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Musuroi SI, Voinescu A, Musuroi C, Baditoiu LM, Muntean D, Izmendi O, Jumanca R, Licker M. The Challenges of The Diagnostic and Therapeutic Approach of Patients with Infectious Pathology in Emergency Medicine. J Pers Med 2023; 14:46. [PMID: 38248747 PMCID: PMC10821085 DOI: 10.3390/jpm14010046] [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: 11/13/2023] [Revised: 12/23/2023] [Accepted: 12/24/2023] [Indexed: 01/23/2024] Open
Abstract
The emergency department (ED) represents an important setting for addressing inappropriate antimicrobial prescribing practices because of the time constraints and the duration of microbiological diagnosis. The purpose of this study is to evaluate the etiology and antimicrobial resistance (AMR) pattern of the community-acquired pathogens, as well as the epidemiological characteristics of patients admitted through the ED, in order to guide appropriate antibiotic therapy. METHODS A retrospective observational study was performed on 657 patients, from whom clinical samples (urine, purulent secretions, blood cultures, etc.) were collected for microbiological diagnosis in the first 3 days after presentation in the ED. The identification of pathogens and the antimicrobial susceptibility testing with minimum inhibitory concentration determination were carried out according to the laboratory protocols. RESULTS From the 767 biological samples analyzed, 903 microbial isolates were identified. E. coli was most frequently isolated (24.25%), followed by Klebsiella spp., S. aureus (SA), and non-fermentative Gram-negative bacilli. E. coli strains maintained their natural susceptibility to most antibiotics tested. In the case of Pseudomonas spp. and Acinetobacter spp., increased rates of AMR were identified. Also, 32.3% of SA strains were community-acquired MRSA. CONCLUSIONS The introduction of rapid microbiological diagnostic methods in emergency medicine is imperative in order to timely identify AMR strains and improve therapeutic protocols.
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Affiliation(s)
- Silvia Ioana Musuroi
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Internal Medicine Department, Municipal Emergency Clinical Hospital, 300254 Timisoara, Romania
| | - Adela Voinescu
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Corina Musuroi
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Luminita Mirela Baditoiu
- Epidemiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Delia Muntean
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Oana Izmendi
- Doctoral School, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.M.)
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
| | - Romanita Jumanca
- Romanian and Foreign Languages Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
| | - Monica Licker
- Microbiology Department, Multidisciplinary Research Center of Antimicrobial Resistance, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (D.M.); (M.L.)
- Microbiology Laboratory, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
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Lautenbach E, Mosepele M, Smith RM, Styczynski A, Gross R, Cressman L, Jaskowiak-Barr A, Alby K, Glaser L, Richard-Greenblatt M, Cowden L, Sewawa K, Otukile D, Paganotti GM, Mokomane M, Bilker WB, Mannathoko N. Risk Factors for Community Colonization With Extended-Spectrum Cephalosporin-Resistant Enterobacterales (ESCrE) in Botswana: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study. Clin Infect Dis 2023; 77:S89-S96. [PMID: 37406040 DOI: 10.1093/cid/ciad259] [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] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in low- and middle-income countries (LMICs) is poorly described. Identifying risk factors for ESCrE colonization is critical to inform antibiotic resistance reduction strategies because colonization is typically a precursor to infection. METHODS From 15 January 2020 to 4 September 2020, we surveyed a random sample of clinic patients at 6 sites in Botswana. We also invited each enrolled participant to refer up to 3 adults and children. All participants had rectal swabs collected that were inoculated onto chromogenic media followed by confirmatory testing. Data were collected on demographics, comorbidities, antibiotic use, healthcare exposures, travel, and farm and animal contact. Participants with ESCrE colonization (cases) were compared with noncolonized participants (controls) to identify risk factors for ESCrE colonization using bivariable, stratified, and multivariable analyses. RESULTS A total of 2000 participants were enrolled. There were 959 (48.0%) clinic participants, 477 (23.9%) adult community participants, and 564 (28.2%) child community participants. The median (interquartile range) age was 30 (12-41) and 1463 (73%) were women. There were 555 cases and 1445 controls (ie, 27.8% of participants were ESCrE colonized). Independent risk factors (adjusted odds ratio [95% confidence interval]) for ESCrE included healthcare exposure (1.37 [1.08-1.73]), foreign travel [1.98 (1.04-3.77]), tending livestock (1.34 [1.03-1.73]), and presence of an ESCrE-colonized household member (1.57 [1.08-2.27]). CONCLUSIONS Our results suggest healthcare exposure may be important in driving ESCrE. The strong links to livestock exposure and household member ESCrE colonization highlight the potential role of common exposure or household transmission. These findings are critical to inform strategies to curb further emergence of ESCrE in LMICs.
