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Kibwana UO, Manyahi J, Sandnes HH, Blomberg B, Mshana SE, Langeland N, Roberts AP, Moyo SJ. Fluoroquinolone resistance among fecal extended spectrum βeta lactamases positive Enterobacterales isolates from children in Dar es Salaam, Tanzania. BMC Infect Dis 2023; 23:135. [PMID: 36882712 PMCID: PMC9993647 DOI: 10.1186/s12879-023-08086-2] [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: 09/29/2022] [Accepted: 02/15/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Fluoroquinolones have been, and continue to be, routinely used for treatment of many bacterial infections. In recent years, most parts of the world have reported an increasing trend of fluoroquinolone resistant (FQR) Gram-negative bacteria. METHODS A cross-sectional study was conducted between March 2017 and July 2018 among children admitted due to fever to referral hospitals in Dar es Salaam, Tanzania. Rectal swabs were used to screen for carriage of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE). ESBL-PE isolates were tested for quinolone resistance by disk diffusion method. Randomly selected fluroquinolone resistant isolates were characterized by using whole genome sequencing. RESULTS A total of 142 ESBL-PE archived isolates were tested for fluoroquinolone resistance. Overall phenotypic resistance to ciprofloxacin, levofloxacin and moxifloxacin was found in 68% (97/142). The highest resistance rate was seen among Citrobacter spp. (100%, 5/5), followed by Klebsiella. pneumoniae (76.1%; 35/46), Escherichia coli (65.6%; 42/64) and Enterobacter spp. (31.9%; 15/47). Whole genome sequencing (WGS) was performed on 42 fluoroquinolone resistant-ESBL producing isolates and revealed that 38/42; or 90.5%, of the isolates carried one or more plasmid mediated quinolone resistance (PMQR) genes. The most frequent PMQR genes were aac(6')-lb-cr (74%; 31/42), followed by qnrB1 (40%; 17/42), oqx, qnrB6 and qnS1. Chromosomal mutations in gyrA, parC and parE were detected among 19/42 isolates, and all were in E. coli. Most of the E. coli isolates (17/20) had high MIC values of > 32 µg/ml for fluoroquinolones. In these strains, multiple chromosomal mutations were detected, and all except three strains had additional PMQR genes. Sequence types, ST131 and ST617 predominated among E. coli isolates, while ST607 was more common out of 12 sequence types detected among the K. pneumoniae. Fluoroquinolone resistance genes were mostly associated with the IncF plasmids. CONCLUSION The ESBL-PE isolates showed high rates of phenotypic resistance towards fluoroquinolones likely mediated by both chromosomal mutations and PMQR genes. Chromosomal mutations with or without the presence of PMQR were associated with high MIC values in these bacteria strains. We also found a diversity of PMQR genes, sequence types, virulence genes, and plasmid located antimicrobial resistance (AMR) genes towards other antimicrobial agents.
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Affiliation(s)
- Upendo O Kibwana
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Joel Manyahi
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Bjørn Blomberg
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Norwegian National Advisory Unit On Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Stephen E Mshana
- Department of Microbiology and Immunology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Norwegian National Advisory Unit On Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Adam P Roberts
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sabrina J Moyo
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Norwegian National Advisory Unit On Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway.,Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
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Valiulin SV, Onischuk AA, Baklanov AM, Dubtsov SN, An'kov SV, Shkil NN, Nefedova EV, Plokhotnichenko ME, Tolstikova TG, Dolgov AM, Dultseva GG. Aerosol inhalation delivery of cefazolin in mice: Pharmacokinetic measurements and antibacterial effect. Int J Pharm 2021; 607:121013. [PMID: 34419591 DOI: 10.1016/j.ijpharm.2021.121013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/26/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022]
Abstract
Aerosol inhalation delivery of cefazolin, a broad-spectrum first-generation cephalosporin antibiotic, was investigated. Inhalation system based on ultrasonic nebulizer was developed for the generation of dry cefazolin aerosol within mean particle diameter range 0.5-3.0 μm and mass concentration 0.01-3 μg/cm3. Pharmacokinetic measurements were carried out for the aerosolized form of cefazolin delivered in mice using nose-only chamber. Cefazolin concentrations in blood serum and in the lungs of mice were measured as a function of time by means of high performance liquid chromatography. Body-delivered dose depending on particle size, concentration and inhalation time as well as other pharmacokinetic parameters were determined. The antibacterial effect of aerosolized cefazolin was assessed through the aerosol inhalation treatment of mice infected with Klebsiella pneumoniae. Survival rate for infected mice after the treatment with cefazolin aerosol demonstrated high antibacterial efficiency of the inhalation delivery of cefazolin in comparison with intraperitoneal delivery.
