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Tracy KC, McKaig J, Kinnear C, Millar J, King AA, Read AF, Woods RJ. Reversion to sensitivity explains limited transmission of resistance in a hospital pathogen. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.03.597162. [PMID: 38895443 PMCID: PMC11185621 DOI: 10.1101/2024.06.03.597162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Bacterial pathogens that are successful in hospital environments must survive times of intense antibiotic exposure and times of no antibiotic exposure. When these organisms are closely associated with human hosts, they must also transmit from one patient to another for the resistance to spread. The resulting evolutionary dynamics have, in some settings, led to rising levels of resistance in hospitals. Here, we focus on an important but understudied aspect of this dynamic: the loss of resistance when the resistant organisms evolve in environments where the antibiotic pressure is removed. Based on prior data, we hypothesize that resistance arising in the context of strong selection may carry a high cost and revert to sensitivity quickly once the selective pressure is removed. Conversely, resistant isolates that persist through times of no antibiotic pressure should carry a lower cost and revert less quickly. To test this hypothesis, we utilize a genetically diverse set of patient-derived, daptomycin-resistant Enterococcus faecium isolates that include cases of both de novo emergence of resistance within patients and putatively transmitted resistance. Both of these sets of strains have survived periods of antibiotic exposure, but only putatively transmitted resistant strains have survived extended periods without antibiotic exposure. These strains were then allowed to evolve in antibiotic free laboratory conditions. We find that putatively transmitted resistant strains tended to have lower level resistance but that evolution in antibiotic-free conditions resulted in minimal loss of resistance. In contrast, resistance that arose de novo within patients was higher level but exhibited greater declines in resistance in vitro. Sequencing of the experimentally evolved isolates revealed that reversal of high level resistance resulted from evolutionary pathways that were frequently genetically associated with the unique resistance mutations of that strain. Thus, the rapid reversal of high-level resistance was associated with accessible evolutionary pathways where an increase in fitness is associated with decreased resistance. We describe how this rapid loss of resistance may limit the spread of resistance within the hospital and shape the diversity of resistance phenotypes across patients.
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Affiliation(s)
- Kevin C. Tracy
- Department of Computational Medicine and Bioinformatics, University of Michigan
| | | | - Clare Kinnear
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan
| | - Jess Millar
- Department of Computational Medicine and Bioinformatics, University of Michigan
| | - Aaron A. King
- Department of Ecology and Evolutionary Biology, University of Michigan
- Center for the Study of Complex Systems, University of Michigan
- The Santa Fe Institute
| | - Andrew F. Read
- Department of Biology, Pennsylvania State University
- Department of Entomology, Pennsylvania State University
| | - Robert J. Woods
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan
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Axell-House DB, Simar SR, Panesso D, Rincon S, Miller WR, Khan A, Pemberton OA, Valdez L, Nguyen AH, Hood KS, Rydell K, DeTranaltes AM, Jones MN, Atterstrom R, Reyes J, Sahasrabhojane PV, Suleyman G, Zervos M, Shelburne SA, Singh KV, Shamoo Y, Hanson BM, Tran TT, Arias CA. LiaX is a surrogate marker for cell envelope stress and daptomycin non-susceptibility in Enterococcus faecium. Antimicrob Agents Chemother 2024; 68:e0106923. [PMID: 38289081 PMCID: PMC10916372 DOI: 10.1128/aac.01069-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024] Open
Abstract
Daptomycin (DAP) is often used as a first-line therapy to treat vancomycin-resistant Enterococcus faecium infections, but emergence of DAP non-susceptibility threatens the effectiveness of this antibiotic. Moreover, current methods to determine DAP minimum inhibitory concentrations (MICs) have poor reproducibility and accuracy. In enterococci, DAP resistance is mediated by the LiaFSR cell membrane stress response system, and deletion of liaR encoding the response regulator results in hypersusceptibility to DAP and antimicrobial peptides. The main genes regulated by LiaR are a cluster of three genes, designated liaXYZ. In Enterococcus faecalis, LiaX is surface-exposed with a C-terminus that functions as a negative regulator of cell membrane remodeling and an N-terminal domain that is released to the extracellular medium where it binds DAP. Thus, in E. faecalis, LiaX functions as a sentinel molecule recognizing DAP and controlling the cell membrane response, but less is known about LiaX in E. faecium. Here, we found that liaX is essential in E. faecium with an activated LiaFSR system. Unlike E. faecalis, E. faecium LiaX is not detected in the extracellular milieu and does not appear to alter phospholipid architecture. We further postulated that LiaX could be used as a surrogate marker for cell envelope activation and non-susceptibility to DAP. For this purpose, we developed and optimized a LiaX enzyme-linked immunosorbent assay (ELISA). We then assessed 86 clinical E. faecium bloodstream isolates for DAP MICs and used whole genome sequencing to assess for substitutions in LiaX. All DAP-resistant clinical strains of E. faecium exhibited elevated LiaX levels. Strikingly, 73% of DAP-susceptible isolates by standard MIC determination also had elevated LiaX ELISAs compared to a well-characterized DAP-susceptible strain. Phylogenetic analyses of predicted amino acid substitutions showed 12 different variants of LiaX without a specific association with DAP MIC or LiaX ELISA values. Our findings also suggest that many E. faecium isolates that test DAP susceptible by standard MIC determination are likely to have an activated cell stress response that may predispose to DAP failure. As LiaX appears to be essential for the cell envelope response to DAP, its detection could prove useful to improve the accuracy of susceptibility testing by anticipating therapeutic failure.
