 74:96-107. [PMID: 30272195 PMCID: PMC6322280 DOI: 10.1093/jac/dky386] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background The ability of MDR Gram-negative bacteria to evade even antibiotics of last resort is a severe global challenge. The development pipeline for conventional antibiotics cannot address this issue, but antimicrobial peptides (AMPs) offer an alternative solution. Objectives Two insect-derived AMPs (LS-sarcotoxin and LS-stomoxyn) were profiled to assess their suitability for systemic application in humans. Methods The peptides were tested against an extended panel of 114 clinical MDR Gram-negative bacterial isolates followed by time–kill analysis, interaction studies and assays to determine the likelihood of emerging resistance. In further in vitro studies we addressed cytotoxicity, cardiotoxicity and off-target interactions. In addition, an in vivo tolerability and pharmacokinetic study in mice was performed. Results LS-sarcotoxin and LS-stomoxyn showed potent and selective activity against Gram-negative bacteria and no cross-resistance with carbapenems, fluoroquinolones or aminoglycosides. Peptide concentrations of 4 or 8 mg/L inhibited 90% of the clinical MDR isolates of Escherichia coli, Enterobacter cloacae, Acinetobacter baumannii and Salmonella enterica isolates tested. The ‘all-d’ homologues of the peptides displayed markedly reduced activity, indicating a chiral target. Pharmacological profiling revealed a good in vitro therapeutic index, no cytotoxicity or cardiotoxicity, an inconspicuous broad-panel off-target profile, and no acute toxicity in mice at 10 mg/kg. In mouse pharmacokinetic experiments LS-sarcotoxin and LS-stomoxyn plasma levels above the lower limit of quantification (1 and 0.25 mg/mL, respectively) were detected after 5 and 15 min, respectively. Conclusions LS-sarcotoxin and LS-stomoxyn are suitable as lead candidates for the development of novel antibiotics; however, their pharmacokinetic properties need to be improved for systemic administration.
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Affiliation(s)
- Rolf Hirsch
- Fraunhofer Institute for Molecular Biology and Applied Ecology, Department of Bioresources, Gießen, Germany
- Present address: Evotec International GmbH, Hamburg, Germany
| | - Jochen Wiesner
- Fraunhofer Institute for Molecular Biology and Applied Ecology, Department of Bioresources, Gießen, Germany
| | - Alexander Marker
- Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
| | - Yvonne Pfeifer
- Department 1 – Infectious Diseases, Robert Koch Institute, Wernigerode, Germany
| | - Armin Bauer
- Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
| | - Peter E Hammann
- Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany
- Present address: Evotec International GmbH, Hamburg, Germany
| | - Andreas Vilcinskas
- Fraunhofer Institute for Molecular Biology and Applied Ecology, Department of Bioresources, Gießen, Germany
- Institute for Insect Biotechnology, Justus Liebig University of Gießen, Gießen, Germany
- Corresponding author. Tel: +49 641 99 39500; E-mail: orcid.org/0000-0001-8276-4968
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da Silva KE, Baker S, Croda J, Nguyen TNT, Boinett CJ, Barbosa LS, Tetila A, Simionatto S. Risk factors for polymyxin-resistant carbapenemase-producing Enterobacteriaceae in critically ill patients: An epidemiological and clinical study. Int J Antimicrob Agents 2020; 55:105882. [PMID: 31923570 DOI: 10.1016/j.ijantimicag.2020.105882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/19/2019] [Accepted: 12/28/2019] [Indexed: 11/16/2022]
Abstract
This study aimed to assess the clinical impact and potential risk factors associated with polymyxin-resistant Enterobacteriaceae strains isolated from patients hospitalized in adult and neonatal intensive care units. A case-control study was conducted from September 2015 to January 2017. Antimicrobial susceptibility of polymyxin-resistant Enterobacteriaceae strains was determined by broth microdilution. The presence of resistance genes was evaluated by polymerase chain reaction and DNA sequencing. Renal failure [P=0.02, odds ratio (OR) 11.37, 95% confidence interval (CI) 1.0-128.63], use of a urinary catheter (P<0.01, OR 4.16, 95% CI 38.82-366.07), transfer between hospital units (P=0.03, OR 9.98, 95% CI 1.01-98.42), carbapenem use (P<0.01, OR 45.49, 95% CI 6.93-298.62) and surgical procedure (P<0.01, OR 16.52, 95% CI 2.83-96.32) were found to be risk factors for the acquisition of polymyxin-resistant strains in adult patients. For neonatal patients, use of a central venous catheter (P<0.01, OR 69.59, 95% CI 7.33-660.30) was the only risk factor associated with the acquisition of polymyxin-resistant strains. Analysis of the outcomes revealed that the mortality rate was significantly higher in adult (66.6%) and neonatal (23.5%) patients with polymyxin-resistant strains than in those with polymyxin-susceptible strains. In addition, carbapenem exposure (P<0.01, OR 50.93, 95% CI 2.26->999.999) was strongly associated with mortality. On the other hand, aminoglycoside use (P<0.03, OR 0.06, 95% CI 0.004-0.97) was a protective factor against mortality from polymyxin-resistant strains. Several risk factors were associated with polymyxin-resistant strains. The high mortality rates showed that acquisition of these strains is a predictor for unfavourable outcomes. Combination treatment with an aminoglycoside and polymyxin might be a better combination to improve patient outcomes.
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Affiliation(s)
- Kesia Esther da Silva
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Stephen Baker
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK; Department of Medicine, Cambridge University, Cambridge, UK
| | - Julio Croda
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil; Fundação Osvaldo Cruz, Campo Grande, Mato Grosso do Sul, Brazil; Universidade Federal do Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - To Nguyen Thi Nguyen
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Christine J Boinett
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Leticia Spanivello Barbosa
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Andyane Tetila
- Hospital Universitário de Dourados, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil
| | - Simone Simionatto
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Mato Grosso do Sul, Brazil.