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Affiliation(s)
- S V Valiulin
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - A A Onischuk
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - A M Baklanov
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - S N Dubtsov
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - S V An'kov
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia; Vorozhtsov Institute of Organic Chemistry SB RAS, Novosibirsk 630090, Russia
| | - N N Shkil
- Siberian Federal Scientific Center of Agro-Biotechnologies RAS, Krasnoobsk 630501, Russia
| | - E V Nefedova
- Siberian Federal Scientific Center of Agro-Biotechnologies RAS, Krasnoobsk 630501, Russia
| | - M E Plokhotnichenko
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - T G Tolstikova
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia; Vorozhtsov Institute of Organic Chemistry SB RAS, Novosibirsk 630090, Russia
| | - A M Dolgov
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
| | - G G Dultseva
- Voevodsky Institute of Chemical Kinetics and Combustion SB RAS, Novosibirsk, 630090, Russia
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Macy E. Why Was There Ever a Warning Not to Use Cephalosporins in the Setting of a Penicillin "Allergy"? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3929-3933. [PMID: 34303019 DOI: 10.1016/j.jaip.2021.06.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022]
Abstract
It is now well-established that avoiding β-lactam antibiotics, when they are the drugs of choice, results in significantly worse long-term global outcomes for patients. Much of this avoidable morbidity has been caused by widespread warnings in electronic health care record systems not to use cephalosporins in the setting of penicillin allergy. High rates, up to 1000-fold higher than now seen, of immunologically mediated reactions were associated with early impure penicillin preparations. This instilled a rational fear of β-lactam-associated anaphylaxis in generations of physicians. In the late 1970s, several editorial comments regarding a potential increased risk to patients given cephalosporins who had a history of a penicillin allergy resulted in the warning that became imbedded in the culture of medicine. Over the past 40 years, compelling data have been developed that refute this warning and showed that the risks of avoiding cephalosporins outweighed the benefits. In late 2017, Kaiser Permanente Southern California completely removed all warnings not to use cephalosporins in the setting of a penicillin allergy. The results have recently been published in JAMA Network Open. This Rostrum article provides some of the backstory on the establishment and removal of this warning for physicians who trained over the past 30 years.
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Affiliation(s)
- Eric Macy
- Allergy Department, Kaiser San Diego Medical Center, Permanente Southern California, San Diego, Calif.
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Jaffa RK, Hammer J, Medaris LA, Anderson WE, Heffner AC, Pillinger KE. Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock. Am J Emerg Med 2021; 48:255-260. [PMID: 34004470 DOI: 10.1016/j.ajem.2021.04.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/10/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents. METHODS This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality. RESULTS Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups. CONCLUSIONS Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.
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Affiliation(s)
- Rupal K Jaffa
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - John Hammer
- Division of Pharmacy, Atrium Health's Carolinas Medical Center, United States of America.
| | - Leigh Ann Medaris
- Department of Infectious Diseases, Atrium Health's Carolinas Medical Center, United States of America.
| | - William E Anderson
- Center for Outcomes Research and Evaluation, Atrium Health's Carolinas Medical Center, United States of America
| | - Alan C Heffner
- Department of Internal Medicine, Division of Critical Care, Atrium Health's Carolinas Medical Center, United States of America; Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, United States of America.
| | - Kelly E Pillinger
- University of Rochester Medical Center - Strong Memorial Hospital, United States of America.