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Affiliation(s)
- Dierdre B. Axell-House
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Shelby R. Simar
- Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Diana Panesso
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
- Molecular Genetics and Antimicrobial Resistance Unit, Universidad El Bosque, Bogotá, Colombia
| | - Sandra Rincon
- Molecular Genetics and Antimicrobial Resistance Unit, Universidad El Bosque, Bogotá, Colombia
| | - William R. Miller
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ayesha Khan
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Lizbet Valdez
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - April H. Nguyen
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kara S. Hood
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Kirsten Rydell
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Andrea M. DeTranaltes
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Mary N. Jones
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Rachel Atterstrom
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Jinnethe Reyes
- Molecular Genetics and Antimicrobial Resistance Unit, Universidad El Bosque, Bogotá, Colombia
| | - Pranoti V. Sahasrabhojane
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Geehan Suleyman
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Marcus Zervos
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Samuel A. Shelburne
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kavindra V. Singh
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Yousif Shamoo
- Department of Biosciences, Rice University, Houston, Texas, USA
| | - Blake M. Hanson
- Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Truc T. Tran
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Cesar A. Arias
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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Axell-House DB, Simar SR, Panesso D, Rincon S, Miller WR, Khan A, Pemberton OA, Valdez L, Nguyen AH, Hood KS, Rydell K, DeTranaltes AM, Jones MN, Atterstrom R, Reyes J, Sahasrabhojane PV, Suleyman G, Zervos M, Shelburne SA, Singh KV, Shamoo Y, Hanson BM, Tran TT, Arias CA. LiaX is a surrogate marker for cell-envelope stress and daptomycin non-susceptibility in Enterococcus faecium. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.18.553907. [PMID: 37645818 PMCID: PMC10462152 DOI: 10.1101/2023.08.18.553907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Daptomycin (DAP) is often used as a first line therapy to treat vancomycin-resistant Enterococcus faecium (VR Efm ) infections but emergence of DAP non-susceptibility threatens the effectiveness of this antibiotic. Moreover, current methods to determine DAP MICs have poor reproducibility and accuracy. In enterococci, DAP resistance is mediated by the LiaFSR cell membrane stress response system and deletion of liaR encoding the response regulator results in hypersusceptibility to DAP and antimicrobial peptides. The main genes regulated by LiaR are a cluster of three genes, designated liaXYZ . In Enterococcus faecalis , LiaX is surface exposed with a C-terminus that functions as a negative regulator of cell membrane remodeling and an N-terminal domain that is released to the extracellular medium where it binds DAP. Thus, in E. faecalis , LiaX functions as a sentinel molecule recognizing DAP and controlling the cell membrane response, but less is known about LiaX in E. faecium . Here, we found that liaX is essential in E. faecium ( Efm ) with an activated LiaFSR system. Unlike E. faecalis , Efm LiaX is not detected in the extracellular milieu and does not appear to alter phospholipid architecture. We further postulated that LiaX could be used as a surrogate marker for cell envelope activation and non-susceptibility to DAP. For this purpose, we developed and optimized a LiaX ELISA. We then assessed 86 clinical E. faecium BSI isolates for DAP MICs and used whole genome sequencing to assess for substitutions in LiaX. All DAP-R clinical strains of E. faecium exhibited elevated LiaX levels. Strikingly, 73% of DAP-S isolates by standard MIC determination had elevated LiaX ELISAs above the established cut-off. Phylogenetic analyses of predicted amino acid substitutions showed 12 different variants of LiaX without a specific association with DAP MIC or LiaX ELISA values. Our findings also suggest that many Efm isolates that test DAP susceptible by standard MIC determination are likely to have an activated cell stress response that may predispose to DAP failure. As LiaX appears to be essential for the cell envelope response to DAP, its detection could prove useful to improve the accuracy of susceptibility testing by anticipating therapeutic failure.
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Cairns KA, Udy AA, Peel TN, Abbott IJ, Dooley MJ, Peleg AY. Therapeutics for Vancomycin-Resistant Enterococcal Bloodstream Infections. Clin Microbiol Rev 2023; 36:e0005922. [PMID: 37067406 PMCID: PMC10283489 DOI: 10.1128/cmr.00059-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Vancomycin-resistant enterococci (VRE) are common causes of bloodstream infections (BSIs) with high morbidity and mortality rates. They are pathogens of global concern with a limited treatment pipeline. Significant challenges exist in the management of VRE BSI, including drug dosing, the emergence of resistance, and the optimal treatment for persistent bacteremia and infective endocarditis. Therapeutic drug monitoring (TDM) for antimicrobial therapy is evolving for VRE-active agents; however, there are significant gaps in the literature for predicting antimicrobial efficacy for VRE BSIs. To date, TDM has the greatest evidence for predicting drug toxicity for the three main VRE-active antimicrobial agents daptomycin, linezolid, and teicoplanin. This article presents an overview of the treatment options for VRE BSIs, the role of antimicrobial dose optimization through TDM in supporting clinical infection management, and challenges and perspectives for the future.
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Affiliation(s)
- Kelly A. Cairns
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Trisha N. Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Iain J. Abbott
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michael J. Dooley
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Anton Y. Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Infection Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
- Centre to Impact AMR, Monash University, Clayton, Victoria, Australia
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Humphries RM, Miller L, Zimmer B, Matuschek E, Hindler JA. Contemporary Considerations for Establishing Reference Methods for Antibacterial Susceptibility Testing. J Clin Microbiol 2023; 61:e0188622. [PMID: 36971571 PMCID: PMC10281161 DOI: 10.1128/jcm.01886-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Antibacterial susceptibility testing (AST) is performed to guide therapy, perform resistance surveillance studies, and support development of new antibacterial agents. For 5 decades, broth microdilution (BMD) has served as the reference method to assess in vitro activity of antibacterial agents against which both novel agents and diagnostic tests have been measured. BMD relies on in vitro inhibition or killing of bacteria. It is associated with several limitations: it is a poor mimic of the in vivo milieu of bacterial infections, requires multiple days to perform, and is associated with subtle, difficult to control variability. In addition, new reference methods will soon be needed for novel agents whose activity cannot be evaluated by BMD (e.g., those that target virulence). Any new reference methods must be standardized, correlated with clinical efficacy and be recognized internationally by researchers, industry, and regulators. Herein, we describe current reference methods for in vitro assessment of antibacterial activity and highlight key considerations for the generation of novel reference methods.
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Affiliation(s)
- Romney M. Humphries
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Linda Miller
- CMID Pharma Consulting, LLC, Dresher, Pennsylvania, USA
| | - Barbara Zimmer
- Beckman Coulter Microbiology, Sacramento, California, USA
| | | | - Janet A. Hindler
- Los Angeles County Department of Public Health, Public Health Laboratory, Los Angeles, California, USA
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White BP, Barber KE, Chastain DB. Treatment decisions in VRE bacteraemia: a survey of infectious diseases pharmacists. JAC Antimicrob Resist 2023; 5:dlad063. [PMID: 37223393 PMCID: PMC10202426 DOI: 10.1093/jacamr/dlad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/23/2023] [Indexed: 05/25/2023] Open
Abstract
Background VRE infections increased in 2020. High-dose daptomycin (≥10 mg/kg) has shown mortality benefit over other regimens, though daptomycin resistance is increasing. Limited data exist on the practice patterns of ID pharmacists for VRE bloodstream infections (VRE BSIs). Objectives To describe practice patterns for VRE BSI in ID pharmacists. Methods A 22-question REDCap survey was distributed to ID pharmacist members of the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (ID PRN) via e-mail listserv. The survey was distributed on 7 April 2022 and remained open for 4 weeks. Results Sixty-eight pharmacists responded. All pharmacists completed additional training or certification in infectious diseases past their PharmD, and most (70.5%) had been practising for 10 years or less. Pharmacists at academic medical centres (80.0%) were more likely (P = 0.001) to have implemented the updated CLSI breakpoints than pharmacists at other types of institutions (55.2%). Daptomycin was the preferred drug for VRE BSI (92.6%), with 10 mg/kg (72.1%) being the preferred dose. Adjusted body weight was the most common weight (61.2%) used for obese patients. Fourteen days (76.1%) was the most common treatment duration for VRE BSI. Pharmacists defined persistent VRE BSI as 5 days (68.7%) after first blood culture. Conclusions ID pharmacists overwhelmingly selected high-dose daptomycin for VRE BSI. There were variations in practice and response rate when selecting combination therapy, managing persistent bacteraemia, and treating patients with high daptomycin MICs or previous exposure to daptomycin.
