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Yetiş Ö, Ali S, Coen P, Wilson P. Is screening of patients for Pseudomonas aeruginosa groin/rectal carriage useful in identifying those at risk of bacteraemia in haematology and other high-risk clinical settings? J Hosp Infect 2024:S0195-6701(24)00254-8. [PMID: 39032566 DOI: 10.1016/j.jhin.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND P. aeruginosa is a leading cause of healthcare-associated infections (HAIs) in patients exposed to hospital waters. A rising incidence of P. aeruginosa bacteraemia prompted microbiological screening at patient-admission to support early identification of acquisition. MATERIALS/METHODS A 41-bed haematology ward (800-bed teaching-hospital, London) was surveyed between 24/01/2020-13/05/2020. Concurrent rectal and groin swabs were collected in duplicate (two swabs at a time) upon admission weekly. Results were compared with historical shower, drain and tap water contamination data. RESULTS 606 groin/rectal swabs were collected from 154 patients; 61 female (median age: 53years [IQR-42-66; range:13-82]) and 93 male (median: 57years [IQR-36-67; range:20-93]). Six of 154 patients admitted (3.9%) were positive for P. aeruginosa. Two patients (1.3% (CI=0.16-4.6%)) were colonised at admission while four patients (2.6% (CI=0.7-6.5%)) became colonised by 33 days (IQR:13-54) of stay. Concurrent duplicate sampling yielded both positive and negative results in all colonised patient-cases. One patient subsequently developed P. aeruginosa bacteraemia. Shower water and corresponding drains from the four patient rooms where P. aeruginosa was acquired were heavily contaminated (>300 CFU/100 mL) with P. aeruginosa 265 days (median; range:247-283) before patient admission. Point-of-use filtration devices were installed to affected outlets to prevent patient acquisition. However, HWB waters in corresponding rooms were free of P. aeruginosa contamination. CONCLUSIONS Rectal/groin swab-screening at admission to hospital might be valuable for early-detection of patient colonisation but is intrusive, resource-demanding and yield may be low. In high-risk settings, enhanced environmental-monitoring, decontamination of surfaces and drains, and point-of-use filter-barriers is recommended, especially if expected duration of stay exceeds 30 days.
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Affiliation(s)
- Özge Yetiş
- Faculty of Medical Sciences, Division of Infection and Immunity, University College London, London, UK; Environmental Research Laboratory, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Shanom Ali
- Faculty of Medical Sciences, Division of Infection and Immunity, University College London, London, UK; Environmental Research Laboratory, University College London Hospitals NHS Foundation Trust, London, UK
| | - Pietro Coen
- Department of Clinical Microbiology & Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Wilson
- Faculty of Medical Sciences, Division of Infection and Immunity, University College London, London, UK; Department of Clinical Microbiology & Virology, University College London Hospitals NHS Foundation Trust, London, UK
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Gómez-Zorrilla S, Becerra-Aparicio F, Sendra E, Zamorano L, Grau I, Pintado V, Padilla B, Benito N, Boix-Palop L, Fariñas MC, Peñaranda M, Gamallo MR, Martinez JA, Morte-Romea E, Del Pozo JL, Montesinos IL, Durán-Jordà X, Ponz R, Cotarelo M, Cantón R, Oliver A, Ruiz-Garbajosa P, Horcajada JP, Siverio A, Montesinos IL, Gijón D, Merino I, López de Gopegui E, López-Causapé C, Sabé N, Shaw E, Berbel D, Quintano FT, Carrillo CS, Cercenado E, Rubio V, Rivera A, Calvo E, Badía C, Xercavins M, de Malet A, Canoura-Fernández L, Salvo S, Paño-Pardo JR, Carmona-Torre F. Risk factors and clinical impact of multidrug resistance in healthcare-associated bacteremic urinary tract infections: a post-hoc analysis of a multicenter prospective cohort in Spain. J Hosp Infect 2024:S0195-6701(24)00219-6. [PMID: 38945399 DOI: 10.1016/j.jhin.2024.05.020] [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: 03/31/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION The global burden associated with antimicrobial resistance is of increasing concern. The aim of this study was to evaluate risk factors associated with multidrug-resistant (MDR) infection and its clinical impact in a cohort of patients with healthcare-associated (HCA) bacteremic urinary tract infections (BUTI). METHODS This is a post-hoc analysis a prospective multicenter study of patients with HCA-BUTI (ITUBRAS-2). The primary outcome was MDR profile. Secondary outcomes were clinical response (at 48-72h and at hospital discharge) and length of hospital stay from onset of BUTI. Logistic regression was used to evaluate variables associated with MDR profile and clinical response. Length of hospital stay was evaluated using multivariate median regression. RESULTS 443 episodes were included, of which 271 (61.17%) were classified as expressing an MDR profile. In univariate analysis, MDR profile was associated with E. coli episodes (OR 3.13, 95% CI 2.11-4.69, p<0.001) and the extensively drug-resistant (XDR) pattern with P. aeruginosa etiology (OR 7.84, 95% CI 2.37-25.95; p=0.001). MDR was independently associated with prior use of fluoroquinolones (aOR 2.43; 95% CI 1.25-4.69), cephalosporins (aOR 2.14; 95% CI 1.35-3.41) and imipenem or meropenem (aOR 2.08; 95% CI 1.03-4.20) but not with prior ertapenem. In terms of outcomes, MDR profile was not associated with lower frequency of clinical cure, but with longer hospital stay. CONCLUSIONS MDR profile was independently associated with prior use of fluoroquinolones, cephalosporins, imipenem and meropenem, but not with prior ertapenem. MDR-BUTI episodes were not associated with worse clinical cure, although was independently associated with longer duration of hospital stay.