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Pérez-Nadales E, Gutiérrez-Gutiérrez B, Natera AM, Abdala E, Reina Magalhães M, Mularoni A, Monaco F, Camera Pierrotti L, Pinheiro Freire M, Iyer RN, Mehta Steinke S, Grazia Calvi E, Tumbarello M, Falcone M, Fernández-Ruiz M, María Costa-Mateo J, Rana MM, Mara Varejão Strabelli T, Paul M, Carmen Fariñas M, Clemente WT, Roilides E, Muñoz P, Dewispelaere L, Loeches B, Lowman W, Tan BH, Escudero-Sánchez R, Bodro M, Antonio Grossi P, Soldani F, Gunseren F, Nestorova N, Pascual Á, Martínez-Martínez L, Aguado JM, Rodríguez-Baño J, Torre-Cisneros J. Predictors of mortality in solid organ transplant recipients with bloodstream infections due to carbapenemase-producing Enterobacterales: The impact of cytomegalovirus disease and lymphopenia. Am J Transplant 2019; 20:S1600-6135(22)22362-4. [PMID: 31891235 DOI: 10.1111/ajt.15769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/30/2019] [Accepted: 12/22/2019] [Indexed: 01/25/2023]
Abstract
Treatment of carbapenemase-producing Enterobacterales bloodstream infections in solid organ transplant recipients is challenging. The objective of this study was to develop a specific score to predict mortality in solid organ transplant recipients with carbapenemase-producing Enterobacterales bloodstream infections. A multinational, retrospective (2004-2016) cohort study (INCREMENT-SOT, ClinicalTrials.gov NCT02852902) was performed. The main outcome variable was 30-day all-cause mortality. The INCREMENT-SOT-CPE score was developed using logistic regression. The global cohort included 216 patients. The final logistic regression model included the following variables: INCREMENT-CPE mortality score ≥8 (8 points), no source control (3 points), inappropriate empirical therapy (2 points), cytomegalovirus disease (7 points), lymphopenia (4 points), and the interaction between INCREMENT-CPE score ≥8 and CMV disease (minus 7 points). This score showed an area under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI] 0.76-0.88) and classified patients into 3 strata: 0-7 (low mortality), 8-11 (high mortality), and 12-17 (very-high mortality). We performed a stratified analysis of the effect of monotherapy vs combination therapy among 165 patients who received appropriate therapy. Monotherapy was associated with higher mortality only in the very-high (adjusted hazard ratio [HR] 2.82, 95% CI 1.13-7.06, P = .03) and high (HR 9.93, 95% CI 2.08-47.40, P = .004) mortality risk strata. A score-based algorithm is provided for therapy guidance.
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Affiliation(s)
- Elena Pérez-Nadales
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Alejandra M Natera
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, Spain
| | - Edson Abdala
- Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | | | | | | | - Mario Tumbarello
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marco Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Universidad Complutense, Madrid, Spain
| | - José María Costa-Mateo
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | | | | | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus and Faculty of Medicine, Technion - Israel Faculty of Technology, Haifa, Israel
| | - María Carmen Fariñas
- Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Wanessa Trindade Clemente
- Faculty of Medicine, Liver Transplantation Program, Hospital das Clínicas -Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Emmanuel Roilides
- Infectious Diseases Unit and 3rd, Department of Pediatrics, Aristotle University School of Health Sciences, Hippokration Hospital, Thessaloniki, Greece
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Laurent Dewispelaere
- Department of Microbiology, CUB-Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Belén Loeches
- Infectious Diseases Unit, Hospital La Paz, Madrid, Spain
| | - Warren Lowman
- Wits Donald Gordon Medical Centre, Vermaak & Partners/Pathcare, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Rosa Escudero-Sánchez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Ramón y Cajal University Hospital, Madrid, Spain
| | - Marta Bodro
- Infectious Diseases Department, Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Fabio Soldani
- Department of Medicine, Infectious Diseases Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Filiz Gunseren
- Department of Infectious Diseases, Akdeniz University Hospital, Antalya, Turkey
| | | | - Álvaro Pascual
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Luis Martínez-Martínez
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad de Gestión Clínica de Microbiología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Cordoba, Cordoba, Spain
| | - José María Aguado
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Universidad Complutense, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla, Seville, Spain
| | - Julián Torre-Cisneros
- Spanish Network for Research in Infectious Diseases (REIPI), ISCIII, Spain
- Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
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Tian X, Huang C, Ye X, Jiang H, Zhang R, Hu X, Xu D. Molecular Epidemiology of and Risk Factors for Extensively Drug-Resistant Klebsiella pneumoniae Infections in Southwestern China: A Retrospective Study. Front Pharmacol 2019; 10:1307. [PMID: 31736765 PMCID: PMC6838015 DOI: 10.3389/fphar.2019.01307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 12/23/2022] Open
Abstract
Background: The increasing prevalence of extensively drug-resistant Klebsiella pneumoniae (XDR-KP) poses a serious threat to clinical anti-infective treatment. This retrospective study assessed the molecular epidemiology of and risk factors for infections with XDR-KP to investigate the mechanism of drug resistance and the epidemiological characteristics. Methods: A retrospective 1:2 case-control study was conducted at Chongqing Renji Affiliated Hospital of the Chinese Academy of Sciences University from January 2015 to December 2017. A total of 69 non-repetitive XDR-KP strains were collected. Patients infected with XDR-KP comprised the case group, and 138 matched patients with non-XDR-KP infection at the same site comprised the control group. The chi-square test and logistic regression were performed to evaluate the related risk factors. Molecular typing was performed by multilocus sequence typing (MLST). Potential resistance genes were detected by polymerase chain reaction (PCR) and sequencing. Predictors of 28-day mortality in patients with XDR-KP infection were also identified in our study. Results: Only tigecycline and polymyxin B showed favorable in vitro drug sensitivity tests. These XDR-KP strains had a high prevalence rate (n = 66, 95.7%) of carbapenemase-related drug resistance genes. Among them, KPC-2 was the most frequently detected gene (n = 52, 75.4%). Particularly, all of the isolates harbored multiple drug resistance genes. Epidemiological analysis showed that fifty-eight XDR-KP isolates were resistant strains with the ST-11 genotype. Multivariate logistic regression analysis showed that ICU admission (OR: 3.28, 95% CI: 1.66–6.49, P < 0.001), tracheal cannula (OR: 3.16, 95% CI: 1.48–6.76, P = 0.003), and carbapenem exposure (OR: 3.16, 95% CI: 1.25–7.98, P = 0.015) were independent risk factors for XDR-KP infection. Solid tumors (OR: 7.22, 95% CI: 1.84–28.34, P = 0.005) and septic shock (OR: 9.46, 95% CI: 2.00–44.72, P = 0.005) were independent risk factors for 28-day mortality from XDR-KP infection. Conclusion: This study showed that XDR-KP isolates were highly resistant and exhibited clonal transmission. ST11 was the predominant epidemic type of XDR-KP producing KPC-2 in Southwestern China. Physicians should be aware of these high-risk patients with notable predictive factors for XDR-KP infection. These findings may provide some recommendation for the diagnosis and treatment of patients infected with XDR-KP strains in Southwestern China.