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Affiliation(s)
- Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mosepele Mosepele
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Rachel M Smith
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Ashley Styczynski
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Robert Gross
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Jaskowiak-Barr
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Laurel Glaser
- Department of Pathology and Laboratory Medicine, University Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Melissa Richard-Greenblatt
- Department of Microbiology, Public Health Ontario, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Laura Cowden
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kgotlaetsile Sewawa
- Department of Medicine, Botswana-University of Pennsylvania Partnership (BUP), Gaborone, Botswana
| | - Dimpho Otukile
- Department of Medicine, Botswana-University of Pennsylvania Partnership (BUP), Gaborone, Botswana
| | - Giacomo M Paganotti
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biomedical Sciences, University of Botswana, Gaborone, Botswana
| | - Margaret Mokomane
- Department of Biomedical Sciences, University of Botswana, Gaborone, Botswana
| | - Warren B Bilker
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Naledi Mannathoko
- Department of Biomedical Sciences, University of Botswana, Gaborone, Botswana
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Mannathoko N, Mosepele M, Gross R, Smith RM, Alby K, Glaser L, Richard-Greenblatt M, Dumm R, Sharma A, Jaskowiak-Barr A, Cressman L, Sewawa K, Cowden L, Reesey E, Otukile D, Paganotti GM, Mokomane M, Lautenbach E. Colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) in healthcare and community settings in Botswana: an antibiotic resistance in communities and hospitals (ARCH) study. Int J Infect Dis 2022; 122:313-320. [PMID: 35688308 DOI: 10.1016/j.ijid.2022.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/09/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Although extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) are a global challenge, data on these organisms in low- and middle-income countries are limited. In this study, we sought to characterize colonization data critical for greater antibiotic resistance surveillance efforts. METHODS This study was conducted in three hospitals and six clinics in Botswana. We conducted ongoing surveillance of adult patients in hospitals and clinics and adults and children in the community. All participants underwent rectal swab sampling to identify ESCrE and CRE. RESULTS Enrollment occurred from January 15, 2020, to September 4, 2020, but paused from April 2, 2020, to May 21, 2020, because of a countrywide COVID-19 lockdown. Of 5088 individuals approached, 2469 (49%) participated. ESCrE colonization prevalence was 30.7% overall (43% for hospital participants, 31% for clinic participants, 24% for adult community participants, and 26% for child community participants) (P <0.001). A total of 42 (1.7%) participants were colonized with CRE. CRE colonization prevalence was 1.7% overall (6.8% for hospital participants, 0.7% for clinic participants, 0.2% for adult community participants, and 0.5% for child community participants) (P <0.001). ESCrE and CRE prevalence varied substantially across regions and was significantly higher prelockdown versus postlockdown. CONCLUSIONS ESCrE colonization was high in all settings in Botswana. CRE prevalence in hospitals was also considerable. Colonization prevalence varied by region and clinical setting and decreased after a countrywide lockdown.