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Affiliation(s)
- Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute. Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Federico Becerra-Aparicio
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain
| | - Elena Sendra
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute. Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Zamorano
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Microbiology Service, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Inmaculada Grau
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Vicente Pintado
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Belén Padilla
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Service, Hospital de la Santa Creui Sant Pau - Institut d'Investigació Biomèdica Sant Pau. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lucía Boix-Palop
- Infectious Diseases Service, Hospital Mutua de Terrassa, Barcelona, Spain
| | - Maria Carmen Fariñas
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Universitario Marqués de Valdecilla, Santander
| | - María Peñaranda
- Infectious Diseases Service, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Maria Rocío Gamallo
- Infectious Diseases Service, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Jose Antonio Martinez
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Clinic, Barcelona, Spain
| | - Elena Morte-Romea
- Infectious Diseases Service, Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain
| | - Jose Luis Del Pozo
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Diseases Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Inmaculada López Montesinos
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute. Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Xavier Durán-Jordà
- Methodology and Biostatistics Support Unit, Hospital del Mar Research Institute, Barcelona, Spain
| | | | | | - Rafael Cantón
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain
| | - Antonio Oliver
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Microbiology Service, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Patricia Ruiz-Garbajosa
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute. Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Siverio
- Microbiology Service, Hospital del Mar Research Hospital, Barcelona, Spain
| | | | - Desiré Gijón
- Microbiology Service, Hospital Universitario Ramón y Cajal-IRYCIS, Madrid, Spain
| | - Irene Merino
- Microbiology Service, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Carla López-Causapé
- Microbiology Service, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Nuria Sabé
- Infectious Diseases Service, Hospital Universitario de Bellvitge- Institut d'Investigacio Biomedica de Bellvitge, Barcelona, Spain
| | - Evelyn Shaw
- Infectious Diseases Service, Hospital Universitario de Bellvitge- Institut d'Investigacio Biomedica de Bellvitge, Barcelona, Spain
| | - Dámaris Berbel
- Microbiology Service, Hospital Universitario de Bellvitge- Institut d'Investigacio Biomedica de Bellvitge, Barcelona, Spain
| | - Fe Tubau Quintano
- Microbiology Service, Hospital Universitario de Bellvitge- Institut d'Investigacio Biomedica de Bellvitge, Barcelona, Spain
| | | | | | - Verónica Rubio
- Infectious Diseases Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Microbiology Service, Hospital de la Santa Creu i Sant Pau- Institut d'Investigació Biomèdica Sant Pau. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Esther Calvo
- Infectious Diseases Service, Hospital Mutua de Terrassa, Barcelona, Spain
| | - Cristina Badía
- Infectious Diseases Service, Hospital Mutua de Terrassa, Barcelona, Spain
| | | | - Ana de Malet
- Microbiology Service, Hospital Marqués de Valdecilla, Santander
| | | | - Soledad Salvo
- Microbiology Service, Hospital Clínico Lozano Blesa, Zaragoza
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Heath MR, Fan W, Leu CS, Gomez-Simmonds A, Lodise T, Freedberg DE. Gut colonization with multidrug resistant organisms in the intensive care unit: a systematic review and meta-analysis. Crit Care 2024; 28:211. [PMID: 38943133 PMCID: PMC11214232 DOI: 10.1186/s13054-024-04999-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Gut colonization with multidrug-resistant organisms (MDRO) frequently precedes infection among patients in the intensive care unit (ICU), although the dynamics of colonization are not completely understood. We performed a systematic review and meta-analysis of ICU studies which described the cumulative incidence and rates of MDRO gut acquisition. METHODS We systematically searched PubMed, Embase, and Web of Science for studies published from 2010 to 2023 reporting on gut acquisition of MDRO in the ICU. MDRO were defined as multidrug resistant non-Pseudomonas Gram-negative bacteria (NP-GN), Pseudomonas spp., and vancomycin-resistant Enterococcus (VRE). We included observational studies which obtained perianal or rectal swabs at ICU admission (within 48 h) and at one or more subsequent timepoints. Our primary outcome was the incidence rate of gut acquisition of MDRO, defined as any MDRO newly detected after ICU admission (i.e., not present at baseline) for all patient-time at risk. The study was registered with PROSPERO, CRD42023481569. RESULTS Of 482 studies initially identified, 14 studies with 37,305 patients met criteria for inclusion. The pooled incidence of gut acquisition of MDRO during ICU hospitalization was 5% (range: 1-43%) with a pooled incidence rate of 12.2 (95% CI 8.1-18.6) per 1000 patient-days. Median time to acquisition ranged from 4 to 26 days after ICU admission. Results were similar for NP-GN and Pseudomonas spp., with insufficient data to assess VRE. Among six studies which provided sufficient data to perform curve fitting, there was a quasi-linear increase in gut MDRO colonization of 1.41% per day which was stable through 30 days of ICU hospitalization (R2 = 0.50, p < 0.01). CONCLUSIONS Acquisition of gut MDRO was common in the ICU and increases with days spent in ICU through 30 days of follow-up. These data may guide future interventions seeking to prevent gut acquisition of MDRO in the ICU.
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Affiliation(s)
- Madison R Heath
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Weijia Fan
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Cheng-Shiun Leu
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Angela Gomez-Simmonds
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA.