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Affiliation(s)
| | - Katie E Barber
- Department of Clinical Pharmacy, University of Mississippi College of Pharmacy, 2500 North State Street, USA
| | - Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1000 Jefferson Street, USA
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Chuang YC, Lin HY, Wang JT, Yang JL, Lin CY, Huang SH, Chen YC, Chang SC. Daptomycin area under the curve to minimum inhibitory concentration ratio by broth microdilution for predicting the outcome of vancomycin-resistant Enterococcus bloodstream infection. Biomed Pharmacother 2022; 155:113710. [PMID: 36156368 DOI: 10.1016/j.biopha.2022.113710] [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: 08/04/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES Different methods are used to determine the minimum inhibitory concentration (MIC) for daptomycin. The threshold is unknown for the free drug area under the concentration-time curve to MIC ratio (fAUC/MIC) of daptomycin using broth microdilution (BMD) to predict outcome of vancomycin-resistant enterococcus (VRE) bacteremia. The MIC testing method which is best for predicting the outcome remains unclear. METHODS This is a retrospective cohort study. The inclusion criterion was VRE bacteremia treated with ≥ 8 mg/kg of daptomycin. As we aimed to compare different daptomycin MIC testing methods for predicting the clinical outcome of VRE bacteremia, the inclusion criteria included the availability of MIC values for BMD, Etest, and automated antimicrobial susceptibility testing (AST). The primary end point was 28-day mortality. The fAUC/MIC was dichotomized using classification and regression tree analysis for predicting survival. RESULTS A total of 393 patients were included; 215 survived and 178 died. In the multivariable logistic model for predicting mortality, the dichotomized fAUC/MICs for Etest and AST were 0.508 and 0.065 times as probable, respectively, as that for BMD to minimize information loss. An fAUC/MIC > 75.07 for BMD significantly predicted lower mortality (adjusted odds ratio, 0.53, 95% confidence interval, 0.30-0.95; P = 0.03) after adjusting for underlying disease and bacteremia severity. Using Monte Carlo simulation, none of the doses had a probability of target attainment of ≥ 50% with an MIC of ≥ 2 mg/L. CONCLUSION The dichotomized threshold for fAUC/MIC for BMD was the best predictor of mortality. An fAUC/MIC > 75.07 for BMD independently predicted better survival.
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Affiliation(s)
- Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Hsin-Yi Lin
- Department of Economics, National Chengchi University, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Ling Yang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ying Lin
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
Enterococci are major, recalcitrant nosocomial pathogens with a wide repertoire of intrinsic and acquired resistance determinants and the potential of developing resistance to all clinically available antimicrobials. As such, multidrug-resistant enterococci are considered a serious public health threat. Due to limited treatment options and rapid emergence of resistance to all novel agents, the clinical microbiology laboratory plays a critical role in deploying accurate, reproducible, and feasible antimicrobial susceptibility testing methods to guide appropriate treatment of patients with deep-seated enterococcal infections. In this review, we provide an overview of the advantages and disadvantages of existing manual and automated methods that test susceptibility of Enterococcus faecium and Enterococcus faecalis to β-lactams, aminoglycosides, vancomycin, lipoglycopeptides, oxazolidinones, novel tetracycline-derivatives, and daptomycin. We also identify unique problems and gaps with the performance and clinical utility of antimicrobial susceptibility testing for enterococci, provide recommendations for clinical laboratories to circumvent select problems, and address potential future innovations that can bridge major gaps in susceptibility testing.
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Udaondo Z, Abram KZ, Kothari A, Jun SR. Insertion sequences and other mobile elements associated with antibiotic resistance genes in Enterococcus isolates from an inpatient with prolonged bacteraemia. Microb Genom 2022; 8. [PMID: 35921144 PMCID: PMC9484755 DOI: 10.1099/mgen.0.000855] [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] [Indexed: 11/23/2022] Open
Abstract
Insertion sequences (ISs) and other transposable elements are associated with the mobilization of antibiotic resistance determinants and the modulation of pathogenic characteristics. In this work, we aimed to investigate the association between ISs and antibiotic resistance genes, and their role in the dissemination and modification of the antibiotic-resistant phenotype. To that end, we leveraged fully resolved Enterococcus faecium and Enterococcus faecalis genomes of isolates collected over 5 days from an inpatient with prolonged bacteraemia. Isolates from both species harboured similar IS family content but showed significant species-dependent differences in copy number and arrangements of ISs throughout their replicons. Here, we describe two inter-specific IS-mediated recombination events and IS-mediated excision events in plasmids of E. faecium isolates. We also characterize a novel arrangement of the ISs in a Tn1546-like transposon in E. faecalis isolates likely implicated in a vancomycin genotype–phenotype discrepancy. Furthermore, an extended analysis revealed a novel association between daptomycin resistance mutations in liaSR genes and a putative composite transposon in E. faecium, offering a new paradigm for the study of daptomycin resistance and novel insights into its dissemination. In conclusion, our study highlights the role ISs and other transposable elements play in the rapid adaptation and response to clinically relevant stresses such as aggressive antibiotic treatment in enterococci.