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Al-Hasan MN, Gould AP, Drennan C, Hill O, Justo JA, Kohn J, Bookstaver PB. Empirical fluoroquinolones versus broad-spectrum beta-lactams for Gram-negative bloodstream infections in the absence of antimicrobial resistance risk factors. J Glob Antimicrob Resist 2019; 22:87-93. [PMID: 31887412 DOI: 10.1016/j.jgar.2019.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES Increasing antimicrobial resistance rates limit empirical antimicrobial treatment options for Gram-negative bloodstream infections (GN-BSI). However, antimicrobial resistance may be predicted based on patient-specific risk factors using precision medicine concepts. This retrospective, 1:2 matched cohort examined clinical outcomes in hospitalized adults without major risk factors for antimicrobial resistance receiving empirical fluoroquinolones or broad-spectrum beta-lactams (BSBL) for GN-BSI at Prisma Health-Midlands hospitals in Columbia, SC, USA from January 2010 through June 2015. METHODS Multivariable logistic regression was used to examine early treatment failure at 72-96 h from GN-BSI. Cox proportional hazards regression was used to examine 28-day mortality and hospital length of stay (HLOS). RESULTS Among 74 and 148 patients receiving empirical fluoroquinolones and BSBL for GN-BSI, respectively, median age was 68 years, 159 (72%) were women, and 152 (68%) had a urinary source of infection. Early treatment failure rates were comparable in fluoroquinolone and BSBL groups (27% vs. 30%, respectively, odds ratio 0.82, 95% confidence intervals [CI] 0.43-1.54, P = 0.53), as well as 28-day mortality (8.9% vs. 9.7%, respectively, hazards ratio [HR] 0.74, 95% CI 0.26-1.90, P = 0.54). Median HLOS was 6.1 days in the fluoroquinolone group and 7.1 days in the BSBL group (HR 0.73, 95% CI 0.54-0.99, P = 0.04). Transition from intravenous to oral therapy occurred sooner in the fluoroquinolone group than in the BSBL group (3.0 vs. 4.9 days, P < 0.001). CONCLUSIONS In the absence of antimicrobial resistance risk factors, fluoroquinolones provide an additional empirical treatment option to BSBL for GN-BSI. Shorter HLOS in the fluoroquinolone group may be due to earlier transition from intravenous to oral antimicrobial therapy.
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Affiliation(s)
- Majdi N Al-Hasan
- School of Medicine, University of South Carolina, Columbia, SC, USA; Palmetto Health-USC Medical Group, University of South Carolina, Columbia, SC, USA.
| | | | - Chelsea Drennan
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Olivia Hill
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Julie Ann Justo
- College of Pharmacy, University of South Carolina, Columbia, SC, USA; Prisma Health Richland Hospital, Columbia, SC, USA
| | - Joseph Kohn
- Prisma Health Richland Hospital, Columbia, SC, USA
| | - P Brandon Bookstaver
- College of Pharmacy, University of South Carolina, Columbia, SC, USA; Prisma Health Richland Hospital, Columbia, SC, USA
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Streamlining to Oral β-Lactam Versus Fluoroquinolone as Definitive Therapy for Enterobacteriaceae Bacteremia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vaughan D, Pakyz A, Stevens M, Lee K, Bernard S. Adequacy of empiric gram-negative coverage for septic patients at an academic medical center. Am J Infect Control 2019; 47:1194-1199. [PMID: 31109743 DOI: 10.1016/j.ajic.2019.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gram-negative organisms (GNOs) have increasing resistance rates to levofloxacin at Virginia Commonwealth University Health System (VCUHS), where levofloxacin is the most common agent added to provide double coverage of gram-negative infections. The goal of this study was to determine the adequacy of empiric gram-negative coverage for septic patients at our institution. METHODS A retrospective review of patients admitted to VCUHS, from January 1, 2014, to December 31, 2014, with a diagnosis of sepsis, severe sepsis, or septic shock and documented infection, was performed to determine the adequacy of various empiric antibiotic combinations. RESULTS Of 219 patients who met the inclusion criteria, 56% of patients received monotherapy and 21% of patients received combination therapy (2 antibiotics) covering GNOs. GNOs (84%) were susceptible to piperacillin-tazobactam. When used in combination with cefepime and meropenem, levofloxacin did not increase coverage. However, levofloxacin provided an 8% increase in coverage and gentamicin provided an additional 13% increase in coverage, respectively, when used in combination with piperacillin-tazobactam. CONCLUSIONS Among septic patients at VCUHS, gentamicin provided increased gram-negative coverage when compared with levofloxacin. Although susceptibility to piperacillin-tazobactam alone was relatively low, the combination of piperacillin-tazobactam and gentamicin provided nearly equivalent coverage to meropenem and gentamicin.