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Mendes Pedro D, Paulo SE, Santos CM, Fonseca AB, Melo Cristino J, Pereira ÁA, Caneiras C. Extensively drug-resistant Pseudomonas aeruginosa: clinical features and treatment with ceftazidime/avibactam and ceftolozane/tazobactam in a tertiary care university hospital center in Portugal - A cross-sectional and retrospective observational study. Front Microbiol 2024; 15:1347521. [PMID: 38414772 PMCID: PMC10896734 DOI: 10.3389/fmicb.2024.1347521] [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: 11/30/2023] [Accepted: 01/15/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) is a growing concern due to its increasing incidence, limited therapeutic options, limited data on the optimal treatment, and high mortality rates. The study aimed to characterize the population, the outcome and the microbiological characteristics of XDR-PA identified in a Portuguese university hospital center. Methods All XDR-PA isolates between January 2019 and December 2021 were identified. XDR-PA was defined as resistance to piperacillin-tazobactam, third and fourth generation cephalosporins, carbapenems, aminoglycosides and fluoroquinolones. A retrospective analysis of the medical records was performed. Results One hundred seventy-eight individual episodes among 130 patients with XDR-PA detection were identified. The most common sources of infection were respiratory (32%) and urinary tracts (30%), although skin and soft tissue infections (18%) and primary bacteremia (14%) were also prevalent. Colonization was admitted in 64 cases. Several patients had risk factors for complicated infections, most notably immunosuppression, structural lung abnormalities, major surgery, hemodialysis or foreign intravascular or urinary devices. XDR-PA identification was more frequent in male patients with an average age of 64.3 ± 17.5 years. One non-susceptibility to colistin was reported. Only 12.4% were susceptible to aztreonam. Ceftazidime-avibactam (CZA) was susceptible in 71.5% of the tested isolates. Ceftolozane-tazobactam (C/T) was susceptible in 77.5% of the tested isolates. Antibiotic regimens with XDR-PA coverage were reserved for patients with declared infection, except to cystic fibrosis. The most frequently administered antibiotics were colistin (41 cases), CZA (39 cases), and C/T (16 cases). When combination therapy was used, CZA plus colistin was preferred. The global mortality rate among infected patients was 35.1%, significantly higher in those with hematologic malignancy (50.0%, p < 0.05), followed by the ones with bacteremia (44.4%, p < 0.05) and those medicated with colistin (39.0%, p < 0.05), especially the ones with respiratory infections (60.0%). Among patients treated with CZA or C/T, the mortality rate seemed to be lower. Discussion XDR-PA infections can be severe and difficult to treat, with a high mortality rate. Even though colistin seems to be a viable option, it is likely less safe and efficient than CZA and C/T. To the best of the authors' knowledge, this is the first description of the clinical infection characteristics and treatment of XDR-PA in Portugal.
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Affiliation(s)
- Diogo Mendes Pedro
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Laboratório de Microbiologia na Saúde Ambiental, Laboratório Associado TERRA, Instituto de Saúde Ambiental, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Sérgio Eduardo Paulo
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Carla Mimoso Santos
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Ana Bruschy Fonseca
- Serviço de Patologia Clínica, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - José Melo Cristino
- Serviço de Patologia Clínica, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Instituto de Microbiologia, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Álvaro Ayres Pereira
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Cátia Caneiras
- Laboratório de Microbiologia na Saúde Ambiental, Laboratório Associado TERRA, Instituto de Saúde Ambiental, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, Monte da Caparica, Portugal
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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De Blasiis MR, Sciurti A, Baccolini V, Isonne C, Ceparano M, Iera J, De Vito C, Marzuillo C, Villari P, Migliara G. Impact of antibiotic exposure on antibiotic-resistant Acinetobacter baumannii isolation in intensive care unit patients: a systematic review and meta-analysis. J Hosp Infect 2024; 143:123-139. [PMID: 37972711 DOI: 10.1016/j.jhin.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Acinetobacter baumannii (AB) poses a significant threat to critically ill patients in intensive care units (ICUs). Although an association between antibiotic exposure and resistant AB is reported in the literature, a synthesis of evidence in ICU patients is still lacking. AIM To summarize the evidence on the association between prior antibiotic exposure and the occurrence of resistant AB in ICU patients. METHODS Online databases were searched for cohort and case-control studies providing data on the association of interest. Carbapenem/multidrug-resistant AB isolation was compared with non-isolation; carbapenem/multidrug-resistant AB was compared with carbapenem/antibiotic-susceptible AB; and extensively drug-resistant AB isolation was compared with non-isolation. Each comparison was subjected to a restricted maximum likelihood random-effects meta-analysis per antibiotic class, estimating pooled ORs. Stratified meta-analyses were performed by study design, outcome type and association-measure adjustment. FINDINGS Overall, 25 high-quality studies were retrieved. Meta-analyses showed that carbapenem/multidrug-resistant AB isolation was associated with previous exposure to aminoglycosides, carbapenems, third-generation cephalosporines, glycylcyclines, and nitroimidazoles. Increased risk of isolation of carbapenem/multidrug-resistant AB isolation vs carbapenem/antibiotic-susceptible AB was shown for prior exposure to aminoglycosides, antipseudomonal penicillins, carbapenems, fluoroquinolones, glycopeptides, and penicillins. Third-generation cephalosporin exposure increased the risk of extensively drug-resistant AB isolation vs non-isolation. CONCLUSION This systematic review clarifies the role of antibiotic use in antibiotic-resistant AB spread in ICUs, although for some antibiotic classes the evidence is still uncertain due to the small number of adjusted analyses, methodological and reporting issues, and limited number of studies. Future studies need to be carried out with standardized methods and appropriate reporting of multivariable models.