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Affiliation(s)
- Xiaolang Tian
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Changwu Huang
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Xiaoli Ye
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Hongyan Jiang
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Rufang Zhang
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Xiaofang Hu
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
| | - Dongshuang Xu
- Department of Clinical Laboratory, University of Chinese Academy of Sciences Chongqing Renji Hospital, Fifth People's Hospital of Chongqing, Chongqing, China
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Cano A, Gutiérrez-Gutiérrez B, Machuca I, Gracia-Ahufinger I, Pérez-Nadales E, Causse M, Castón JJ, Guzman-Puche J, Torre-Giménez J, Kindelán L, Martínez-Martinez L, Rodriguez-Baño J, Torre-Cisneros J. Risks of Infection and Mortality Among Patients Colonized With Klebsiella pneumoniae Carbapenemase-Producing K. pneumoniae: Validation of Scores and Proposal for Management. Clin Infect Dis 2019; 66:1204-1210. [PMID: 29126110 DOI: 10.1093/cid/cix991] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background The management and indication of empiric treatment in Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp)-colonized patients should be improved. Methods A prospective cohort of 94 patients colonized by KPC-Kp was followed for 90 days to validate (i) the Giannella risk score (GRS) to predict the development of any type of KPC-Kp infection and (ii) the INCREMENT-CPE score (ICS) to predict 30-day mortality in patients with infection. Both scores were combined to recommend appropriate empiric treatment. The predictive ability of the scores was measured by calculating the area under the receiver operating characteristic (AUROC) curve. Results The GRS showed an AUROC curve for infection due to KPC-Kp of 0.92 (95% confidence interval [CI], .87-.98). The optimal cutoff point was fixed at <7 and ≥7 (92.9% sensitivity, 84.8% specificity); infection developed in 6.3% patients in the 0-6 GRS group and in 84.8% patient in the ≥7 GRS group. According to the ICS, the severity of the infection was also significantly higher in the ≥7 GRS group. The ICS showed an AUROC of 0.78 (95% CI, .65-.91) for 30-day all-cause mortality among patients with infection. A classification and regression tree analysis confirmed the GRS cutoff point at 7, and selected ≥12 points to predict a KPC-Kp infection with a high ICS. Conclusions Our results validate the GRS and ICS for indicating empiric therapy in KPC-Kp-colonized patients.
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Affiliation(s)
- Angela Cano
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS), Spain.,Department of Medicine, Universidad de Sevilla, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Irene Gracia-Ahufinger
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Elena Pérez-Nadales
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC)-Reina Sofia University Hospital, University of Córdoba, Spain
| | - Manuel Causse
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Juan José Castón
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Julia Guzman-Puche
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Julian Torre-Giménez
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Lara Kindelán
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Luis Martínez-Martinez
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Jesús Rodriguez-Baño
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS), Spain.,Department of Medicine, Universidad de Sevilla, Spain
| | - Julian Torre-Cisneros
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
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Abstract
PURPOSE OF REVIEW In the absence of randomized clinical trial data, questions remain regarding the optimal treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections. CRE have historically been susceptible to polymyxins, tigecycline or aminoglycosides (mostly gentamicin), and these antibiotics have long been considered the drugs of choice for CRE infections, although varying rates of resistance to all have been reported. This review looks at data from clinical studies assessing the outcomes of CRE infections treated with different antibiotic regimens. RECENT FINDINGS The recently approved fixed-dose combination agent, ceftazidime-avibactam (CAZ-AVI), is active against KPC and OXA-48-producing Enterobacteriaceae. The limited clinical data available on CAZ-AVI indicate that it is associated with survival benefits relative to other commonly used regimens, although development of resistance is a concern. New drugs active against CRE isolates (including the recently approved meropenem-vaborbactam) are in different stages of development. SUMMARY CAZ-AVI and meropenem-vaborbactam seem destined to become the backbone of target therapy for high-risk patients with severe infections caused by susceptible CRE strains. However, empirical therapy should be based on risk factors to be defined in the near future, whereas the necessity of combinations with CAZ-AVI requires further studies. Polymyxins are still important options for low-risk patients with susceptible CRE infections, but also for high-risk patients in regions where metallo-β-lactamase-producing CRE predominate because CAZ-AVI and meropenem-vaborbactam are both ineffective against these strains.
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Zhang W, Guo Y, Yang Y, Dong D, Zheng Y, Zhu D, Hu F. Study of In Vitro Synergistic Bactericidal Activity of Dual β-Lactam Antibiotics Against KPC-2-Producing Klebsiella pneumoniae. Microb Drug Resist 2019; 26:204-210. [PMID: 31553260 DOI: 10.1089/mdr.2019.0126] [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] [Indexed: 01/10/2023] Open
Abstract
Objectives: To study the in vitro synergistic bactericidal activity of dual β-lactam antibiotics against KPC-2-producing Klebsiella pneumoniae and to explore the new therapeutic regimens for infections caused by carbapenem-resistant strains. Materials and Methods: The antimicrobial susceptibility testing of imipenem, meropenem, ceftazidime, and clavulanic acid on 40 clinically isolated strains of KPC-2-producing K. pneumoniae from 5 cities across the country was performed by microdilution broth method. The in vitro synergistic bactericidal activity of combined antibiotics mentioned above was determined at various concentrations using checkerboard techniques. The combination of antibiotics include imipenem with clavulanic acid, meropenem with clavulanic acid, imipenem with ceftazidime, meropenem with ceftazidime, and meropenem with imipenem. The combined effectiveness of synergistic, indifferent, or antagonistic was calculated by fractional inhibitory concentration indexes. Based on the results of synergistic bactericidal activity, 16 strains were selected for time-kill assays. Results: All 40 strains of K. pneumoniae were shown resistant to every single antimicrobial agent tested, with minimal inhibitory concentrations of carbapenems >32 mg/L in most isolates. None of the combinations was antagonistic. Synergies of combination of imipenem with clavulanic acid, or imipenem with ceftazidime were observed in 80% (32/40) and 7.5% (3/40) of strains, respectively; Combinations of meropenem and clavulanic acid, or meropenem and ceftazidime revealed a synergistic antibacterial activity on 25% (10/40) and 30% (12/40) of strains, respectively. Synergy of meropenem and imipenem combination was shown in 30% (12/40) of strains. Time-kill assays validated the data from checkerboard testing. Conclusions: The study strongly supported the hypothesis that combined dual β-lactam antibiotics might be effective in the treatment of infections caused by KPC-2-producing K. pneumoniae. The combination of imipenem and clavulanic acid possessed the best efficiency, followed by the regimens of combined meropenem-ceftazidime and imipenem-meropenem.