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Phillips CJ, Gilchrist M, Cooke FJ, Franklin BD, Enoch DA, Murphy ME, Santos R, Brannigan ET, Holmes AH. Adherence to antibiotic guidelines and reported penicillin allergy: pooled cohort data on prescribing and allergy documentation from two English National Health Service (NHS) trusts. BMJ Open 2019; 9:e026624. [PMID: 30826801 PMCID: PMC6398633 DOI: 10.1136/bmjopen-2018-026624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate documentation of antimicrobial allergy and to determine prescribing adherence to local antibiotic guidelines for inpatients with and without reported penicillin allergy treated for infection in a National Health Service (NHS) context. SETTING Data were collected at two English hospital NHS trusts over two time-periods: June 2016 and February 2017. DESIGN Cohort study. Trust 1 data were sourced from prospective point prevalence surveys. Trust 2 data were extracted retrospectively from an electronic report. PARTICIPANTS Inpatients treated for urinary tract infection (UTI), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and skin and soft tissue infection (SSTI). Data on allergy were collected, and antibiotic selection assessed for adherence to trust guidelines with differences between groups presented as adjusted ORs. RESULTS A total of 1497 patients were included, with 2645 antibiotics orders. Patients were treated for CAP (n=495; 33.1%), UTI (407; 27.2%), HAP (330; 22%) and SSTI (265; 17.7%). There were 240 (16%) patients with penicillin allergy. Penicillin allergy was recorded as allergy (n=52; 21.7%), side effect (27; 11.3%) and no documentation (161; 67.1%). Overall, 2184 (82.6%) antibiotic orders were guideline-adherent. Adherence was greatest for those labelled penicillin allergy (453 of 517; 87.6%) versus no allergy (1731 of 2128; 81.3%) (OR 0.52 (95% CI 0.37 to 0.73) p<0.001). Guideline-adherence for CAP was higher if penicillin allergy (151 of 163; 92.6%) versus no allergy (582 of 810; 71.9%) (OR 0.20 (95% CI 0.10 to 0.37) p<0.001). There was no difference in adherence between those with and without penicillin allergy for UTI, HAP or SSTI treatment. CONCLUSIONS A relatively high proportion of patients had a penicillin allergy and two thirds of these had no description of their allergy, which has important implications for patient safety. Patients with penicillin allergy treated for CAP, received more guideline adherent antibiotics than those without allergy. Future studies investigating the clinical impact of penicillin allergy should include data on adherence to antibiotic guidelines.
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Affiliation(s)
- Cameron J Phillips
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Fiona J Cooke
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bryony D Franklin
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael E Murphy
- Clinical Microbiology and Public Health Laboratory, National Infection Service, Public Health England, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Reem Santos
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Alison H Holmes
- Imperial College Healthcare NHS Trust, London, UK
- NIHR, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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Macy E, Vyles D. Who needs penicillin allergy testing? Ann Allergy Asthma Immunol 2018; 121:523-529. [PMID: 30092265 DOI: 10.1016/j.anai.2018.07.041] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/20/2018] [Accepted: 07/30/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Eric Macy
- Department of Allergy, Southern California Permanente Medical Group, San Diego Medical Center, San Diego, California.