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Affiliation(s)
- M R De Blasiis
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - A Sciurti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy.
| | - V Baccolini
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - C Isonne
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - M Ceparano
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - J Iera
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy; Management and Health Laboratory, Institute of Management, Department EMbeDS, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - C De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - C Marzuillo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - P Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - G Migliara
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Kothari A, Kherdekar R, Mago V, Uniyal M, Mamgain G, Kalia RB, Kumar S, Jain N, Pandey A, Omar BJ. Age of Antibiotic Resistance in MDR/XDR Clinical Pathogen of Pseudomonas aeruginosa. Pharmaceuticals (Basel) 2023; 16:1230. [PMID: 37765038 PMCID: PMC10534605 DOI: 10.3390/ph16091230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
Antibiotic resistance in Pseudomonas aeruginosa remains one of the most challenging phenomena of everyday medical science. The universal spread of high-risk clones of multidrug-resistant/extensively drug-resistant (MDR/XDR) clinical P. aeruginosa has become a public health threat. The P. aeruginosa bacteria exhibits remarkable genome plasticity that utilizes highly acquired and intrinsic resistance mechanisms to counter most antibiotic challenges. In addition, the adaptive antibiotic resistance of P. aeruginosa, including biofilm-mediated resistance and the formation of multidrug-tolerant persisted cells, are accountable for recalcitrance and relapse of infections. We highlighted the AMR mechanism considering the most common pathogen P. aeruginosa, its clinical impact, epidemiology, and save our souls (SOS)-mediated resistance. We further discussed the current therapeutic options against MDR/XDR P. aeruginosa infections, and described those treatment options in clinical practice. Finally, other therapeutic strategies, such as bacteriophage-based therapy and antimicrobial peptides, were described with clinical relevance.
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Affiliation(s)
- Ashish Kothari
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Radhika Kherdekar
- Department of Dentistry, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Vishal Mago
- Department of Burn and Plastic Surgery, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Madhur Uniyal
- Department of Trauma Surgery, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Garima Mamgain
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Roop Bhushan Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Sandeep Kumar
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA 30912, USA;
| | - Neeraj Jain
- Department of Medical Oncology, All India Institute of Medical Sciences, Rishikesh 249203, India
- Division of Cancer Biology, Central Drug Research Institute, Lucknow 226031, India
| | - Atul Pandey
- Department of Entomology, University of Kentucky, Lexington, KY 40503, USA
| | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh 249203, India;
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Gut to lung translocation and antibiotic mediated selection shape the dynamics of Pseudomonas aeruginosa in an ICU patient. Nat Commun 2022; 13:6523. [PMID: 36414617 PMCID: PMC9681761 DOI: 10.1038/s41467-022-34101-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022] Open
Abstract
Bacteria have the potential to translocate between sites in the human body, but the dynamics and consequences of within-host bacterial migration remain poorly understood. Here we investigate the link between gut and lung Pseudomonas aeruginosa populations in an intensively sampled ICU patient using a combination of genomics, isolate phenotyping, host immunity profiling, and clinical data. Crucially, we show that lung colonization in the ICU was driven by the translocation of P. aeruginosa from the gut. Meropenem treatment for a suspected urinary tract infection selected for elevated resistance in both the gut and lung. However, resistance was driven by parallel evolution in the gut and lung coupled with organ specific selective pressures, and translocation had only a minor impact on AMR. These findings suggest that reducing intestinal colonization of Pseudomonas may be an effective way to prevent lung infections in critically ill patients.
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Paprocka P, Durnaś B, Mańkowska A, Król G, Wollny T, Bucki R. Pseudomonas aeruginosa Infections in Cancer Patients. Pathogens 2022; 11:pathogens11060679. [PMID: 35745533 PMCID: PMC9230571 DOI: 10.3390/pathogens11060679] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
Pseudomonas aeruginosa (P. aeruginosa) is one of the most frequent opportunistic microorganisms causing infections in oncological patients, especially those with neutropenia. Through its ability to adapt to difficult environmental conditions and high intrinsic resistance to antibiotics, it successfully adapts and survives in the hospital environment, causing sporadic infections and outbreaks. It produces a variety of virulence factors that damage host cells, evade host immune responses, and permit colonization and infections of hospitalized patients, who usually develop blood stream, respiratory, urinary tract and skin infections. The wide intrinsic and the increasing acquired resistance of P. aeruginosa to antibiotics make the treatment of infections caused by this microorganism a growing challenge. Although novel antibiotics expand the arsenal of antipseudomonal drugs, they do not show activity against all strains, e.g., MBL (metalo-β-lactamase) producers. Moreover, resistance to novel antibiotics has already emerged. Consequently, preventive methods such as limiting the transmission of resistant strains, active surveillance screening for MDR (multidrug-resistant) strains colonization, microbiological diagnostics, antimicrobial stewardship and antibiotic prophylaxis are of particular importance in cancer patients. Unfortunately, surveillance screening in the case of P. aeruginosa is not highly effective, and a fluoroquinolone prophylaxis in the era of increasing resistance to antibiotics is controversial.
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Affiliation(s)
- Paulina Paprocka
- Department of Microbiology and Immunology, Institute of Medical Science, Collegium Medicum, Jan Kochanowski University, IX Wieków Kielc 19A, 25-317 Kielce, Poland; (P.P.); (B.D.); (A.M.); (G.K.)
| | - Bonita Durnaś
- Department of Microbiology and Immunology, Institute of Medical Science, Collegium Medicum, Jan Kochanowski University, IX Wieków Kielc 19A, 25-317 Kielce, Poland; (P.P.); (B.D.); (A.M.); (G.K.)
| | - Angelika Mańkowska
- Department of Microbiology and Immunology, Institute of Medical Science, Collegium Medicum, Jan Kochanowski University, IX Wieków Kielc 19A, 25-317 Kielce, Poland; (P.P.); (B.D.); (A.M.); (G.K.)
| | - Grzegorz Król
- Department of Microbiology and Immunology, Institute of Medical Science, Collegium Medicum, Jan Kochanowski University, IX Wieków Kielc 19A, 25-317 Kielce, Poland; (P.P.); (B.D.); (A.M.); (G.K.)
| | - Tomasz Wollny
- Holy Cross Oncology Center of Kielce, Artwińskiego 3, 25-734 Kielce, Poland;
| | - Robert Bucki
- Department of Microbiology and Immunology, Institute of Medical Science, Collegium Medicum, Jan Kochanowski University, IX Wieków Kielc 19A, 25-317 Kielce, Poland; (P.P.); (B.D.); (A.M.); (G.K.)