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Affiliation(s)
- Zulema Udaondo
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kaleb Z Abram
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Atul Kothari
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Dept of Health, Healthcare Associated Infections and Outbreak Response Sections, Little Rock, AR 72205, USA
| | - Se-Ran Jun
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Chuang YC, Lin HY, Yang JL, Lin CY, Huang SH, Wang JT, Chen YC, Chang SC. Influence of daptomycin doses on the outcomes of VRE bloodstream infection treated with high-dose daptomycin. J Antimicrob Chemother 2022; 77:2278-2287. [PMID: 35639586 DOI: 10.1093/jac/dkac164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/27/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES The CLSI recommended high-dose daptomycin (8-12 mg/kg) for treating Enterococcus faecium bloodstream infections (BSI). The current study was designed to determine the safety and efficacy of increasing the daptomycin dose for VRE BSI patients receiving ≥8 mg/kg. METHODS We conducted a multicentre prospective observational study of patients who received a ≥8 mg/kg dose of daptomycin for treatment of VRE BSI. The primary outcome was 28 day mortality. RESULTS A total of 661 patients were included. The 28 day mortality rate was 45.1%. The survivors received higher doses of daptomycin than non-survivors (10.1 versus 9.8 mg/kg; P < 0.001). An increase in the daptomycin dose independently predicted lower mortality [adjusted OR (aOR) = 0.85; 95% CI = 0.73-0.99; P = 0.03]. Eighty-six survivors (23.7%) and 43 non-survivors (14.4%) received a ≥11 mg/kg dose of daptomycin (P = 0.003). The 8 to <11 and ≥11 mg/kg doses of daptomycin differed in the 28 day mortality in the higher MIC group (≥2 mg/L) (49.4% versus 33.3%; P = 0.004), but not in the lower MIC group (≤1 mg/L) (29.3% versus 29.4%; P = 0.99). A dose of ≥11 mg/kg was associated with a higher (3.9%) rate of highly elevated creatine kinase (>2000 U/L) compared with 1.1% with 8 to <11 mg/kg (P = 0.04). CONCLUSIONS The efficacy of daptomycin is dose dependent. A high daptomycin dose, especially at ≥11 mg/kg, improved survival in patients with VRE BSI, but was associated with highly elevated creatine kinase. We recommend a ≥11 mg/kg dose of daptomycin be considered for treatment of VRE BSI, particularly for isolates with higher MICs.
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Affiliation(s)
- Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yi Lin
- Department of Economics, National Chengchi University, Taipei, Taiwan
| | - Jia-Ling Yang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ying Lin
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Contreras GA, Munita JM, Simar S, Luterbach C, Dinh AQ, Rydell K, Sahasrabhojane PV, Rios R, Diaz L, Reyes K, Zervos M, Misikir HM, Sanchez-Petitto G, Liu C, Doi Y, Abbo LM, Shimose L, Seifert H, Gudiol C, Barberis F, Pedroza C, Aitken SL, Shelburne SA, van Duin D, Tran TT, Hanson BM, Arias CA. Contemporary Clinical and Molecular Epidemiology of Vancomycin-Resistant Enterococcal Bacteremia: A Prospective Multicenter Cohort Study (VENOUS I). Open Forum Infect Dis 2022; 9:ofab616. [PMID: 35155713 PMCID: PMC8830530 DOI: 10.1093/ofid/ofab616] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) are major therapeutic challenges. Prospective contemporary data characterizing the clinical and molecular epidemiology of VRE bloodstream infections (BSIs) are lacking. METHODS The Vancomycin-Resistant Enterococcal BSI Outcomes Study (VENOUS I) is a prospective observational cohort of adult patients with enterococcal BSI in 11 US hospitals. We included patients with Enterococcus faecalis or Enterococcus faecium BSI with ≥1 follow-up blood culture(s) within 7 days and availability of isolate(s) for further characterization. The primary study outcome was in-hospital mortality. Secondary outcomes were mortality at days 4, 7, 10, 12, and 15 after index blood culture. A desirability of outcome ranking was constructed to assess the association of vancomycin resistance with outcomes. All index isolates were subjected to whole genome sequencing. RESULTS Forty-two of 232 (18%) patients died in hospital and 39 (17%) exhibited microbiological failure (lack of clearance in the first 4 days). Neutropenia (hazard ratio [HR], 3.13), microbiological failure (HR, 2.4), VRE BSI (HR, 2.13), use of urinary catheter (HR, 1.85), and Pitt BSI score ≥2 (HR, 1.83) were significant predictors of in-hospital mortality. Microbiological failure was the strongest predictor of in-hospital mortality in patients with E faecium bacteremia (HR, 5.03). The impact of vancomycin resistance on mortality in our cohort changed throughout the course of hospitalization. Enterococcus faecalis sequence type 6 was a predominant multidrug-resistant lineage, whereas a heterogeneous genomic population of E faecium was identified. CONCLUSIONS Failure of early eradication of VRE from the bloodstream is a major factor associated with poor outcomes.
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Affiliation(s)
- German A Contreras
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - Jose M Munita
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- Genomics and Resistant Microbes Group, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
- Millennium Initiative for Collaborative Research on Bacterial Resistance (MICROB-R), Santiago, Chile
| | - Shelby Simar
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- Center for Infectious Diseases, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Courtney Luterbach
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - An Q Dinh
- Center for Infectious Diseases Research, Houston Methodist Research Institute, Houston, Texas, USA
| | - Kirsten Rydell
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Rafael Rios
- Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - Lorena Diaz
- Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - Katherine Reyes
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Marcus Zervos
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Helina M Misikir
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, Michigan, USA
| | - Gabriela Sanchez-Petitto
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Catherine Liu
- Department of Medicine, Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lilian M Abbo
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Jackson Health System, Miami Transplant Institute, Miami, Florida, USA
| | - Luis Shimose
- Division of Infectious Disease, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Harald Seifert
- University of Cologne, Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, l’Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salut Carlos III, Madrid, Spain
| | - Fernanda Barberis
- Unidad de Infectología, Sanatorio Dr Julio Méndez, Buenos Aires, Argentina
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Samuel L Aitken
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel A Shelburne
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Truc T Tran
- Center for Infectious Diseases Research, Houston Methodist Research Institute, Houston, Texas, USA
| | - Blake M Hanson
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
- Center for Infectious Diseases, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Cesar A Arias
- Center for Infectious Diseases Research, Houston Methodist Research Institute, Houston, Texas, USA
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas, USA
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12
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1432-1435. [DOI: 10.1093/jac/dkac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
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13
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Dadashi M, Sharifian P, Bostanshirin N, Hajikhani B, Bostanghadiri N, Khosravi-Dehaghi N, van Belkum A, Darban-Sarokhalil D. The Global Prevalence of Daptomycin, Tigecycline, and Linezolid-Resistant Enterococcus faecalis and Enterococcus faecium Strains From Human Clinical Samples: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:720647. [PMID: 34568377 PMCID: PMC8460910 DOI: 10.3389/fmed.2021.720647] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/17/2021] [Indexed: 12/21/2022] Open
Abstract
Background and Aim: The predominant species of the Enterococcus, Enterococcus faecalis (E. faecalis) and Enterococcus faecium (E. faecium) cause great variety of infections. Therefore, the expansion of antimicrobial resistance in the Enterococcus is one of the most important global concerns. This study was conducted to investigate the prevalence of resistance to linezolid, tigecycline, and daptomycin among enterococcal strains isolated from human clinical specimens worldwide. Methods: Several databases including Web of Science, EMBASE, and Medline (via PubMed), were carefully searched and reviewed for original research articles available in databases and published between 2000 and 2020. A total of 114 studies worldwide that address E. faecalis and E. faecium resistance to linezolid, tigecycline, and daptomycin were analyzed by STATA software. Results: The overall prevalence of antibiotic-resistant E. faecalis and E. faecium was reported to be 0.9 and 0.6%, respectively. E. faecalis and E. faecium were more resistant to the linezolid (2.2%) and daptomycin (9%), respectively. The prevalence of tigecyline-resistant E. facium (1%) strains was higher than E. faecalis strains (0.3%). Accordingly, the prevalence of linezolid-resistant E. faecalis was higher in Asia (2.8%), while linezolid-resistant E. faecium was higher in the America (3.4%). Regarding tigecycline-resistance, a higher prevalence of E. faecalis (0.4%) and E. faecium (3.9%) was reported in Europe. Conclusion: In conclusion, this meta-analysis shows that there is an emerging resistance in Enterococcus strains. Despite the rising resistance of enterococci to antibiotics, our results demonstrate that tigecycline, daptomycin, and linezolid can still be used for the treatment of enterococcal infections worldwide.