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Affiliation(s)
| | | | - Robert Gross
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel M Smith
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Laurel Glaser
- Department of Pathology and Laboratory Medicine, University Pennsylvania, Philadelphia, PA, USA
| | | | - Rebekah Dumm
- Department of Pathology and Laboratory Medicine, University Pennsylvania, Philadelphia, PA, USA
| | - Aditya Sharma
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Anne Jaskowiak-Barr
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Leigh Cressman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Laura Cowden
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Reesey
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dimpho Otukile
- Botswana-University of Pennsylvania Partnership (BUP), Gaborone, Botswana
| | - Giacomo M Paganotti
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; University of Botswana, Gaborone, Botswana; Botswana-University of Pennsylvania Partnership (BUP), Gaborone, Botswana
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Dziri R, Talmoudi A, Barguellil F, Ouzari HI, El Asli MS, Klibi N. Huge Diversity of TEM and SHV β-Lactamases Types Among CTX-M-15-Producing Enterobacteriaceae Species in Tunisia. Microb Drug Resist 2019; 25:1149-1154. [DOI: 10.1089/mdr.2018.0445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Raoudha Dziri
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Arbia Talmoudi
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Farouk Barguellil
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Hadda-Imen Ouzari
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Selim El Asli
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Naouel Klibi
- Laboratory of Microorganisms and Active Biomolecules, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Hamdy RF, Handy LK, Spyridakis E, Dona D, Bryan M, Collins JL, Gerber JS. Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children. Surg Infect (Larchmt) 2019; 20:399-405. [PMID: 30874482 DOI: 10.1089/sur.2018.234] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.
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Affiliation(s)
- Rana F Hamdy
- 1 Department of Pediatrics, Children's National Health System, Washington, DC
| | - Lori K Handy
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evangelos Spyridakis
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele Dona
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- 3 Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia
| | - Joy L Collins
- 4 Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department. CAN J EMERG MED 2017; 19:441-449. [PMID: 28399946 DOI: 10.1017/cem.2017.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such as Clostridium difficile (C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers. OBJECTIVE To determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage. METHODS Interventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital's ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED. RESULTS There was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p<0.001) by 2.26 urine cultures per 100 ED patient visits. CONCLUSIONS FLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.
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Zahar JR, Lesprit P, Ruckly S, Eden A, Hikombo H, Bernard L, Harbarth S, Timsit JF, Brun-Buisson C. Predominance of healthcare-associated cases among episodes of community-onset bacteraemia due to extended-spectrum β-lactamase-producing Enterobacteriaceae. Int J Antimicrob Agents 2016; 49:67-73. [PMID: 27890442 DOI: 10.1016/j.ijantimicag.2016.09.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/03/2016] [Accepted: 09/24/2016] [Indexed: 01/09/2023]
Abstract
Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are endemic pathogens worldwide. Infection with ESBL-PE may be associated with inadequate antibiotic therapy and a poor outcome. However, risk factors for ESBL-PE community-acquired infections are ill-defined. An observational multicentre study was performed in 50 hospitals to identify the prevalence of and risk factors for community-acquired ESBL-PE bacteraemia. All patients presenting with community-onset Enterobacteriaceae bacteraemia were recorded over a 2-month period (between June and November 2013). Risk factors and 14-day outcomes of patients were investigated. Among 682 Enterobacteriaceae bacteraemia episodes recorded, 58 (8.5%) were caused by ESBL-PE. The most frequent species isolated were Escherichia coli (537; 76.7%) and Klebsiella spp. (68; 9.7%), of which 49 (9.1%) and 8 (11.8%), respectively, were ESBL-producers. Most ESBL-PE episodes were healthcare-associated, and only 22 (38%) were apparently community-acquired. The main risk factor for community-acquired ESBL-PE bacteraemia was a prior hospital stay of ≥5 days within the past year. The overall 14-day survival was 90%; only 4 (6.9%) of 58 patients with ESBL-PE bacteraemia died. Inadequate initial antibiotic therapy was administered to 55% of patients with ESBL-PE bacteraemia but was not associated with increased 14-day mortality. Although many patients had community-onset ESBL-PE bacteraemia, almost two-thirds of the episodes were actually healthcare-associated, and true community-acquired ESBL-PE bacteraemia remains rare. In our essentially non-severely ill population, inappropriate initial therapy was not associated with a higher risk of mortality.