- Department of Medical Microbiology and Nanobiomedical Engineering, Medical University of Białystok, Jana Kilińśkiego 1 Białystok, 15-089 Białystok, Poland
- Correspondence: ; Tel.: +48-85-748-54-83
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Martak D, Gbaguidi-Haore H, Meunier A, Valot B, Conzelmann N, Eib M, Autenrieth IB, Slekovec C, Tacconelli E, Bertrand X, Peter S, Hocquet D, Guther J. High prevalence of Pseudomonas aeruginosa carriage in residents of French and German long-term care facilities. Clin Microbiol Infect 2022; 28:1353-1358. [PMID: 35597505 DOI: 10.1016/j.cmi.2022.05.004] [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: 12/23/2021] [Revised: 04/22/2022] [Accepted: 05/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine prevalence, incidence, and factors associated with Pseudomonas aeruginosa (PA) intestinal carriage in residents of long-term care facilities (LTCFs) and to understand the population structure of this pathogen in LTCFs from two European countries. METHODS We assessed the prevalence of PA intestinal carriage and the incidence of acquisition by collecting fecal samples from 403 residents of 20 LTCFs. We collected 289 environmental samples from sinks and drinking water. Factors associated with carriage and acquisition of intestinal PA were identified. All PA isolates had their antibiotic phenotypic resistance profile determined and their genome sequenced, from which we assessed the population structure of the collection and identified resistance determinants. RESULTS We found a high proportion of residents with PA intestinal carriage (51.6%) over the entire study period. Over the follow-up period, 28.6% of the residents acquired intestinal PA. Older age (Odds ratio [OR] = 1.29, 95% confidence interval [CI]: 1.09-1.52; p = 0.002), urinary incontinence (OR = 2.56, 95% CI: 1.37-4.88; p = 0.003), and male gender (OR = 2.55), 95% CI: 1.05-6.18; p = 0.039) were associated with higher probability of carriage. Wheelchair usage (OR = 4.56, 95% CI: 1.38-15.05; p = 0.013) and a body mass index >25 (OR = 3.71, 95% CI: 1.17-11.82; p = 0.026) were associated with higher risk of PA acquisition. Population structure of our isolates was mainly non-clonal with 112 different STs among the 241 isolates. Most represented STs were high risk clones ST253 (n=26), ST17 (n=11), ST244 (n=11), ST309 (n=10), and ST395 (n=10). Most PA isolates (86.3%) were susceptible to antibiotics, with no acquired genes conferring resistance to antipseudomonal agents. CONCLUSIONS We found an unexpected high prevalence of PA intestinal carriage in LTCF residents mainly associated with individual-level factors. Our study revealed a polyclonal PA population structure suggesting that individual acquisition is more frequent than resident-to-resident transmission.
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Affiliation(s)
- Daniel Martak
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France.
| | - Houssein Gbaguidi-Haore
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Alexandre Meunier
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Benoit Valot
- UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Nadine Conzelmann
- Infectious Diseases, Dept. of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Michael Eib
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
| | - Ingo B Autenrieth
- University Hospital Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Céline Slekovec
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Xavier Bertrand
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France
| | - Silke Peter
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
| | - Didier Hocquet
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire, Besançon, France; UMR 6249 Chrono-environnement, CNRS, Université de Bourgogne Franche-Comté, Besançon, France; Centre de Ressources Biologiques - Filière Microbiologique de Besançon, Centre Hospitalier Universitaire, Besançon, France
| | - Julia Guther
- Institute of Medical Microbiology and Hygiene, University Hospital Tübingen, Tübingen, Germany
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Prado V, Hernández-Tejero M, Mücke MM, Marco F, Gu W, Amoros A, Toapanta D, Reverter E, Peña-Ramirez CDL, Altenpeter L, Bassegoda O, Mezzano G, Aziz F, Juanola A, Rodríguez-Tajes S, Chamorro V, López D, Reyes M, Hogardt M, Kempf VAJ, Ferstl PG, Zeuzem S, Martínez JA, Vila J, Arroyo V, Trebicka J, Fernandez J. Rectal colonization by resistant bacteria increases the risk of infection by the colonizing strain in critically ill patients with cirrhosis. J Hepatol 2022; 76:1079-1089. [PMID: 35074475 DOI: 10.1016/j.jhep.2021.12.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/01/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS It remains unclear whether rectal colonization with multidrug-resistant organisms (MDROs) is prevalent and predisposes to infections by the same pathogens in patients with cirrhosis. METHODS Two series of critically ill patients were evaluated. In the Barcelona cohort, 486 consecutive patients were prospectively evaluated, 129 with and 357 without cirrhosis (2015-2016). Rectal swabs were performed at admission and weekly thereafter (until intensive care unit [ICU] discharge) to detect MDRO colonization. Risk factors for colonization and infection by MDROs were evaluated. A retrospective cohort from Frankfurt (421 patients with cirrhosis; 2010-2018) was investigated to evaluate MDRO rectal colonization in another epidemiological scenario. RESULTS In the Barcelona cohort, 159 patients were colonized by MDROs (32.7%), 102 (64.2%) at admission and 57 (35.8%) during follow-up. Patients with cirrhosis showed higher rates of rectal colonization at admission than those without cirrhosis (28.7% vs. 18.2%, p = 0.01) but similar colonization rates during ICU stay. Extended-spectrum beta-lactamase-Enterobacterales were the most frequent MDROs isolated in both groups. Colonization by MDROs independently increased the risk of infection by MDROs at admission and during follow-up. Risk of new infection by the colonizing strain was also significantly increased in patients with (hazard ratio [HR] 7.41) and without (HR 5.65) cirrhosis. Rectal colonization by MDROs was also highly prevalent in Frankfurt (n = 198; 47%; 131 at admission [66.2%] and 67 [33.8%] during follow-up), with vancomycin-resistant enterococci being the most frequent colonizing organism. Rectal colonization by MDROs was also associated with an increased risk of infection by MDROs in this cohort. Infections occurring in MDR carriers were mainly caused by the colonizing strain. CONCLUSION Rectal colonization by MDROs is extremely frequent in critically ill patients with cirrhosis. Colonization increases the risk of infection by the colonizing resistant strain. LAY SUMMARY Rectal colonization by multidrug-resistant organisms (MDROs) is a prevalent problem in patients with cirrhosis requiring critical care. The pattern of colonizing bacteria is heterogeneous with relevant differences between centers. Colonization by MDROs is associated with increased risk of infection by the colonizing bacteria in the short term. This finding suggests that colonization data could be used to guide empirical antibiotic therapy and de-escalation policies in patients with cirrhosis.