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Affiliation(s)
- Wenxia Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Yan Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
| | - Yang Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
| | - Dong Dong
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
| | - Yonggui Zheng
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
| | - Demei Zhu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, P.R. China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, P.R. China
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Menekşe Ş, Çağ Y, Işık ME, Şahin S, Hacıseyitoğlu D, Can F, Ergonul O. The effect of colistin resistance and other predictors on fatality among patients with bloodstream infections due to Klebsiella pneumoniae in an OXA-48 dominant region. Int J Infect Dis 2019; 86:208-211. [PMID: 31402295 DOI: 10.1016/j.ijid.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/14/2019] [Accepted: 06/09/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the effect of colistin resistance and other predictors on fatality among patients with Klebsiella pneumoniae bloodstream infections (Kp-BSI) and to describe the effect of amikacin and tigecycline on the outcome in an OXA-48 dominant country. METHOD This was a retrospective study performed among patients >16 years of age in a tertiary hospital with 465 beds. All cases had ≥1 positive blood culture for K. pneumoniae 48 h after admission. RESULTS Among 210 patients with Kp-BSI, the 30-day mortality rate after isolation of the microorganism was 58%. The rate of carbapenem resistance was higher (64% vs. 38%, p < 0.001) and the colistin minimum inhibitory concentration (MIC) was elevated (7 vs. 4, p < 0.029) among the patients who died. Among the colistin-resistant K. pneumoniae, the rates of OXA-48, ST101, and NDM-1 were 78%, 67%, and 35%, respectively. Amikacin was added to the treatment of 13 patients with carbapenem and colistin-resistant Kp-BSI and 77% survived (p < 0.001). Tigecycline was added to the treatment of 24 patients with carbapenem and colistin-resistant Kp-BSI, and the 30-day mortality rate was 71% (p = 0.576). In the multivariate analysis, carbapenem resistance (odds ratio (OR) 5.2, 95% confidence interval (CI) 2.47-10.9, p < 0.001) and increasing APACHE II score (OR 1.19, 95% CI 1.12-1.26, p < 0.001) were significantly associated with 30-day mortality. The addition of amikacin to the treatment regimen (OR 0.05, 95% CI 0.01-0.23, p < 0.001) was significantly beneficial. CONCLUSIONS Carbapenem resistance, increasing MIC of colistin, and the lungs as the source of the infection were significantly associated with 30-day mortality. The empirical use of combined active aminoglycosides was found to be beneficial in the treatment of colistin-resistant K. pneumoniae infections.
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Affiliation(s)
- Şirin Menekşe
- Infectious Diseases and Clinical Microbiology Department, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey.
| | - Yasemin Çağ
- Infectious Diseases and Clinical Microbiology Department, School of Medicine, Medeniyet University, Istanbul, Turkey
| | - Mehmet Emirhan Işık
- Infectious Diseases and Clinical Microbiology Department, Kartal Koşuyolu Training and Research Hospital, Istanbul, Turkey
| | - Suzan Şahin
- Infectious Diseases and Clinical Microbiology Department, Lütfü Kırdar Training and Research Hospital, Istanbul, Turkey
| | - Demet Hacıseyitoğlu
- Clinical Microbiology Department, Lütfü Kırdar Training and Research Hospital, Istanbul, Turkey
| | - Fusun Can
- Infectious Diseases and Clinical Microbiology Department, Koç University School of Medicine, Istanbul, Turkey
| | - Onder Ergonul
- Infectious Diseases and Clinical Microbiology Department, Koç University School of Medicine, Istanbul, Turkey
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Machuca I, Gutiérrez-Gutiérrez B, Rivera-Espinar F, Cano A, Gracia-Ahufinger I, Guzman-Puche J, Marfil-Pérez E, Pérez-Nadales E, Castón JJ, Bonomo RA, Carmeli Y, Paterson D, Pascual Á, Martínez-Martínez L, Rodríguez-Baño J, Torre-Cisneros J. External validation of the INCREMENT-CPE mortality score in a carbapenem-resistant Klebsiella pneumoniae bacteraemia cohort: the prognostic significance of colistin resistance. Int J Antimicrob Agents 2019; 54:442-448. [PMID: 31377343 DOI: 10.1016/j.ijantimicag.2019.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/18/2019] [Accepted: 07/21/2019] [Indexed: 12/31/2022]
Abstract
External validation of the INCREMENT-CPE risk score (ICS) for 30-day all-cause mortality is needed. There is also scarce information about whether colistin resistance influences the prognosis of carbapenem-resistant Klebsiella pneumoniae (CRKp) bacteraemia. In this study, the ability of ICS to predict all-cause mortality in the KAPECOR cohort was calculated using the area under the receiver operating characteristic (AUROC) curve. The association of colistin resistance with mortality was studied. The ICS showed an AUROC curve of 0.77 (95% CI 0.68-0.86). A cut-off of 8 points showed 96.8% sensitivity and 50.7% specificity. Mortality of low-risk patients was not different in those treated with monotherapy versus combination therapy. However, mortality of high-risk patients treated with combination therapy (37.8%) was significantly lower than in those treated with monotherapy (68.4%) (P = 0.008). To study the prognostic significance of colistin resistance, 83 selected cases of bacteraemia due to colistin-susceptible CRKp were obtained from the INCREMENT cohort for comparison. Colistin resistance could not be shown to be associated with higher mortality in either the high-risk ICS group [adjusted odds ratio (aOR) = 1.56, 95% CI 0.69-3.33; P = 0.29] or in 37 ICS-matched pairs (aOR = 1.38, 95% CI 0.55-3.42; P = 0.49), or in a sensitivity analysis including only KPC isolates (aOR = 1.81, 95% CI 0.73-4.57; P = 0.20), but the precision of estimates was low. These results validate ICS for all-cause mortality and to optimise targeted therapy for CRKp bacteraemia. Colistin resistance was not clearly associated with increased mortality.