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Affiliation(s)
- Masoud Dadashi
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.,Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Parastoo Sharifian
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Nazila Bostanshirin
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Bahareh Hajikhani
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Narjess Bostanghadiri
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nafiseh Khosravi-Dehaghi
- Department of Pharmacognosy, School of Pharmacy, Alborz University of Medical Sciences, Karaj, Iran.,Evidence-Based Phytotherapy and Complementary Medicine Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Alex van Belkum
- Data Analytics Unit, bioMérieux, La Balme-les-Grottes, France
| | - Davood Darban-Sarokhalil
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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14
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Leroy AG, Lavigne-Quilichini V, Le Turnier P, Loufti B, Le Breton E, Piau C, Kempf M, Pantel A, Amara M, Neuwirth C, Sanchez R, Guinard J, Huon JF, Grégoire M, Corvec S. Accuracy of gradient diffusion method for susceptibility testing of dalbavancin and comparators. Expert Rev Anti Infect Ther 2021; 20:457-461. [PMID: 34469266 DOI: 10.1080/14787210.2021.1976143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This multicenter study aimed to assess the performances of gradient diffusion (GD) method in comparison to broth microdilution (BMD) method for susceptibility testing of dalbavancin, daptomycin, vancomycin, and teicoplanin. METHODS Minimum Inhibitory Concentrations (MICs) were retrospectively determined concomitantly by BMD and GD methods, for 93 staphylococci and enterococci isolated from clinical samples. BMD was considered as the gold standard. Essential (EA) and categorical agreements (CA) were calculated. Discordant categorical results were categorized as major (ME) and very major errors (VME). RESULTS EA and CA were 95.7% and 96.8%, 82.8% and 100%, 97.8% and 96.8%, and 94.6% and 95.7% for dalbavancin, daptomycin, vancomycin, and teicoplanin respectively. Concerning dalbavancin, 3 ME without any VME were observed and discrepancies were low (≤ to 2 two-fold dilutions) between both methods. VME were noted in 1 and 3 cases for vancomycin and teicoplanin, respectively, and resulted from 1 two-fold dilution discrepancy in each case. EA was lower for daptomycin. When they were discrepant, BMD MICs were systematically higher than GD ones. Nevertheless, no categorical discrepancy was noted. CONCLUSIONS GD appears as an acceptable and convenient alternative for dalbavancin, vancomycin, and teicoplanin MICs determination. Our study also emphasizes how achieving accurate daptomycin MICs remains challenging.
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Affiliation(s)
- A G Leroy
- Department of Microbiology, University Hospital of Nantes, Nantes, France
| | | | - P Le Turnier
- Department of Infectious Diseases, University Hospital of Nantes, and CIC 1413, INSERM, Nantes, France
| | - B Loufti
- Department of Microbiology, Centre Hospitalier Layné, Mont de Marsan, France
| | - E Le Breton
- Department of Microbiology, Centre Hospitalier de Cornouaille, Quimper, France
| | - C Piau
- Department of Clinical Microbiology, Rennes University Hospital, Rennes, France
| | - M Kempf
- Department of Microbiology, Angers University Hospital, Angers, France
| | - A Pantel
- Department of Microbiology, Nîmes University Hospital, Nîmes, France
| | - M Amara
- Department of Microbiology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - C Neuwirth
- Department of Microbiology, University Hospital of Dijon, Dijon, France
| | - R Sanchez
- Department of Microbiology, Centre Hospitalier de Périgueux, Périgueux, France
| | - J Guinard
- Department of Microbiology, CHR Orléans, Orléans, France
| | - J F Huon
- Clinical Pharmacy Unit, Nantes University Hospital, Nantes, France
| | - M Grégoire
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France.,UMR INSERM 1235, The Enteric Nervous System in Gut and Brain Disorders, University of Nantes, Nantes, France
| | - S Corvec
- Department of Microbiology, University Hospital of Nantes, Nantes, France.,CRCINA, INSERM U1232, University Hospital of Nantes, Nantes, France
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15
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Variability of Beta-Lactam Broth Microdilution for Pseudomonas aeruginosa. Antimicrob Agents Chemother 2021; 65:e0064021. [PMID: 34310211 DOI: 10.1128/aac.00640-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial susceptibility testing for Pseudomonas aeruginosa is critical to determine suitable treatment options. Commercial susceptibility tests are typically calibrated against the reference method, broth microdilution (BMD). Imprecision of minimum inhibitory concentrations (MICs) obtained by BMD for the same isolate on repeat testing is known to exist. Factors that impact the extent of variability include concentration of the inoculum, operator effects, contents of the media, inherent strain properties, and the testing process or materials. We evaluated the variability of BMD for anti-pseudomonal beta-lactams (aztreonam, cefepime, ceftazidime, meropenem, piperacillin-tazobactam, ceftazidime-avibactam, ceftolozane-tazobactam) tested against a collection of P. aeruginosa isolates. Multiple replicate BMD tests were performed and MICs were compared to assess reproducibility, including the impact of the inoculum and operator. Overall, essential agreement (EA) was ≥ 90% for all beta-lactams tested. Absolute agreement (AA) was as low as 70% for some beta-lactams. Variability from the inoculum and operators impacted the reproducibility of MICs. Piperacillin-tazobactam exhibited the highest degree of variability with 74% AA and 94%% EA. The implications of MIC variability are extensive as the MIC is essential for multiple facets of microbiology, such as the development of new compounds and susceptibility tests, dose optimization and pharmacokinetic/pharmacodynamic (PK/PD) targets for individual patients.