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Affiliation(s)
- Jean-Ralph Zahar
- Infection Control Unit, Avicenne University Hospital, APHP, Paris-Nord University (UFR SMBH), Bobigny, France; IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France
| | - Philippe Lesprit
- Antibiotic Team, Department of Biology, Hôpital Foch, Suresnes, France
| | - Stephane Ruckly
- IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France; Department of Biostatistics, Outcomerea, Bobigny, France
| | - Aurelia Eden
- Infectious and Tropical Diseases Department, Perpignan General Hospital, Perpignan, France
| | - Hitoto Hikombo
- Infectious and Tropical Diseases Department, Le Mans General Hospital, Le Mans, France
| | - Louis Bernard
- Internal Medicine and Infectious Diseases, Bretonneau University Hospital, Tours, France
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jean-François Timsit
- IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France; Department of Biostatistics, Outcomerea, Bobigny, France; Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Christian Brun-Buisson
- Medical Intensive Care Unit and Infection Control Unit, Henri Mondor University Hospital, APHP, Paris-Est Créteil University (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France.
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Sonda T, Kumburu H, van Zwetselaar M, Alifrangis M, Lund O, Kibiki G, Aarestrup FM. Meta-analysis of proportion estimates of Extended-Spectrum-Beta-Lactamase-producing Enterobacteriaceae in East Africa hospitals. Antimicrob Resist Infect Control 2016; 5:18. [PMID: 27186369 PMCID: PMC4868002 DOI: 10.1186/s13756-016-0117-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/09/2016] [Indexed: 01/16/2023] Open
Abstract
Background A high proportion of Extended-Spectrum-Beta-Lactamase (ESBL) producing Enterobacteriaceae is causing common infections in all regions of the world. The burden of antibiotic resistance due to ESBL in East Africa is large but information is scarce and thus it is unclear how big the problem really is. To gain insight into the magnitude and molecular epidemiology of ESBL-producing Enterobacteriaceae in East Africa a literature search was performed in PubMed on 31 July 2015 to retrieve articles with relevant information on ESBL. Methods and results Meta-analysis was performed to determine overall proportion estimate of ESBL-producing Enterobacteriaceae. A total of 4076 bacterial isolates were included in the analysis. The overall pooled proportion of ESBL-producing Enterobacteriaceae among included surveys done in East African hospitals was found to be 0.42 (95 % CI: 0.34–0.50). Heterogeneity (I2) between countries’ proportions in ESBL was significantly high (96.95 % and p < 0.001). The frequently detected genes encoding ESBL were CTX-M, TEM, SHV and OXA while the most infrequent reported genes were KPC and NDM. Conclusion The available studies show a very wide variation in resistance due to ESBL between countries. This highlights a need for active surveillance systems which can help understand the actual epidemiology of ESBL, aid in formulating national or regional guidelines for proper screening of ESBL, and support developing standardized approaches for managing patients colonized with ESBL. Electronic supplementary material The online version of this article (doi:10.1186/s13756-016-0117-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tolbert Sonda
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania ; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Happiness Kumburu
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania ; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Marco van Zwetselaar
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark ; Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Lund
- Centre for Biological Sequence Analysis, Technical University of Denmark, Copenhagen, Denmark
| | - Gibson Kibiki
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania ; Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Frank M Aarestrup
- Centre for Genomic Epidemiology, Technical University of Denmark, Copenhagen, Denmark