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Affiliation(s)
- Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; Hepato-Gastro-enterology Department, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - María Hernández-Tejero
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Marcus M Mücke
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Francesc Marco
- Microbiology Department, Hospital Clinic, University of Barcelona, Spain; ISGlobal, Hospital Clínic - University of Barcelona, Spain
| | - Wenyi Gu
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Alex Amoros
- EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | | | - Laura Altenpeter
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Gabriel Mezzano
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Fátima Aziz
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Adria Juanola
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Sergio Rodríguez-Tajes
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Vanessa Chamorro
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - David López
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Marta Reyes
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Philip G Ferstl
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Stefan Zeuzem
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | | | - Jordi Vila
- Microbiology Department, Hospital Clinic, University of Barcelona, Spain; ISGlobal, Hospital Clínic - University of Barcelona, Spain
| | | | - Jonel Trebicka
- Department for Internal Medicine I, Goethe University Frankfurt, Germany; EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
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Risk Factors for Multidrug-Resistant Gram-Negative Bacteria Carriage upon Admission to the Intensive Care Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031039. [PMID: 35162062 PMCID: PMC8834020 DOI: 10.3390/ijerph19031039] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 01/27/2023]
Abstract
Multidrug-resistant Gram-negative bacteria (MDR-GNB) are microorganisms that have acquired resistance to extended-spectrum antibacterials and constitute an emerging threat to public health. Although carriers are an important source of transmission in healthcare settings, data about risk factors for MDR-GNB carriage are limited. Therefore, we aimed to identify risk factors for MDR-GNB carriage upon intensive care unit (ICU) admission and to optimise screening strategies. We conducted a case–control study. Admissions of adult patients to the ICU of a 1000-bed hospital during a year were included. We collected sociodemographic, clinical and microbiological data and performed a multivariate logistic regression model. A total of 1342 patients resulted in 1476 episodes of ICU admission, 91 (6.2%) of whom harboured MDR-GNB (38.5% women; median age 63.9 years). The most frequently isolated pathogens were Escherichia coli (57%) and Klebsiella pneumoniae (16%). The most frequent resistance mechanism was production of extended-spectrum beta lactamases. MDR-GNB carriage was associated to liver cirrhosis (OR 6.54, 95% CI 2.17–19.17), previous MDR-GNB carriage (OR 5.34, 1.55–16.60), digestive surgery (OR 2.83, 1.29–5.89) and length of hospital stay (OR 1.01 per day, 1.00–1.03). Several risk factors for MDR-GNB carriage upon admission to a high-risk setting were identified; the main comorbidity was liver cirrhosis.
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12
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Gómez-Zorrilla S, Becerra-Aparicio F, López Montesinos I, Ruiz de Gopegui E, Grau I, Pintado V, Padilla B, Benito N, Boix-Palop L, Fariñas MC, Peñaranda M, Gamallo MR, Martinez JA, Morte-Romea E, Del Pozo JL, Durán-Jordá X, Díaz-Regañón J, López-Mendoza D, Cantón R, Oliver A, Ruiz-Garbajosa P, Horcajada JP. A Large Multicenter Prospective Study of Community-Onset Healthcare Associated Bacteremic Urinary Tract Infections in the Era of Multidrug Resistance: Even Worse than Hospital Acquired Infections? Infect Dis Ther 2021; 10:2677-2699. [PMID: 34626347 PMCID: PMC8572918 DOI: 10.1007/s40121-021-00537-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/14/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Healthcare-associated (HCA) infections represent a growing public health problem. The aim of this study was to compare community-onset healthcare associated (CO-HCA) bacteremic urinary tract infections (BUTI) and hospital-acquired (HA)-BUTI with special focus on multidrug resistances (MDR) and outcomes. METHODS ITUBRAS-project is a prospective multicenter cohort study of patients with HCA-BUTI. All consecutive hospitalized adult patients with CO-HCA-BUTI or HA-BUTI episode were included in the study. Exclusion criteria were: patients < 18 years old, non-hospitalized patients, bacteremia from another source or primary bacteremia, non-healthcare-related infections and infections caused by unusual pathogens of the urinary tract. The main outcome variable was 30-day all-cause mortality with day 1 as the first day of positive blood culture. Logistic regression was used to analyze factors associated with clinical cure at hospital discharge and with receiving inappropriate initial antibiotic treatment. Cox regression was used to evaluate 30-day all-cause mortality. RESULTS Four hundred forty-three episodes were included, 223 CO-HCA-BUTI. Patients with CO-HCA-BUTI were older (p < 0.001) and had more underlying diseases (p = 0.029) than those with HA-BUTI. The severity of the acute illness (Pitt score) was also higher in CO-HCA-BUTI (p = 0.026). Overall, a very high rate of MDR profiles (271/443, 61.2%) was observed, with no statistical differences between groups. In multivariable analysis, inadequate empirical treatment was associated with MDR profile (aOR 3.35; 95% CI 1.77-6.35), Pseudomonas aeruginosa (aOR 2.86; 95% CI 1.27-6.44) and Charlson index (aOR 1.11; 95% CI 1.01-1.23). Mortality was not associated with the site of acquisition of the infection or the presence of MDR profile. However, in the logistic regression analyses patients with CO-HCA-BUTI (aOR 0.61; 95% CI 0.40-0.93) were less likely to present clinical cure. CONCLUSION The rate of MDR infections was worryingly high in our study. No differences in MDR rates were found between CO-HCA-BUTI and HA-BUTI, in the probability of receiving inappropriate empirical treatment or in 30-day mortality. However, CO-HCA-BUTIs were associated with worse clinical cure.