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16
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Jones TW, Jun AH, Michal JL, Olney WJ. High-Dose Daptomycin and Clinical Applications. Ann Pharmacother 2021; 55:1363-1378. [PMID: 33535792 DOI: 10.1177/1060028021991943] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate evidence for high-dose daptomycin (doses ≥ 8 mg/kg/d). DATA SOURCES A PubMed/MEDLINE literature search was performed (January 2000 to December 2020) using the search terms daptomycin, high dose, and dosing. Review article references and society guidelines were reviewed. STUDY SELECTION AND DATA EXTRACTION Clinical trials, observational studies, retrospective studies, meta-analyses, and systematic reviews reporting on high-dose daptomycin were included. DATA SYNTHESIS Experimentally, daptomycin outperforms other antimicrobials for high inoculum and biofilm-associated infections. Clinically, high-dose daptomycin is supported as salvage and first-line therapy for endocarditis and bacteremia, primarily when caused by methicillin-resistant Staphylococcus aureus (when vancomycin minimum inhibitory concentration is >1 mg/L) and Enterococcus. High-dose daptomycin appears effective for osteomyelitis and central nervous system infections, although comparative studies are lacking. High dosing in renal replacement therapy requires considering clearance modality to achieve exposures like normal renal function. Weight-based dosing in obesity draws concern for elevated exposures, although high doses have not been evaluated kinetically in obesity. Some data show benefits of high doses in overweight populations. Burn patients clear daptomycin more rapidly, and high doses may only achieve drug exposures similar to standard doses (6 mg/kg). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review analyzes the efficacy and safety of high-dose daptomycin in serious gram-positive infections. Discussion of specific infectious etiologies and patient populations should encourage clinicians to evaluate their daptomycin dosing standards. CONCLUSIONS The efficacy of high-dose daptomycin and limited safety concerns encourage clinicians to consider high-dose daptomycin more liberally in severe gram-positive infections.
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17
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Satlin MJ, Nicolau DP, Humphries RM, Kuti JL, Campeau SA, Lewis Ii JS, Weinstein MP, Jorgensen JH. Development of Daptomycin Susceptibility Breakpoints for Enterococcus faecium and Revision of the Breakpoints for Other Enterococcal Species by the Clinical and Laboratory Standards Institute. Clin Infect Dis 2021; 70:1240-1246. [PMID: 31504338 DOI: 10.1093/cid/ciz845] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022] Open
Abstract
Daptomycin is one of the few treatment options for infections caused by enterococci that are resistant to ampicillin and vancomycin, such as vancomycin-resistant Enterococcus faecium. The emergence and clinical significance of daptomycin-resistant enterococci and evolving microbiologic, pharmacokinetic-pharmacodynamic, and clinical data indicated that the pre-2019 Clinical and Laboratory Standards Institute (CLSI) susceptible-only breakpoint of ≤4 μg/mL for daptomycin and enterococci was no longer appropriate. After analyzing data that are outlined in this article, the CLSI Subcommittee on Antimicrobial Susceptibility Testing established new breakpoints for daptomycin and enterococci. For E. faecium, a susceptible dose-dependent (SDD) breakpoint of ≤4 μg/mL was established based on an increased dosage of 8-12 mg/kg/day (≥8 μg/mL-resistant). CLSI suggests infectious diseases consultation to guide daptomycin use for the SDD category. For Enterococcus faecalis and other enterococcal species, revised breakpoints of ≤2 μg/mL-susceptible, 4 μg/mL-intermediate, and ≥8 μg/mL-resistant were established based on a standard dosage of 6 mg/kg/day.
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Affiliation(s)
- Michael J Satlin
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Connecticut
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Connecticut
| | | | - James S Lewis Ii
- Department of Pharmacy, Oregon Health and Science University, Portland
| | - Melvin P Weinstein
- Departments of Medicine and Pathology and Laboratory Medicine Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - James H Jorgensen
- Department of Pathology, University of Texas Health Sciences Center at San Antonio
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18
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Abstract
Antimicrobial susceptibility testing (AST) is now, more than ever, a critical role of the microbiology laboratory. Several factors limit its application for patient care and antimicrobial resistance epidemiology, including time to results, requirements for pure cultures, and high starting concentration of bacteria. This review discusses the global status of AST and new phenotypic and genotypic methods in late-stage development or that are new to market.
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Affiliation(s)
- Romney M Humphries
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South C-3322 MCN, Nashville, TN 37232-2561, USA.
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19
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Mercer DK, Torres MDT, Duay SS, Lovie E, Simpson L, von Köckritz-Blickwede M, de la Fuente-Nunez C, O'Neil DA, Angeles-Boza AM. Antimicrobial Susceptibility Testing of Antimicrobial Peptides to Better Predict Efficacy. Front Cell Infect Microbiol 2020; 10:326. [PMID: 32733816 PMCID: PMC7358464 DOI: 10.3389/fcimb.2020.00326] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/29/2020] [Indexed: 12/11/2022] Open
Abstract
During the development of antimicrobial peptides (AMP) as potential therapeutics, antimicrobial susceptibility testing (AST) stands as an essential part of the process in identification and optimisation of candidate AMP. Standard methods for AST, developed almost 60 years ago for testing conventional antibiotics, are not necessarily fit for purpose when it comes to determining the susceptibility of microorganisms to AMP. Without careful consideration of the parameters comprising AST there is a risk of failing to identify novel antimicrobials at a time when antimicrobial resistance (AMR) is leading the planet toward a post-antibiotic era. More physiologically/clinically relevant AST will allow better determination of the preclinical activity of drug candidates and allow the identification of lead compounds. An important consideration is the efficacy of AMP in biological matrices replicating sites of infection, e.g., blood/plasma/serum, lung bronchiolar lavage fluid/sputum, urine, biofilms, etc., as this will likely be more predictive of clinical efficacy. Additionally, specific AST for different target microorganisms may help to better predict efficacy of AMP in specific infections. In this manuscript, we describe what we believe are the key considerations for AST of AMP and hope that this information can better guide the preclinical development of AMP toward becoming a new generation of urgently needed antimicrobials.