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Maseda E, Gimenez MJ, Gilsanz F, Aguilar L. Basis for selecting optimum antibiotic regimens for secondary peritonitis. Expert Rev Anti Infect Ther 2015; 14:109-24. [PMID: 26568097 DOI: 10.1586/14787210.2016.1120669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate management of severely ill patients with secondary peritonitis requires supportive therapy of organ dysfunction, source control of infection and antimicrobial therapy. Since secondary peritonitis is polymicrobial, appropriate empiric therapy requires combination therapy in order to achieve the needed coverage for both common and more unusual organisms. This article reviews etiological agents, resistance mechanisms and their prevalence, how and when to cover them and guidelines for treatment in the literature. Local surveillances are the basis for the selection of compounds in antibiotic regimens, which should be further adapted to the increasing number of patients with risk factors for resistance (clinical setting, comorbidities, previous antibiotic treatments, previous colonization, severity…). Inadequate antimicrobial regimens are strongly associated with unfavorable outcomes. Awareness of resistance epidemiology and of clinical consequences of inadequate therapy against resistant bacteria is crucial for clinicians treating secondary peritonitis, with delicate balance between optimization of empirical therapy (improving outcomes) and antimicrobial overuse (increasing resistance emergence).
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Affiliation(s)
- Emilio Maseda
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
| | | | - Fernando Gilsanz
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
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Kronman MP, Hersh AL, Gerber JS, Ross RK, Newland JG, Goldin A, Rangel SJ, Oron AP, Zerr DM. Identifying Antimicrobial Stewardship Targets for Pediatric Surgical Patients. J Pediatric Infect Dis Soc 2015; 4:e100-8. [PMID: 26407258 DOI: 10.1093/jpids/piv022] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/27/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND More than 80% of surgical inpatients at US children's hospitals receive antibiotics, accounting for >40% of all inpatient pediatric antibiotic use. We aimed to examine the collective pool of all systemic antibiotics prescribed to children hospitalized for surgical conditions and identify common surgical conditions with highly variable and potentially unnecessary antibiotic use, because these conditions may represent antimicrobial stewardship priorities. METHODS We conducted a retrospective cross-sectional study of surgical inpatients discharged in 2012 at 37 freestanding children's hospitals. We captured all systemic antibiotic use as days of therapy (DOT), and we reported surgical conditions by frequency and contribution to overall antibiotic use. We used multivariable logistic and Poisson regression with marginal standardization to estimate (1) the standardized proportion and (2) DOT of condition-specific targeted antibiotic use among top surgical condition patients. RESULTS Among 151 345 surgical inpatients, 82.9% received antimicrobials for a median 2 DOT per subject (interquartile range, 1-5; range, 1-958). The most commonly received antibiotics were cefazolin (16.7% of all DOT), vancomycin (12.5%), and piperacillin/tazobactam (6.9%). The top 10 conditions contributing most to antibiotic use accounted for 51.3% of all antibiotic use. Among these, adjusted use of postoperative and perioperative vancomycin varied across hospitals among craniotomy and cardiothoracic surgery subjects (all P < .001); adjusted use of broad-spectrum antipseudomonal agents varied across hospitals among gastrointestinal surgery subjects (all P < .001). CONCLUSIONS Use of (1) vancomycin for pediatric cardiothoracic and neurosurgical patients and (2) broad-spectrum antipseudomonal agents for gastrointestinal surgery patients represent potentially high-yield targets for stewardship efforts to reduce unnecessary antimicrobial use.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, Division of Infectious Diseases Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Rachael K Ross
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Jason G Newland
- Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Adam Goldin
- Department of Pediatric Surgery, University of Washington, Seattle
| | - Shawn J Rangel
- Department of Pediatric Surgery, Harvard Medical School, Boston, Massachusetts
| | - Assaf P Oron
- Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Danielle M Zerr
- Department of Pediatrics, Division of Infectious Diseases Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
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11
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Prevention and control of multi-drug-resistant Gram-negative bacteria: recommendations from a Joint Working Party. J Hosp Infect 2015; 92 Suppl 1:S1-44. [PMID: 26598314 DOI: 10.1016/j.jhin.2015.08.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Indexed: 12/25/2022]
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12