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Affiliation(s)
- Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain.
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain.
| | - Federico Becerra-Aparicio
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Inmaculada López Montesinos
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Enrique Ruiz de Gopegui
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Microbiology Service, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Inmaculada Grau
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Vicente Pintado
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Belén Padilla
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Service, Hospital de la Santa Creui Sant Pau-Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lucía Boix-Palop
- Infectious Diseases Service, Hospital Mutua de Terrassa, Barcelona, Spain
| | - Maria Carmen Fariñas
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - María Peñaranda
- Infectious Diseases Service, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Maria Rocío Gamallo
- Infectious Diseases Service, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Jose Antonio Martinez
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Clinic, Barcelona, Spain
| | - Elena Morte-Romea
- Infectious Diseases Service, Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain
| | - Jose Luis Del Pozo
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - Xavier Durán-Jordá
- Methodology and Biostatistics Support Unit, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | | | - Rafael Cantón
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Antonio Oliver
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Microbiology Service, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Patricia Ruiz-Garbajosa
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain.
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain.
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Arzilli G, Scardina G, Casigliani V, Petri D, Porretta A, Moi M, Lucenteforte E, Rello J, Lopalco P, Baggiani A, Privitera GP, Tavoschi L. Screening for Antimicrobial-Resistant Gram-negative bacteria in hospitalised patients, and risk of progression from colonisation to infection: Systematic review. J Infect 2021; 84:119-130. [PMID: 34793762 DOI: 10.1016/j.jinf.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Transmission of antimicrobial-resistant Gram-negative bacteria (AMR-GNB) among hospitalised patients can lead to new cases of carriage, infection and outbreaks, hence the need for early carrier identification. We aim to explore two key elements that may guide control policies for colonisation/infection in hospital settings: screening practices on admission to hospital wards and risk of developing infection from colonisation. METHODS We searched on PubMed, Scopus and Cochrane databases for studies published from 2010 up to 2021 reporting on adult patients hospitalised in high-income countries. RESULTS The search retrieved 11853 articles. After screening, 100 studies were included. Combining target patient groups and setting type, we identified six screening approaches. The most reported approach was all admitted patients to high-risk (HR) wards (49.4%). The overall prevalence of AMR-GNB was 13.8% (95%CI 9.3-19.0) with significant differences across regions and time. Risk of progression to infection among colonised patients was 11.0% (95%CI 8.0-14.3) and varied according to setting and pathogens' group (p value<0.0001), with higher values reported for Klebsiella species (18.1%; 95%CI 8.9-29.3). CONCLUSIONS While providing a comprehensive overview of the screening approaches, our study underlines the considerable burden of AMR-GNB colonisation and risk of progression to infection in hospitals by pathogen, setting and time.
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Affiliation(s)
- Guglielmo Arzilli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Giuditta Scardina
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Virginia Casigliani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Davide Petri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56123, Italy
| | - Andrea Porretta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy.
| | - Marco Moi
- Department of Surgical Sciences, University of Cagliari, Cagliari 09124, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56123, Italy
| | - Jordi Rello
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Clinical Research/epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Clinical Research, CHU Nîmes, Nîmes, France
| | - Pierluigi Lopalco
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Angelo Baggiani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy
| | - Gaetano Pierpaolo Privitera
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
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14
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Vink J, Edgeworth J, Bailey SL. Acquisition of MDR-GNB in hospital settings: a systematic review and meta-analysis focusing on ESBL-E. J Hosp Infect 2020; 106:419-428. [PMID: 32918969 DOI: 10.1016/j.jhin.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/03/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) and other multi-drug-resistant Gram-negative bacteria (MDR-GNB) have disseminated globally since their discovery in the late 20th century. Various infection prevention and control measures are in place to prevent nosocomial transmission of these organisms, but their efficacy remains disputed. New literature has emerged in recent years providing further evidence which can be used to formulate effective strategies to tackle this issue in the future. METHODS A systematic review was performed to characterize the prevalence of colonization of multi-drug-resistant organisms and subsequent acquisition of these organisms within hospital settings. A meta-analysis was performed to characterize the prevalence and acquisition of ESBL-E in Europe and North America. RESULTS Twenty-eight studies fulfilled the inclusion criteria. Escherichia coli formed the main burden of MDR-GNB colonization worldwide. Patient-to-patient transmission of ESBL-E was found to be rare, but increased transmissibility of Klebsiella pneumoniae was described over E. coli. Within European and North American healthcare settings, a meta-analysis of eight studies identified a pooled prevalence of ESBL-E on admission to hospital of 7.91% and an acquisition rate of 3.73%. DISCUSSION Low prevalence at the point of hospital admission and insufficient evidence of patient-to-patient transmission suggests that infection prevention and control measures such as universal surveillance screening and single-room isolation are unlikely to be practical or effective interventions in reducing the overall burden of ESBL-E in hospitals, in line with current European guidelines. Instead, it is argued that efforts should be placed on controlling the spread of these organisms and other MDR-GNB in the community, predominantly long-term care facilities.