| | - David Vyles
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Vazquez-Guillamet MC, Vazquez R, Micek ST, Kollef MH. Predicting Resistance to Piperacillin-Tazobactam, Cefepime and Meropenem in Septic Patients With Bloodstream Infection Due to Gram-Negative Bacteria. Clin Infect Dis 2018; 65:1607-1614. [PMID: 29020294 DOI: 10.1093/cid/cix612] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/08/2017] [Indexed: 11/15/2022] Open
Abstract
Background Predicting antimicrobial resistance in gram-negative bacteria (GNB) could balance the need for administering appropriate empiric antibiotics while also minimizing the use of clinically unwarranted broad-spectrum agents. Our objective was to develop a practical prediction rule able to identify patients with GNB infection at low risk for resistance to piperacillin-tazobactam (PT), cefepime (CE), and meropenem (ME). Methods The study included adult patients with sepsis or septic shock due to bloodstream infections caused by GNB admitted between 2008 and 2015 from Barnes-Jewish Hospital. We used multivariable logistic regression analyses to describe risk factors associated with resistance to the antibiotics of interest (PT, CE, and ME). Clinical decision trees were developed using the recursive partitioning algorithm CHAID (χ2 Automatic Interaction Detection). Results The study included 1618 consecutive patients. Prevalence rates for resistance to PT, CE, and ME were 28.6%, 21.8%, and 8.5%, respectively. Prior antibiotic use, nursing home residence, and transfer from an outside hospital were associated with resistance to all 3 antibiotics. Resistance to ME was specifically linked with infection attributed to Pseudomonas or Acinetobacter spp. Discrimination was similar for the multivariable logistic regression and CHAID tree models, with both being better for ME than for PT and CE. Recursive partitioning algorithms separated out 2 clusters with a low probability of ME resistance and 4 with a high probability of PT, CE, and ME resistance. Conclusions With simple variables, clinical decision trees can be used to distinguish patients at low, intermediate, or high risk of resistance to PT, CE, and ME.
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Affiliation(s)
| | - Rodrigo Vazquez
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico, Albuquerque
| | - Scott T Micek
- Department of Pharmacy Practice, St Louis College of Pharmacy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri
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Al-Hasan MN, Acker EC, Kohn JE, Bookstaver PB, Justo JA. Impact of Penicillin Allergy on Empirical Carbapenem Use in Gram-Negative Bloodstream Infections: An Antimicrobial Stewardship Opportunity. Pharmacotherapy 2017; 38:42-50. [DOI: 10.1002/phar.2054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Majdi N. Al-Hasan
- University of South Carolina School of Medicine; Columbia South Carolina
- Department of Medicine; Palmetto Health USC Medical Group; Columbia South Carolina
| | - Emily C. Acker
- Department of Pharmacy; Cincinnati Children's Hospital; Cincinnati Ohio
| | - Joseph E. Kohn
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
| | - Paul Brandon Bookstaver
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
- Department of Clinical Pharmacy and Outcomes Sciences; University of South College of Pharmacy; Columbia South Carolina
| | - Julie Ann Justo
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
- Department of Clinical Pharmacy and Outcomes Sciences; University of South College of Pharmacy; Columbia South Carolina
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Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, Phillips EJ. The 3 Cs of Antibiotic Allergy-Classification, Cross-Reactivity, and Collaboration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:1532-1542. [PMID: 28843343 PMCID: PMC5681410 DOI: 10.1016/j.jaip.2017.06.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/08/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
Antibiotic allergy labeling is highly prevalent and negatively impacts patient outcomes and antibiotic appropriateness. Reducing the prevalence and burden of antibiotic allergies requires the engagement of key stakeholders such as allergists, immunologists, pharmacists, and infectious diseases physicians. To help address this burden of antibiotic allergy overlabeling, we review 3 key antibiotic allergy domains: (1) antibiotic allergy classification, (2) antibiotic cross-reactivity, and (3) multidisciplinary collaboration. We review the available evidence and research gaps of currently used adverse drug reaction classification systems, antibiotic allergy cross-reactivity, and current and future models of antibiotic allergy care.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - M Lindsay Grayson
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Karen Urbancic
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Pharmacy, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Centre for Improving Cancer Outcomes through Enhanced Infection Services, National Health and Medical Research Council Centre of Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia; National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia; Department of Medicine, Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University Medical School, Nashville, Tenn