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β-lactam and β-lactamase inhibitor combinations in the treatment of extended-spectrum β-lactamase producing Enterobacteriaceae: time for a reappraisal in the era of few antibiotic options? THE LANCET. INFECTIOUS DISEASES 2015; 15:475-85. [PMID: 25716293 DOI: 10.1016/s1473-3099(14)70950-8] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The spread of extended-spectrum β-lactamase (ESBL) genes in Enterobacteriaceae such as Escherichia coli or Klebsiella spp is a major challenge to modern medical practice. Carbapenems are the treatment of choice for serious infections caused by ESBL producers; however, carbapenem resistance has increased globally. ESBL producers might be susceptible to β-lactam-β-lactamase inhibitor (BLBLI) combination antibiotics such piperacillin-tazobactam or amoxicillin-clavulanate. These drugs are frequently avoided in serious infections caused by ESBL producers because of the inoculum effect in-vitro (especially for piperacillin-tazobactam), animal data suggesting inferior efficacy when compared with carbapenems, concerns about pharmacokinetic-pharmacodynamic drug target attainment with standard doses, and poor outcomes shown in some observational studies. Prospective cohort data and a meta-analysis suggest that BLBLIs are non-inferior to carbapenems in the treatment of bloodstream infections caused by ESBL producers. We examine why BLBLIs are perceived as inferior in the treatment of infection with ESBL producers, and discuss data that suggest these concerns might not be strongly supported by clinical evidence.
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13
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Delgado-Valverde M, Sojo-Dorado J, Pascual A, Rodríguez-Baño J. Clinical management of infections caused by multidrug-resistant Enterobacteriaceae. Ther Adv Infect Dis 2014; 1:49-69. [PMID: 25165544 DOI: 10.1177/2049936113476284] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Enterobacteriaceae showing resistance to cephalosporins due to extended-spectrum β-lactamases (ESBLs) or plasmid-mediated AmpC enzymes, and those producing carbapenemases have spread worldwide during the last decades. Many of these isolates are also resistant to other first-line agents such as fluoroquinolones or aminoglycosides, leaving few available options for therapy. Thus, older drugs such as colistin and fosfomycin are being increasingly used. Infections caused by these bacteria are associated with increased morbidity and mortality compared with those caused by their susceptible counterparts. Most of the evidence supporting the present recommendations is from in vitro data, animal studies, and observational studies. While carbapenems are considered the drugs of choice for ESBL and AmpC producers, recent data suggest that certain alternatives may be suitable for some types of infections. Combined therapy seems superior to monotherapy in the treatment of invasive infections caused by carbapenemase-producing Enterobacteriaceae. Optimization of dosage according to pharmacokinetics/pharmacodynamics data is important for the treatment of infections caused by isolates with borderline minimum inhibitory concentration due to low-level resistance mechanisms. The increasing frequency and the rapid spread of multidrug resistance among the Enterobacteriaceae is a true and complex public health problem.
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Affiliation(s)
- Mercedes Delgado-Valverde
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jesús Sojo-Dorado
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Alvaro Pascual
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, and Department of Microbiology, University of Seville, Seville, Spain
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Avda Dr Fedriani 3, 41009 Seville, Spain
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14
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Kronman MP, Zerr DM, Qin X, Englund J, Cornell C, Sanders JE, Myers J, Rayar J, Berry JE, Adler AL, Weissman SJ. Intestinal decontamination of multidrug-resistant Klebsiella pneumoniae after recurrent infections in an immunocompromised host. Diagn Microbiol Infect Dis 2014; 80:87-9. [PMID: 25041704 DOI: 10.1016/j.diagmicrobio.2014.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 04/22/2014] [Accepted: 06/15/2014] [Indexed: 01/13/2023]
Abstract
Multidrug-resistant (MDR) Enterobacteriaceae infections are associated with increased morbidity. We describe a 20-year-old hematopoietic cell transplantation recipient with recurrent MDR Klebsiella pneumoniae infection, prolonged intestinal colonization, and subsequent intestinal decontamination. Further study should evaluate stool surveillance, molecular typing, and fecal microbiota transplantation for patients with intestinal MDR Enterobacteriaceae carriage.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA.