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Affiliation(s)
- Isabel Machuca
- Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Infectious Diseases Unit, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Infectious Diseases, Clinical Microbiology and Preventive Medicine Unit, Hospital Universitario Virgen Macarena and Virgen del Rocío-IBiS, and Department of Medicine, Universidad de Sevilla, Seville, Spain
| | | | - Angela Cano
- Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Infectious Diseases Unit, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Irene Gracia-Ahufinger
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Unit of Microbiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Julia Guzman-Puche
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Unit of Microbiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Eduardo Marfil-Pérez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Unit of Microbiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Elena Pérez-Nadales
- Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Infectious Diseases Unit, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Juan José Castón
- Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Infectious Diseases Unit, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; Departments of Medicine, Pharmacology, Biochemistry, Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Israel; National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - David Paterson
- University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Brisbane, QLD, Australia
| | - Álvaro Pascual
- Infectious Diseases, Clinical Microbiology and Preventive Medicine Unit, Hospital Universitario Virgen Macarena and Virgen del Rocío-IBiS, and Department of Medicine, Universidad de Sevilla, Seville, Spain
| | - Luís Martínez-Martínez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Unit of Microbiology, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain
| | - Jesús Rodríguez-Baño
- Infectious Diseases, Clinical Microbiology and Preventive Medicine Unit, Hospital Universitario Virgen Macarena and Virgen del Rocío-IBiS, and Department of Medicine, Universidad de Sevilla, Seville, Spain.
| | - Julián Torre-Cisneros
- Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Infectious Diseases Unit, Hospital Universitario Reina Sofía, Universidad de Córdoba, Cordoba, Spain.
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Prognosis of urinary tract infection caused by KPC-producing Klebsiella pneumoniae: The impact of inappropriate empirical treatment. J Infect 2019; 79:245-252. [PMID: 31276705 DOI: 10.1016/j.jinf.2019.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION There is scarce information on the prognosis of urinary tract infections (UTI) caused by KPC carbapenemase-producing Klebsiella pneumoniae (KPC-Kp). OBJETIVE To investigate the association between KPC-Kp aetiology and clinical failure and all cause mortality and to explore the impact of inappropriate empirical treatment. MATERIAL AND METHODS This is a retrospective observational study of hospitalized patients with UTI due to K. pneumoniae. We explored clinical failure at day 21 and 30-day all-cause mortality using different models of adjusted analysis. RESULTS We analyzed 142 episodes of UTI; 46 episodes (32.4%) were due to KPC-Kp and 96 episodes (67.6%) were due to non-KPC-Kp strains (62 wild type and 34 EBSL producer). Clinical failure was more frequent in the KPC-Kp group (41.3% vs. 15.6%, p = 0.001). KPC-Kp aetiology and inappropriate empirical therapy were associated in the non-adjusted analysis with clinical failure. When analysed in separate adjusted models, both were found to be associated; inappropriate empirical treatment (OR 2.51; 95% CI, 1.03-6.12; p = 0.04) and KPC-Kp (OR 2.73; 95% CI, 1.03-7.22; p = 0.04) were associated with increased risk of failure. All-cause 30-day mortality was higher in patients with KPC-Kp UTI (39.1% vs. 15.6%, p = 0.002). Bacteraemia was more frequent in patients with KPC-Kp etiology (23.9% vs. 10.4%; p = 0.034). In both cases, the association was not confirmed in the adjusted analysis. CONCLUSION KPC-Kp UTI is associated with higher clinical failure and may be due to an increase in inappropriate empirical treatment.
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Giannella M, Pascale R, Gutiérrez-Gutiérrez B, Cano A, Viale P. The use of predictive scores in the management of patients with carbapenem-resistant Klebsiella pneumoniae infection. Expert Rev Anti Infect Ther 2019; 17:265-273. [PMID: 30876375 DOI: 10.1080/14787210.2019.1595590] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections are associated with high morbidity and mortality rates. A therapeutic approach based on the patient risk stratification could improve outcome and avoid antibiotic misuse. Areas covered: English literature search, from 2008 to 2018, was done using PubMed database. Risk factors for developing CR-KP infection in several settings were reviewed. Since, rectal carriage was a main risk factor for developing infection, we revised in deep clinical score to predict infection among colonized patients. Furthermore, we investigated overall and treatment-related risk factors for poor outcome in patients with CR-KP infection, in particular the carbapenem producing Enterobacteriacieae (CPE)-INCREMENT score. Finally, an algorithm, based on such scores, for the therapeutic management of patients with CR-KP colonization was commented. Expert opinion: The therapeutic approach analyzed in this review could help physicians to avoid antibiotic overuse as well as to start promptly with the most appropriate antibiotic regimen. However, it has to be validated in further studies, mainly among special population such as immunocompromised patients. The availability of new drugs, fast microbiology, and analysis of gut microbiome could significantly improve the management of CR-KP colonized and/or infected patients.
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Affiliation(s)
- Maddalena Giannella
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Renato Pascale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
| | - Belén Gutiérrez-Gutiérrez
- b Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS) and Department of Medicine , Universidad de Sevilla , Sevilla , Spain
| | - Angela Cano
- c Infectious Diseases Unit , Hospital Univesritario Reina Sofia-Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC)-Unversidad de Cordoba , Cordoba , Spain
| | - Pierluigi Viale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi , University of Bologna , Bologna , Italy
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Peri AM, Doi Y, Potoski BA, Harris PNA, Paterson DL, Righi E. Antimicrobial treatment challenges in the era of carbapenem resistance. Diagn Microbiol Infect Dis 2019; 94:413-425. [PMID: 30905487 DOI: 10.1016/j.diagmicrobio.2019.01.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/14/2019] [Accepted: 01/28/2019] [Indexed: 12/22/2022]
Abstract
Infections due to carbapenem-resistant Gram-negative bacteria are burdened by high mortality and represent an urgent threat to address. Clinicians are currently at a dawn of a new era in which antibiotic resistance in Gram-negative bacilli is being dealt with by the availability of the first new antibiotics in this field for many years. Although new antibiotics have shown promising results in clinical trials, there is still uncertainty over whether their use will improve clinical outcomes in real world practice. Some observational studies have reported a survival benefit in carbapenem-resistant Enterobacteriaceae bloodstream infections using combination therapy, often including "old" antibiotics such as colistin, aminoglycosides, tigecycline, and carbapenems. These regimens, however, are linked to increased risk of antimicrobial resistance, and their efficacy has yet to be compared to new antimicrobial options. While awaiting more definitive evidence, antibiotic stewards need clear direction on how to optimize the use of old and novel antibiotic options. Furthermore, carbapenem-sparing regimens should be carefully considered as a potential tool to reduce selective antimicrobial pressure.