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Are Cephalosporins Safe for Use in Penicillin Allergy without Prior Allergy Evaluation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:82-89. [PMID: 28958745 DOI: 10.1016/j.jaip.2017.07.033] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 12/28/2022]
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14
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Nimmich EB, Bookstaver PB, Kohn J, Justo JA, Hammer KL, Albrecht H, Al-Hasan MN. Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence. Hosp Pharm 2017; 52:691-697. [PMID: 29276241 DOI: 10.1177/0018578717720506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Appropriate empirical antimicrobial therapy is associated with improved outcomes of patients with Gram-negative bloodstream infections (BSI). Objective: Development of evidence-based institutional management guidelines for empirical antimicrobial therapy of Gram-negative BSI. Methods: Hospitalized adults with Gram-negative BSI in 2011-2012 at Palmetto Health hospitals in Columbia, SC, USA, were identified. Logistic regression was used to examine the association between site of infection acquisition and BSI due to Pseudomonas aeruginosa or chromosomally mediated AmpC-producing Enterobacteriaceae (CAE). Antimicrobial susceptibility rates of bloodstream isolates were stratified by site of acquisition and acute severity of illness. Retained antimicrobial regimens had predefined susceptibility rates ≥90% for noncritically ill and ≥95% for critically ill patients. Results: Among 390 patients, health care-associated (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.5-6.3] and hospital-acquired sites of acquisition (OR: 3.7, 95% CI: 1.6-8.4) were identified as risk factors for BSI due to P aeruginosa or CAE, compared with community-acquired BSI (referent). Based on stratified bloodstream antibiogram, ceftriaxone met predefined susceptibility criteria for community-acquired BSI in noncritically ill patients (95%). Cefepime and piperacillin-tazobactam monotherapy achieved predefined susceptibility criteria in noncritically ill (95% both) and critically ill patients with health care-associated and hospital-acquired BSI (96% and 97%, respectively) and critically ill patients with community-acquired BSI (100% both). Conclusions: Incorporation of site of acquisition, local antimicrobial susceptibility rates, and acute severity of illness into institutional guidelines provides objective evidence-based approach for optimizing empirical antimicrobial therapy for Gram-negative BSI. The suggested methodology provides a framework for guideline development in other institutions.
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Affiliation(s)
| | - P Brandon Bookstaver
- College of Pharmacy, University of South Carolina, Columbia, USA.,Palmetto Health Richland, Columbia, SC, USA
| | | | - Julie Ann Justo
- College of Pharmacy, University of South Carolina, Columbia, USA.,Palmetto Health Richland, Columbia, SC, USA
| | | | - Helmut Albrecht
- University of South Carolina School of Medicine, Columbia, USA.,Palmetto Health USC Medical Group, Columbia, USA
| | - Majdi N Al-Hasan
- University of South Carolina School of Medicine, Columbia, USA.,Palmetto Health USC Medical Group, Columbia, USA
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15
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Kutob LF, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al-Hasan MN. Effectiveness of oral antibiotics for definitive therapy of Gram-negative bloodstream infections. Int J Antimicrob Agents 2016; 48:498-503. [PMID: 27590704 DOI: 10.1016/j.ijantimicag.2016.07.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/04/2016] [Accepted: 07/15/2016] [Indexed: 11/26/2022]
Abstract
There is paucity of data evaluating intravenous-to-oral antibiotic switch options for Gram-negative bloodstream infections (BSIs). This retrospective cohort study examined the effectiveness of oral antibiotics for definitive treatment of Gram-negative BSI. Patients with Gram-negative BSI hospitalised for <14 days at Palmetto Health Hospitals in Columbia, SC, from 1 January 2010 through 31 December 2013 and discharged on oral antibiotics were included in this study. The cohort was stratified into three groups based on bioavailability of oral antibiotics prescribed (high, ≥95%; moderate, 75-94%; and low, <75%). Kaplan-Meier analysis and multivariate Cox proportional hazards regression were used to examine treatment failure. Among the 362 patients, high, moderate and low bioavailability oral antibiotics were prescribed to 106, 179 and 77 patients, respectively, for definitive therapy of Gram-negative BSI. Mean patient age was 63 years, 217 (59.9%) were women and 254 (70.2%) had a urinary source of infection. Treatment failure rates were 2%, 12% and 14% in patients receiving oral antibiotics with high, moderate and low bioavailability, respectively (P = 0.02). Risk of treatment failure in the multivariate Cox model was higher in patients receiving antibiotics with moderate [adjusted hazard ratio (aHR) = 5.9, 95% CI 1.6-38.5; P = 0.005] and low bioavailability (aHR = 7.7, 95% CI 1.9-51.5; P = 0.003) compared with those receiving oral antimicrobial agents with high bioavailability. These data demonstrate the effectiveness of oral antibiotics with high bioavailability for definitive therapy of Gram-negative BSI. Risk of treatment failure increases as bioavailability of the oral regimen declines.