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Affiliation(s)
| | - Marcelo D. T. Torres
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, Penn Institute for Computational Science, and Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
| | - Searle S. Duay
- Department of Chemistry, Institute of Materials Science, University of Connecticut, Storrs, CT, United States
| | - Emma Lovie
- NovaBiotics Ltd, Aberdeen, United Kingdom
| | | | | | - Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, Penn Institute for Computational Science, and Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Alfredo M. Angeles-Boza
- Department of Chemistry, Institute of Materials Science, University of Connecticut, Storrs, CT, United States
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20
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Turnidge J, Kahlmeter G, Cantón R, MacGowan A, Giske CG. Daptomycin in the treatment of enterococcal bloodstream infections and endocarditis: a EUCAST position paper. Clin Microbiol Infect 2020; 26:1039-1043. [PMID: 32353412 DOI: 10.1016/j.cmi.2020.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 12/20/2022]
Abstract
SCOPE This position paper describes the view adopted by EUCAST on the role of daptomycin in the treatment of serious infections caused by Enterococcus species. BACKGROUND High-dose daptomycin is considered effective in the treatment of enterococcal bloodstream infection (BSI) and endocarditis, although published clinical experience with the latter condition is limited. METHODS EUCAST reviewed the available published data on pharmacokinetics-pharmacodynamics (PK-PD), resistance selection, clinical efficacy and safety for the use of 10-12 mg/kg/day of daptomycin for these conditions, noting that the doses licensed by the European Medicines Agency are only 4-6 mg/kg/day, and only for infections caused by Staphylococcus aureus. FINDINGS AND RECOMMENDATIONS The PK-PD evidence shows that, even with doses of 10-12 mg/kg/day, it is not possible to treat infections caused by isolates at the upper end of the wild-type distributions of Enterococcus faecalis (with MICs of 4 mg/L) and E. faecium (with MICs of 4 or 8 mg/L). For this reason, and because there are ongoing issues with the reliability of laboratory testing, EUCAST lists daptomycin breakpoints for Enterococcus species as "IE"-insufficient evidence. EUCAST advises increased vigilance in the use of high-dose of daptomycin to treat enterococcal BSI and endocarditis. Additional PK-PD studies and prospective efficacy and safety studies of serious Enterococcal infections treated with high-dose daptomycin may permit the setting of breakpoints in the future.
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Affiliation(s)
- J Turnidge
- Adelaide Medical School and School of Biological Sciences, University of Adelaide, Adelaide, Australia.
| | - G Kahlmeter
- Clinical Microbiology, Central Hospital, Växjö, Sweden
| | - R Cantón
- Servicio de Microbiología. Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - A MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Infection Sciences, Severn Pathology Partnership, Southmead Hospital, Bristol, UK
| | - C G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet and Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
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21
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What's New from the CLSI Subcommittee on Antimicrobial Susceptibility Testing M100, 29th Edition. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.clinmicnews.2019.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Avery LM, Kuti JL, Weisser M, Egli A, Rybak MJ, Zasowski EJ, Arias CA, Contreras GA, Chong PP, Aitken SL, DiPippo AJ, Wang JT, Britt NS, Nicolau DP. Reply to Cheng and Chuang. Clin Infect Dis 2019; 69:903-904. [PMID: 30715199 DOI: 10.1093/cid/ciz081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lindsay M Avery
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Maja Weisser
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel
| | - Adrian Egli
- Division of Clinical Microbiology, University Hospital Basel.,Applied Microbiology Research, University of Basel, Switzerland
| | - Michael J Rybak
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan
| | - Evan J Zasowski
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan.,Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston.,Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston.,Molecular Genetics and Antimicrobial Resistance Unit-International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - German A Contreras
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston
| | - Pearlie P Chong
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
| | - Samuel L Aitken
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Adam J DiPippo
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Nicholas S Britt
- Research Department, Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth.,Department of Pharmacy Practice, University of Kansas School of Pharmacy, Kansas City
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Connecticut
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23
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Avery LM, Kuti JL, Weisser M, Egli A, Rybak MJ, Zasowski EJ, Arias CA, Contreras GA, Chong PP, Aitken SL, DiPippo AJ, Wang JT, Britt NS, Nicolau DP. Pharmacodynamics of daptomycin in combination with other antibiotics for the treatment of enterococcal bacteraemia. Int J Antimicrob Agents 2019; 54:346-350. [PMID: 31284042 DOI: 10.1016/j.ijantimicag.2019.07.002] [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: 03/21/2019] [Revised: 05/28/2019] [Accepted: 07/03/2019] [Indexed: 01/12/2023]
Abstract
Daptomycin is commonly prescribed in combination with other antibiotics for treatment of enterococcal bacteraemia. Whilst a free drug area under the concentration-time curve to minimum inhibitory concentration (fAUC/MIC) ratio >27.4 is associated with 30-day survival with daptomycin monotherapy, it is unknown whether receipt of other antibiotics affects this threshold. Data were pooled from seven published trials assessing outcomes in daptomycin-treated enterococcal bacteraemia, including patients receiving daptomycin (≥72 h) and any β-lactam, intravenous aminoglycoside, linezolid, tigecycline and/or vancomycin. Exposures were calculated using a published population pharmacokinetic model based on creatinine clearance, 90% protein binding and daptomycin Etest MIC. The fAUC/MIC threshold predictive of 30-day survival was determined by classification and regression tree analysis. Following pooling of data, 240 adults were included; 137 (57.1%) were alive at 30 days. A majority of patients were immunosuppressed (65.8%) and received a β-lactam (94.6%). Examining the threshold in low-acuity patients (n = 135) to control for co-morbidities, these patients were more likely to survive when fAUC/MIC >12.3 was achieved (63.2% vs. 20.0%; P = 0.015). The difference remained significant in a multivariable logistic regression model that controlled for infection source and immunosuppression (P = 0.017). This threshold is 2-fold lower than that observed with daptomycin monotherapy. Probabilities of threshold attainment using a 10 mg/kg/day dose were 100% for isolates with MICs ≤ 2 mg/L and 95.2% for a 12 mg/kg/day dose for MICs of 4 mg/L. These data support the use of high-dose daptomycin in combination with another antibiotic for treatment of enterococcal bacteraemia.
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Affiliation(s)
- Lindsay M Avery
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Maja Weisser
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland; Applied Microbiology Research, University of Basel, Basel, Switzerland
| | - Michael J Rybak
- Anti-Infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan, USA
| | - Evan J Zasowski
- Anti-Infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan, USA; Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, Texas, USA; Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA; Molecular Genetics and Antimicrobial Resistance Unit-International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - German A Contreras
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, Texas, USA
| | - Pearlie P Chong
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel L Aitken
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adam J DiPippo
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nicholas S Britt
- Research Department, Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth, Kansas, USA; Department of Pharmacy Practice, University of Kansas School of Pharmacy, Kansas City, Kansas, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA.