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Affiliation(s)
- Anna Maria Peri
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy; The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian A Potoski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, PA, USA
| | - Patrick N A Harris
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - David L Paterson
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Elda Righi
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.
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Sheu CC, Chang YT, Lin SY, Chen YH, Hsueh PR. Infections Caused by Carbapenem-Resistant Enterobacteriaceae: An Update on Therapeutic Options. Front Microbiol 2019; 10:80. [PMID: 30761114 PMCID: PMC6363665 DOI: 10.3389/fmicb.2019.00080] [Citation(s) in RCA: 273] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022] Open
Abstract
Carbapenems are considered as last-resort antibiotics for the treatment of infections caused by multidrug-resistant Gram-negative bacteria. With the increasing use of carbapenems in clinical practice, the emergence of carbapenem-resistant pathogens now poses a great threat to human health. Currently, antibiotic options for the treatment of carbapenem-resistant Enterobacteriaceae (CRE) are very limited, with polymyxins, tigecycline, fosfomycin, and aminoglycosides as the mainstays of therapy. The need for new and effective anti-CRE therapies is urgent. Here, we describe the current understanding of issues related to CRE and review combination therapeutic strategies for CRE infections, including high-dose tigecycline, high-dose prolonged-infusion of carbapenem, and double carbapenem therapy. We also review the newly available antibiotics which have potential in the future treatment of CRE infections: ceftazidime/avibactam, which is active against KPC and OXA-48 producers; meropenem/vaborbactam, which is active against KPC producers; plazomicin, which is a next-generation aminoglycoside with in vitro activity against CRE; and eravacycline, which is a tetracycline class antibacterial with in vitro activity against CRE. Although direct evidence for CRE treatment is still lacking and the development of resistance is a concern, these new antibiotics provide additional therapeutic options for CRE infections. Finally, we review other potential anti-CRE antibiotics in development: imipenem/relebactam and cefiderocol. Currently, high-dose and combination strategies that may include the new β-lactam/β-lactamase inhibitors should be considered in severe CRE infections to maximize treatment success. In the future, when more treatment options are available, therapy for CRE infections should be individualized and based on molecular phenotypes of resistance, susceptibility profiles, disease severity, and patient characteristics. More high-quality studies are needed to guide effective treatment for infections caused by CRE.
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Affiliation(s)
- Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ya-Ting Chang
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shang-Yi Lin
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Infectious Disease, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yen-Hsu Chen
- School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, Graduate Institute of Clinical Medicine, Center of Dengue Fever Control and Research, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.,Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Liang Q, Huang M, Xu Z. Early use of polymyxin B reduces the mortality of carbapenem-resistant Klebsiella pneumoniae bloodstream infection. Braz J Infect Dis 2019; 23:60-65. [PMID: 30796888 PMCID: PMC9428011 DOI: 10.1016/j.bjid.2018.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/18/2018] [Accepted: 12/21/2018] [Indexed: 01/02/2023] Open
Abstract
Polymyxin B is one of the last resort option for carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infection in China. Therefore, the timing of administration of polymyxin is frequently delayed. We collected 40 cases of CRKP bloodstream infections (BSIs) treated with combinations based on polymyxin B over 30 months. The primary outcome, 30-day mortality rate, was 52.5% (21/40). Early administration of polymyxin B is meant to administer the drug within 48h of diagnosing bacteremia. Delayed administration was considered when polymyxin B was administered after 48h of bacteremia onset. Polymyxin B duration and total dosages were similar in the two groups (11.57 days versus 11.76 days, p=0.919; 1306.52mg versus 1247.06mg, p=0.711). Compared with delayed administration, early use of polymyxin B-based combination therapy had a significant increase in the rate of bacterial clearance (65.22% versus 29.41%, p=0.025; OR=0.533) and decreased 30-day mortality (39.13% versus 70.59%, p=0.045; OR=0.461) and overall mortality (43.48% versus 82.35%, p=0.022; OR=0.321).
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Affiliation(s)
- Qiqiang Liang
- Second Affiliated Hospital of Zhejiang University, General Intensive Care Unit, Zhejiang, China
| | - Man Huang
- Second Affiliated Hospital of Zhejiang University, General Intensive Care Unit, Zhejiang, China.
| | - Zhijiang Xu
- Second Affiliated Hospital of Zhejiang University, Clinical Laboratory, Zhejiang, China
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Lin YT, Su CF, Chuang C, Lin JC, Lu PL, Huang CT, Wang JT, Chuang YC, Siu LK, Fung CP. Appropriate Treatment for Bloodstream Infections Due to Carbapenem-Resistant Klebsiella pneumoniae and Escherichia coli: A Nationwide Multicenter Study in Taiwan. Open Forum Infect Dis 2018; 6:ofy336. [PMID: 30740468 PMCID: PMC6362312 DOI: 10.1093/ofid/ofy336] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/14/2018] [Indexed: 11/14/2022] Open
Abstract
Background In a multicenter study from Taiwan, we aimed to investigate the outcome of patients who received different antimicrobial therapy in carbapenem-resistant Enterobacteriaceae bloodstream infections and proposed a new definition for tigecycline use. Methods Patients from 16 hospitals in Taiwan who received appropriate therapy for bloodstream infections due to carbapenem-resistant Klebsiella pneumoniae and Escherichia coli were enrolled in the study between January 2012 and June 2015. We used a cox proportional regression model for multivariate analysis to identify independent risk factors of 14-day mortality. Tigecycline was defined as appropriate when the isolates had a minimum inhibitory concentration (MIC) ≤0.5 mg/L, and we investigated whether tigecycline was associated with mortality among patients with monotherapy. Results Sixty-four cases with carbapenem-resistant K pneumoniae (n = 50) and E coli (n = 14) bloodstream infections were analyzed. Of the 64 isolates, 17 (26.6%) had genes that encoded carbapenemases. The 14-day mortality of these cases was 31.3%. In the multivariate analysis, Charlson Comorbidity Index (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.03–1.42; P = .022) and colistin monotherapy (HR, 5.57; 95% CI, 2.13–14.61; P < .001) were independently associated with 14-day mortality. Among the 55 patients with monotherapy, the 14-day mortality was 30.9% (n = 17). Tigecycline use was not associated with mortality in the multivariate analysis. Conclusions Tigecycline monotherapy was a choice if the strains exhibited MIC ≤0.5 mg/L, and colistin monotherapy was not suitable. Our findings can initiate additional clinical studies regarding the efficacy of tigecycline in carbapenem-resistant Enterobacteriaceae infections.