| | - Danielle M Zerr
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Xuan Qin
- Microbiology laboratory, Seattle Children's Hospital, Seattle, WA, USA; Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Janet Englund
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Cathy Cornell
- Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Jean E Sanders
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jeffrey Myers
- Center for Childhood Infections and Prematurity Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Jaipreet Rayar
- Center for Childhood Infections and Prematurity Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Jessica E Berry
- Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Amanda L Adler
- Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Scott J Weissman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA
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Risk factors associated with the community-acquired colonization of extended-spectrum beta-lactamase (ESBL) positive Escherichia Coli. an exploratory case-control study. PLoS One 2013; 8:e74323. [PMID: 24040229 PMCID: PMC3770595 DOI: 10.1371/journal.pone.0074323] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 08/02/2013] [Indexed: 11/24/2022] Open
Abstract
Background The number of extended-spectrum beta-lactamase (ESBL) positive (+) Escherichia coli is increasing worldwide. In contrast with many other multidrug-resistant bacteria, it is suspected that they predominantly spread within the community. The objective of this study was to assess factors associated with community-acquired colonization of ESBL (+) E. coli. Methods We performed a matched case-control study at the Charité University Hospital Berlin between May 2011 and January 2012. Cases were defined as patients colonized with community-acquired ESBL (+) E. coli identified <72 h after hospital admission. Controls were patients that carried no ESBL-positive bacteria but an ESBL-negative E.coli identified <72 h after hospital admission. Two controls per case were chosen from potential controls according to admission date. Case and control patients completed a questionnaire assessing nutritional habits, travel habits, household situation and language most commonly spoken at home (mother tongue). An additional rectal swab was obtained together with the questionnaire to verify colonization status. Genotypes of ESBL (+) E. coli strains were determined by PCR and sequencing. Risk factors associated with ESBL (+) E. coli colonization were analyzed by a multivariable conditional logistic regression analysis. Results We analyzed 85 cases and 170 controls, respectively. In the multivariable analysis, speaking an Asian language most commonly at home (OR = 13.4, CI 95% 3.3–53.8; p<0.001) and frequently eating pork (≥3 meals per week) showed to be independently associated with ESBL colonization (OR = 3.5, CI 95% 1.8–6.6; p<0.001). The most common ESBL genotypes were CTX-M-1 with 44% (n = 37), CTX-M-15 with 28% (n = 24) and CTX-M-14 with 13% (n = 11). Conclusion An Asian mother tongue and frequently consuming certain types of meat like pork can be independently associated with the colonization of ESBL-positive bacteria. We found neither frequent consumption of poultry nor previous use of antibiotics to be associated with ESBL colonization.
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Lynch JP, Clark NM, Zhanel GG. Evolution of antimicrobial resistance among Enterobacteriaceae (focus on extended spectrum β-lactamases and carbapenemases). Expert Opin Pharmacother 2013; 14:199-210. [DOI: 10.1517/14656566.2013.763030] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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May L, Cosgrove S, L'Archeveque M, Talan DA, Payne P, Jordan J, Rothman RE. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med 2012; 62:69-77.e2. [PMID: 23122955 DOI: 10.1016/j.annemergmed.2012.09.002] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 08/27/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Larissa May
- Department of Emergency Medicine, George Washington University, Washington, DC, USA.
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