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Affiliation(s)
- Leila F Kutob
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Science, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA; Department of Pharmacy, Palmetto Health Richland, Columbia, SC, USA
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Science, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Joseph Kohn
- Department of Pharmacy, Palmetto Health Richland, Columbia, SC, USA
| | - Helmut Albrecht
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Majdi N Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA.
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16
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Prediction of Fluoroquinolone Resistance in Gram-Negative Bacteria Causing Bloodstream Infections. Antimicrob Agents Chemother 2016; 60:2265-72. [PMID: 26833166 DOI: 10.1128/aac.02728-15] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/22/2016] [Indexed: 11/20/2022] Open
Abstract
Increasing rates of fluoroquinolone resistance (FQ-R) have limited empirical treatment options for Gram-negative infections, particularly in patients with severe beta-lactam allergy. This case-control study aims to develop a clinical risk score to predict the probability of FQ-R in Gram-negative bloodstream isolates. Adult patients with Gram-negative bloodstream infections (BSI) hospitalized at Palmetto Health System in Columbia, South Carolina, from 2010 to 2013 were identified. Multivariate logistic regression was used to identify independent risk factors for FQ-R. Point allocation in the fluoroquinolone resistance score (FQRS) was based on regression coefficients. Model discrimination was assessed by the area under receiver operating characteristic curve (AUC). Among 824 patients with Gram-negative BSI, 143 (17%) had BSI due to fluoroquinolone-nonsusceptible Gram-negative bacilli. Independent risk factors for FQ-R and point allocation in FQRS included male sex (adjusted odds ratio [aOR], 1.97; 95% confidence intervals [CI], 1.36 to 2.98; 1 point), diabetes mellitus (aOR, 1.54; 95% CI, 1.03 to 2.28; 1 point), residence at a skilled nursing facility (aOR, 2.28; 95% CI, 1.42 to 3.63; 2 points), outpatient procedure within 30 days (aOR, 3.68; 95% CI, 1.96 to 6.78; 3 points), prior fluoroquinolone use within 90 days (aOR, 7.87; 95% CI, 4.53 to 13.74; 5 points), or prior fluoroquinolone use within 91 to 180 days of BSI (aOR, 2.77; 95% CI, 1.17 to 6.16; 3 points). The AUC for both final logistic regression and FQRS models was 0.73. Patients with an FQRS of 0, 3, 5, or 8 had predicted probabilities of FQ-R of 6%, 22%, 39%, or 69%, respectively. The estimation of patient-specific risk of antimicrobial resistance using FQRS may improve empirical antimicrobial therapy and fluoroquinolone utilization in Gram-negative BSI.