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Affiliation(s)
- Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taiwan.,Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Fang Su
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | - Chien Chuang
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taiwan
| | - Jung-Chung Lin
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Centre, Taipei, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital, and College of Medicine, Kaohsiung Medical University, Taiwan
| | - Ching-Tai Huang
- Division of Infectious Diseases, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jann-Tay Wang
- Division of Infectious Diseases, Department of Medicine, National Taiwan University Hospital, Taipei
| | - Yin-Ching Chuang
- Department of Internal Medicine and Medical Research, Chi Mei Medical Centre, Tainan, Taiwan
| | - L Kristopher Siu
- Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Sijhih Cathy General Hospital, New Taipei City, Taiwan
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Zhang W, Guo Y, Li J, Zhang Y, Yang Y, Dong D, Zhu D, He P, Hu F. In vitro and in vivo bactericidal activity of ceftazidime-avibactam against Carbapenemase-producing Klebsiella pneumoniae. Antimicrob Resist Infect Control 2018; 7:142. [PMID: 30479755 PMCID: PMC6249859 DOI: 10.1186/s13756-018-0435-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 11/08/2018] [Indexed: 01/04/2023] Open
Abstract
Background In recent years, the incidence of carbapenem-resistant Enterobacteriaceae (CRE) infections has increased rapidly. Since the CRE strain is usually resistant to most of antimicrobial agents, patients with this infection are often accompanied by a high mortality. Therefore, it instigates a severe challenge the clinical management of infection. In this study, we study the in vitro and in vivo bactericidal activity of ceftazidime-avibactam administrated either alone or in combination with aztreonam against KPC or NDM carbapenemase-producing Klebsiella pneumoniae, and explore a new clinical therapeutic regimen for infections induced by their resistant strains. Methods The microdilution broth method was performed to analyze the minimal inhibitory concentration (MIC). The time-kill curve assay of ceftazidime-avibactam at various concentrations was conducted in 16 strains of KPC-2 and 1 strain of OXA-232 carbapenemase-producing Klebsiella pneumoniae. The in vitro synergistic bactericidal effect of ceftazidime-avibactam combined with aztreonam was determined by checkerboard assay on 28 strains of NDM and 2 strains of NDM coupled with KPC carbapenemase-producing Klebsiella pneumoniae. According to calculating grade, the drugs with synergistic bactericidal effect were selected as an inhibitory concentration index. The in vitro bactericidal tests of ceftazidime-avibactam combined with aztreonam were implemented on 12 strains among them. Effect of ceftazidime-avibactam antibiotic against KPC carbapenemase-producing K. pneumoniae strain Y8 Infection was performed in the mouse model. Results The time-kill assays revealed that ceftazidime-avibactam at various concentrations of 2MIC, 4MIC and 8MIC showed significant bactericidal efficiency to the resistant bacteria strains. However, in 28 strains of NDM and 2 strains of NDM coupled with KPC carbapenemase- producing Klebsiella pneumoniae, only 7 strains appeared the susceptibility to ceftazidime-avibactam treatment, MIC50 and MIC90 were 64 mg/L and 256 mg/L, respectively. Antimicrobial susceptibility testing of ceftazidime-avibactam combined with aztreonam disclosed the synergism of two drugs in 90% (27/30) strains, an additive efficiency in 3.3% (1/30) strains, and irrelevant effects in 6.6% (2/30) strains. No antagonism was found. The subsequent bactericidal tests also confirmed the results mentioned above. Therapeutic efficacy of Ceftazidime-Avibactam against K. pneumoniae strain Y8 infection in mouse indicated 70% of infection group mice died within 4 days, and all mice in this group died within 13 days. Bacterial load testing results showed that there was no significant difference in the amount of bacteria in the blood between the infected group and the treatment group. However, the spleen and liver of treatment group mice showed lower CFU counts, as compare with infected group, indicating that ceftazidime-avibactam has a significant effect on the bacteria and led to a certain therapeutic efficacy. Conclusion This study indicated ceftazidime-avibactam therapy occupied significant bactericidal effects against KPC-2 and OXA-232 carbapenemase-producing Klebsiella pneumoniae. While combined with aztreonam, the stronger synergistic bactericidal effects against NDM carbapenemase-producing Klebsiella pneumoniae were achieved.
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Affiliation(s)
- Wenxia Zhang
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,2Department of Clinical Laboratory, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 528 Zhangheng Rd, Shanghai, 201203 China
| | - Yan Guo
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,4Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Jiayin Li
- 3Department of Medical Microbiology and Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Yiyuan Zhang
- 3Department of Medical Microbiology and Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Yang Yang
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,4Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Dong Dong
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,4Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Demei Zhu
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,4Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | - Ping He
- 3Department of Medical Microbiology and Immunology, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Fupin Hu
- 1Institute of Antibiotics, Huashan Hospital, Fudan University, 12 M. Wulumuqi Rd, Shanghai, 200040 China.,4Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
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Synergistic Activity of Colistin-Containing Combinations against Colistin-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2018; 62:AAC.00873-18. [PMID: 30061285 DOI: 10.1128/aac.00873-18] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/24/2018] [Indexed: 11/20/2022] Open
Abstract
Resistance to colistin, a polypeptide drug used as an agent of last resort for the treatment of infections caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria, including carbapenem-resistant Enterobacteriaceae (CRE), severely limits treatment options and may even transform an XDR organism into one that is pan-resistant. We investigated the synergistic activity of colistin in combination with 19 antibiotics against a collection of 20 colistin-resistant Enterobacteriaceae isolates, 15 of which were also CRE. All combinations were tested against all strains using an inkjet printer-assisted digital dispensing checkerboard array, and the activities of those that demonstrated synergy by this method were evaluated against a single isolate in a time-kill synergy study. Eighteen of 19 combinations demonstrated synergy against two or more isolates, and the 4 most highly synergistic combinations (colistin combined with linezolid, rifampin, azithromycin, and fusidic acid) were synergistic against ≥90% of strains. Sixteen of 18 combinations (88.9%) that were synergistic in the checkerboard array were also synergistic in a time-kill study. Our findings demonstrate that colistin in combination with a range of antibiotics, particularly protein and RNA synthesis inhibitors, exhibits synergy against colistin-resistant strains, suggesting that colistin may exert a subinhibitory permeabilizing effect on the Gram-negative bacterial outer membrane even in isolates that are resistant to it. These findings suggest that colistin combination therapy may have promise as a treatment approach for patients infected with colistin-resistant XDR Gram-negative pathogens.