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24
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Abstract
In 2019, the Clinical and Laboratory Standards Institute revised the daptomycin breakpoints for Enterococcus spp. twice in rapid succession. Analyses leading to these revisions included review of testing issues, murine and human in vivo pharmacodynamics, safety of off-label doses, and treatment outcomes. The data review brought up a dilemma that is encountered with increasing frequency: a breakpoint supported by pharmacokinetic/pharmacodynamic modeling that bisected the wild-type Enterococcus faecium MIC distribution. In such instances, not only does the probability of pharmacokinetic/pharmacodynamic targets need to be taken into account but also the probability that the laboratory can generate an accurate MIC that is reproducible within one interpretive category.
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25
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Understanding and Addressing CLSI Breakpoint Revisions: a Primer for Clinical Laboratories. J Clin Microbiol 2019; 57:JCM.00203-19. [PMID: 30971460 DOI: 10.1128/jcm.00203-19] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The Clinical and Laboratory Standards Institute (CLSI) has revised several breakpoints since 2010 for bacteria that grow aerobically. In 2019, these revisions include changes to the ciprofloxacin and levofloxacin breakpoints for the Enterobacteriaceae and Pseudomonas aeruginosa, daptomycin breakpoints for Enterococcus spp., and ceftaroline breakpoints for Staphylococcus aureus Implementation of the revisions is a challenge for all laboratories, as not all systems have FDA clearance for the revised (current) breakpoints, compounded by the need for laboratories to perform validation studies and to make updates to laboratory information system/electronic medical record builds in the setting of limited information technology infrastructure. This minireview describes the breakpoint revisions in the M100 supplement since 2010 and strategies for the laboratory on how to best adopt these in clinical testing.
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26
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Contreras GA, Munita JM, Arias CA. Novel Strategies for the Management of Vancomycin-Resistant Enterococcal Infections. Curr Infect Dis Rep 2019; 21:22. [PMID: 31119397 DOI: 10.1007/s11908-019-0680-y] [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: 12/13/2022]
Abstract
PURPOSE OF REVIEW Vancomycin-resistant enterococci (VRE) are important nosocomial pathogens that commonly affect critically ill patients. VRE have a remarkable genetic plasticity allowing them to acquire genes associated with antimicrobial resistance. Therefore, the treatment of deep-seated infections due to VRE has become a challenge for the clinician. The purpose of this review is to assess the current and future strategies for the management of recalcitrant deep-seated VRE infections and efforts for infection control in the hospital setting. RECENT FINDINGS Preventing colonization and decolonization of multidrug-resistant bacteria are becoming the most promising novel strategies to control and eradicate VRE from the hospital environment. Fecal microbiota transplantation (FMT) has shown remarkable results on treating colonization and infection due to Clostridiodes difficille and VRE, as well as to recover the integrity of the gut microbiota under antibiotic pressure. Initial reports have shown the efficacy of FMT on reestablishing patient microbiota diversity in the gut and reducing the dominance of VRE in the gastrointestinal tract. In addition, the use of bacteriophages may be a promising strategy in eradicating VRE from the gut of patients. Until these strategies become widely available in the hospital setting, the implementation of infection control measures and stewardship programs are paramount for the control of this pathogen and each program should provide recommendations for the proper use of antibiotics and develop strategies that help to detect populations at risk of VRE colonization, prevent and control nosocomial transmission of VRE, and develop educational programs for all healthcare workers addressing the epidemiology of VRE and the potential impact of these pathogens on the cost and outcomes of patients. In terms of antibiotic strategies, daptomycin has become the standard of care for the management of deep-seated infections due to VRE. However, recent evidence indicates that the efficacy of this antibiotic is limited, and higher (10-12 mg/kg) doses and/or combination with β-lactams is needed for therapeutic success. Clinical data to support the best use of daptomycin against VRE are urgently needed. This review provides an overview of recent developments regarding the prevention, treatment, control, and eradication of VRE in the hospital setting. We aim to provide an update of the most recent therapeutic strategies to treat deep-seated infections due to VRE.
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Affiliation(s)
- German A Contreras
- Division of Infectious Diseases and Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth McGovern Medical School, Houston, TX, USA
- Department of Internal Medicine, UTHealth McGovern Medical School, Houston, TX, USA
| | - Jose M Munita
- Millennium Initiative for Collaborative Research on Bacterial Resistance (MICROB-R), Santiago, Chile
- Genomics and Resistant Microbes Group, Facultad de Medicina Clinica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Cesar A Arias
- Division of Infectious Diseases and Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth McGovern Medical School, Houston, TX, USA.
- Department of Internal Medicine, UTHealth McGovern Medical School, Houston, TX, USA.
- Genomics and Resistant Microbes Group, Facultad de Medicina Clinica Alemana, Universidad del Desarrollo, Santiago, Chile.
- Department of Microbiology and Molecular Genetics, UTHealth McGovern Medical School, Houston, TX, USA.
- Center for Infectious Diseases, UTHealth School of Public Health, Houston, TX, USA.
- Molecular Genetics and Antimicrobial Resistance Unit-International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia.
- University of Texas Health Science Center, 6431 Fannin St. MSB 2.112, Houston, TX, 77030, USA.
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27
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Impact of an Antimicrobial Stewardship Intervention on Within- and Between-Patient Daptomycin Resistance Evolution in Vancomycin-Resistant Enterococcus faecium. Antimicrob Agents Chemother 2019; 63:AAC.01800-18. [PMID: 30718245 DOI: 10.1128/aac.01800-18] [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: 08/26/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
Vancomycin-resistant Enterococcus (VRE) is a leading cause of hospital-acquired infection, with limited treatment options. Resistance to one of the few remaining drugs, daptomycin, is a growing clinical problem and has previously been described in this hospital. In response to increasing resistance, an antimicrobial stewardship intervention was implemented to reduce hospital-wide use of daptomycin. To assess the impact of the intervention, daptomycin prescribing patterns and clinically reported culture results from vancomycin-resistant Enterococcus faecium (VREfm) bloodstream infections (BSIs) from 2011 through 2017 were retrospectively extracted and the impact of the intervention was estimated using interrupted time series analysis (ITS). We corrected for a change in MIC determination methodology by retesting 262 isolates using Etest and broth microdilution. Hospital-wide and within-patient resistance patterns of corrected daptomycin MICs are reported. Our data show that daptomycin prescriptions decreased from an average of 287 days of therapy/month preintervention to 151 days of therapy/month postintervention. Concurrently, the proportion of patients experiencing an increase in daptomycin MIC during an infection declined from 14.6% (7/48 patients) in 2014 to 1.9% (1/54 patients) in 2017. Hospital-wide resistance to daptomycin also decreased in the postintervention period, but this was not maintained. This study shows that an antimicrobial stewardship-guided intervention reduced daptomycin use and improved individual level outcomes but had only transient impact on the hospital-level trend.
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