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17
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Brigmon MM, Bookstaver PB, Kohn J, Albrecht H, Al-Hasan MN. Impact of fluoroquinolone resistance in Gram-negative bloodstream infections on healthcare utilization. Clin Microbiol Infect 2015; 21:843-9. [PMID: 26003282 DOI: 10.1016/j.cmi.2015.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/09/2015] [Accepted: 05/10/2015] [Indexed: 12/21/2022]
Abstract
There has been a concerning increase in fluoroquinolone resistance among Gram-negative bloodstream isolates. This retrospective cohort study examines the implications of fluoroquinolone resistance on use of healthcare resources in patients with Gram-negative bloodstream infections (BSI). Hospitalized adults with first episodes of community-onset Gram-negative BSI from 2010 to 2012 at Palmetto Health Hospitals in Columbia, SC, USA were identified. Multivariate linear regression was used to examine risk factors for prolonged hospital length of stay (HLOS) in survivors of Gram-negative BSI. Among 474 unique patients, 384 (81%) and 90 (19%) had BSI due to fluoroquinolone-susceptible (FQ-S) and fluoroquinolone non-susceptible (FQ-NS) Gram-negative bacilli, respectively. The FQ-NS bloodstream isolates, particularly Escherichia coli, were more likely than FQ-S isolates to be multi-drug resistant (56% versus 6%, p < 0.001). Compared with patients with BSI due to FQ-S bloodstream isolates, those with FQ-NS isolates were more likely to receive inappropriate empirical antimicrobial therapy (26% versus 3%, p < 0.001), have longer mean HLOS (11.6 versus 9.3 days, p 0.03) and treatment duration with intravenous antibiotics during hospitalization (9.1 versus 7.1 days, p 0.001), and use outpatient intravenous antibiotics at hospital discharge (15% versus 8%, p 0.05). After adjustments in the multivariate model, inappropriate empirical antimicrobial therapy was an independent risk factor for prolonged HLOS in survivors of Gram-negative BSI (parameter estimate 3.65 days, 95% CI 0.43-6.86). Multi-drug resistance among FQ-NS bloodstream isolates limits both empirical and definitive antimicrobial treatment options and poses excessive burdens on the healthcare system.
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Affiliation(s)
- M M Brigmon
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Science, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - J Kohn
- Department of Clinical Pharmacy, Palmetto Health Richland, Columbia, SC, USA
| | - H Albrecht
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA
| | - M N Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC, USA.
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Stratification of the impact of inappropriate empirical antimicrobial therapy for Gram-negative bloodstream infections by predicted prognosis. Antimicrob Agents Chemother 2014; 59:245-50. [PMID: 25348527 DOI: 10.1128/aac.03935-14] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The bloodstream infection mortality risk score (BSIMRS) predicts the outcome of patients with Gram-negative bloodstream infections (BSI) with high discrimination. This retrospective cohort study examined the impact of inappropriate antimicrobial therapy on mortality in adult patients with Gram-negative BSI admitted to Palmetto Health Hospitals in Columbia, SC, USA, from 1 January 2011 to 31 December 2012 after stratification by predicted prognosis at initial presentation using BSIMRS. A multivariate Cox regression model was used to identify independent risk factors for 28-day mortality overall and within each predefined BSIMRS category (<5, 5 to 9, and ≥ 10). Relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to treat (NNT) were calculated from a predictive logistic regression model of mortality. Overall, 390 unique patients with first episodes of Gram-negative BSI were identified. The median age was 66 years, and 229 (59%) were women. There was significant association between inappropriate antimicrobial therapy and mortality in patients with BSIMRS of 5 to 9 (adjusted hazard ratio [aHR], 3.55; 95% confidence intervals [CI], 1.22 to 8.31; P = 0.02) and BSIMRS of ≥ 10 (aHR, 4.99; 95% CI, 1.09 to 22.87; P = 0.04) but not in those with BSIMRS of <5 (aHR, 3.34; 95% CI, 0.17 to 22.77; P = 0.34). RRR, ARR, and NNT were 0.25, 0.02, and 63 for BSIMRS of <5; 0.56, 0.32, and 3 for BSIMRS of 5 to 9; and 0.39, 0.39, and 3 for BSIMRS of ≥ 10, respectively. There is a significant benefit from appropriate antimicrobial therapy in patients with Gram-negative BSI with guarded (BSIMRS of 5 to 9) and poor (BSIMRS of ≥ 10) predicted prognosis. Survival difference remains unclear among those with good predicted prognosis (BSIMRS of <5) at initial presentation.
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