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Hypermucoviscous Klebsiella pneumoniae infections induce platelet aggregation and apoptosis and inhibit maturation of megakaryocytes. Thromb Res 2018; 171:45-54. [PMID: 30248660 DOI: 10.1016/j.thromres.2018.09.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/10/2018] [Accepted: 09/19/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Different Klebsiella pneumoniae strains carry different virulence factors and antibiotic resistance and may cause thrombocytopenia. This study aimed to investigate the effects of different infections caused by K. pneumoniae on platelets. METHODS Two hypermucoviscous K. pneumoniae strains and two classic strains were collected from clinical blood culture, and in both groups, there was a carbapenem-resistant strain and a carbapenem-sensitive strain. Mouse infection models were constructed by intraperitoneally injecting different strains, and mice injected with phosphate-buffered saline served as a control. Count, aggregation rate and apoptosis proportion of platelets within 12 h were examined. CD41 expression was measured in bone marrow cells to determine the maturation of megakaryocytes. The concentrations of lipopolysaccharides and related signaling molecules were also measured. RESULTS The platelet aggregation rate was much significantly higher in the two hypermucoviscous groups, while it showed no difference in the classic groups compared to the control group. All infections induced apoptosis of platelets, among which the highest apoptosis proportions were observed in infections caused by the hypermucoviscous carbapenem-sensitive strain. In both hypermucoviscous groups the CD41 mean fluorescence intensity was much lower than that in the control group, indicating that the maturation of megakaryocytes in the hypermucoviscous groups was significantly inhibited. Lipopolysaccharides were significantly higher and TLR4/Myd88 and JNK/MAPK pathways were strongly activated in hypermucoviscous groups. CONCLUSIONS The results indicate that hypermucoviscous K. pneumoniae can reduce platelet count by several pathways. Although antibiotic resistance is rapidly emerging worldwide, it has little influence on the decrease in platelets.
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Risk Factors for Colistin Resistance among Gram-Negative Rods and Klebsiella pneumoniae Isolates. J Clin Microbiol 2018; 56:JCM.00149-18. [PMID: 29976595 DOI: 10.1128/jcm.00149-18] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022] Open
Abstract
Infections due to colistin-resistant (Colr) Gram-negative rods (GNRs) and colistin-resistant Klebsiella pneumoniae isolates in particular result in high associated mortality and poor treatment options. To determine the risk factors for recovery on culture of Colr GNRs and ColrK. pneumoniae, analyses were chosen to aid decisions at two separate time points: the first when only Gram stain results are available without any bacterial species information (corresponding to the Colr GNR model) and the second when organism identification is performed but prior to reporting of antimicrobial susceptibility testing results (corresponding to the ColrK. pneumoniae model). Cases were retrospectively analyzed at a major academic hospital system from 2011 to 2016. After excluding bacteria that were intrinsically resistant to colistin, a total of 28,512 GNR isolates (4,557 K. pneumoniae isolates) were analyzed, 128 of which were Colr (i.e., MIC > 2 μg/ml), including 68 of which that were ColrK. pneumoniae In multivariate analysis, risk factors for Colr GNRs were neurologic disease, residence in a skilled nursing facility prior to admission, receipt of carbapenems in the last 90 days, prior infection with a carbapenem-resistant organism, and receipt of ventilatory support (c-statistic = 0.81). Risk factors for ColrK. pneumoniae specifically were neurologic disease, residence in a skilled nursing facility prior to admission, receipt of carbapenems in the last 90 days, receipt of an anti-methicillin-resistant Staphylococcus aureus antimicrobial in the last 90 days, and prior infection with a carbapenem-resistant organism (c-statistic = 0.89). A scoring system derived from these models can be applied by providers to guide empirical antimicrobial therapy in patients with infections with suspected Colr GNR and ColrK. pneumoniae isolates.
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Comparison of Septic Shock Due to Multidrug-Resistant Acinetobacter baumannii or Klebsiella pneumoniae Carbapenemase-Producing K. pneumoniae in Intensive Care Unit Patients. Antimicrob Agents Chemother 2018; 62:AAC.02562-17. [PMID: 29555630 DOI: 10.1128/aac.02562-17] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/08/2018] [Indexed: 11/20/2022] Open
Abstract
A significant cause of mortality in the intensive care unit (ICU) is multidrug-resistant (MDR) Gram-negative bacteria, such as MDR Acinetobacter baumannii (MDR-AB) and Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp). The aim of the present study was to compare the clinical features, therapy, and outcome of patients who developed septic shock due to either MDR-AB or KPC-Kp. We retrospectively analyzed patients admitted to the ICU of a teaching hospital from November 2010 to December 2015 who developed septic shock due to MDR-AB or KPC-Kp infection. Data from 220 patients were analyzed: 128 patients (58.2%) were diagnosed with septic shock due to KPC-Kp, and 92 patients (41.8%) were diagnosed with septic shock due to MDR-AB. The 30-day mortality rate was significantly higher for the MDR-AB group than the KPC-Kp group (84.8% versus 44.5%, respectively; P < 0.001). Steroid exposure and pneumonia were associated with MDR-AB infection, whereas hospitalization in the previous 90 days, primary bacteremia, and KPC-Kp colonization were associated with KPC-Kp infection. For patients with KPC-Kp infections, the use of ≥2 in vitro-active antibiotics as empirical or definitive therapy was associated with higher 30-day survival, while isolation of colistin-resistant strains was linked to mortality. Patients with MDR-AB infections, age >60 years, and a simplified acute physiology score II (SAPS II) of >45 points were associated with increased mortality rates. We concluded that septic shock due to MDR-AB infection is associated with very high mortality rates compared to those with septic shock due to KPC-Kp. Analysis of the clinical features of these critically ill patients might help physicians in choosing appropriate empirical antimicrobial therapy.
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