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Affiliation(s)
- J Vink
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - J Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - S L Bailey
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London and Guy's & St Thomas' NHS Foundation Trust, London, UK
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15
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O'Donnell JN, Bidell MR, Lodise TP. Approach to the Treatment of Patients with Serious Multidrug-Resistant Pseudomonas aeruginosa Infections. Pharmacotherapy 2020; 40:952-969. [PMID: 32696452 DOI: 10.1002/phar.2449] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 12/21/2022]
Abstract
Multidrug resistance(MDR) among Pseudomonas aeruginosa (PSA) isolates presents a significant clinical challenge and can substantially complicate the approach to selection of optimal antibiotic therapy. This review addresses major considerations in antibiotic selection for patients with suspected or documented serious MDR-PSA infections. Common mechanisms contributing to MDR among clinical PSA isolates are summarized. Empiric and definitive therapy considerations are addressed including the potential role of combination therapy. Newer agents with in vitro activity against MDR-PSA (e.g., ceftolozane-tazobactam, ceftazidime-avibactam, imipenem-relebactam, and cefiderocol) and their potential roles in clinical settings are discussed. Although these newer agents are promising options for the treatment of MDR-PSA, clinical data remain generally limited. Future studies are needed to determine optimal agents for the empiric and definitive treatment of MDR-PSA.
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Affiliation(s)
- J Nicholas O'Donnell
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Monique R Bidell
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
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16
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Hamilton LA, Behal ML. Altering Routine Intensive Care Unit Practices to Support Commensalism. Nutr Clin Pract 2020; 35:433-441. [PMID: 32189422 DOI: 10.1002/ncp.10484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The gastrointestinal (GI) tract consists of trillions of organisms that support multiple functions in the body, from immunity, digestion, and absorption to drug metabolism. These microbes form an overall collection of microorganisms that form the body's microbiome. In critical illness, many of these functions are aberrant, and the microbiome is altered, leading to untoward effects. Some of the most common medications received by patients include antibiotics and proton pump inhibitors, which affect particular changes in the microbiome. In addition, patients receiving prolonged enteral and parenteral nutrition experience changes in the microbiological composition and diversity of their GI tracts. Research is ongoing to characterize the crosstalk between the microbiome and immune function as targets for drug and nutrition therapy.
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Affiliation(s)
- Leslie A Hamilton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
| | - Michael L Behal
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
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17
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Horcajada JP, Montero M, Oliver A, Sorlí L, Luque S, Gómez-Zorrilla S, Benito N, Grau S. Epidemiology and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Pseudomonas aeruginosa Infections. Clin Microbiol Rev 2019; 32:32/4/e00031-19. [PMID: 31462403 PMCID: PMC6730496 DOI: 10.1128/cmr.00031-19] [Citation(s) in RCA: 436] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In recent years, the worldwide spread of the so-called high-risk clones of multidrug-resistant or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa has become a public health threat. This article reviews their mechanisms of resistance, epidemiology, and clinical impact and current and upcoming therapeutic options. In vitro and in vivo treatment studies and pharmacokinetic and pharmacodynamic (PK/PD) models are discussed. Polymyxins are reviewed as an important therapeutic option, outlining dosage, pharmacokinetics and pharmacodynamics, and their clinical efficacy against MDR/XDR P. aeruginosa infections. Their narrow therapeutic window and potential for combination therapy are also discussed. Other "old" antimicrobials, such as certain β-lactams, aminoglycosides, and fosfomycin, are reviewed here. New antipseudomonals, as well as those in the pipeline, are also reviewed. Ceftolozane-tazobactam has clinical activity against a significant percentage of MDR/XDR P. aeruginosa strains, and its microbiological and clinical data, as well as recommendations for improving its use against these bacteria, are described, as are those for ceftazidime-avibactam, which has better activity against MDR/XDR P. aeruginosa, especially strains with certain specific mechanisms of resistance. A section is devoted to reviewing upcoming active drugs such as imipenem-relebactam, cefepime-zidebactam, cefiderocol, and murepavadin. Finally, other therapeutic strategies, such as use of vaccines, antibodies, bacteriocins, anti-quorum sensing, and bacteriophages, are described as future options.
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Affiliation(s)
- Juan P Horcajada
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Milagro Montero
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Antonio Oliver
- Service of Microbiology, Hospital Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Luisa Sorlí
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Sònia Luque
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Gómez-Zorrilla
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
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18
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Druge S, Ruiz S, Vardon-Bounes F, Grare M, Labaste F, Seguin T, Fourcade O, Minville V, Conil JM, Georges B. Risk factors and the resistance mechanisms involved in Pseudomonas aeruginosa mutation in critically ill patients. J Intensive Care 2019; 7:36. [PMID: 31360523 PMCID: PMC6639906 DOI: 10.1186/s40560-019-0390-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background The objective of this study was to determine the main risk factors of Pseudomonas aeruginosa mutation as well as the mechanisms of acquired resistance. Methods We conducted a 2-year prospective study in patients who were carriers of a Pseudomonas aeruginosa strain and who had been admitted to a medical/surgical ICU. Results Of the 153 patients who were included, 34 had a mutation in their strain. In a multivariate analysis, a duration of ventilation > 24 days was a risk factor for mutation (risk ratio 4.29; CI 95% 1.94-9.49) while initial resistance was a protective factor (RR 0.36; CI 95% 0.18-0.71). In a univariate analysis, exposure of P. aeruginosa to ceftazidime was associated with an over-production of AmpC cephalosporinase and exposure to meropenem was associated with impermeability. A segmentation method based on the duration of ventilation (> 24 days), initial resistance, and exposure of strains to ceftazidime made it possible to predict at 83% the occurrence of mutation. Conclusion The duration of ventilation and the presence of resistance as soon as P. aeruginosa is identified are predictive factors of mutation in ICU patients.
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Affiliation(s)
- Stéphanie Druge
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Stéphanie Ruiz
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Fanny Vardon-Bounes
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Marion Grare
- Laboratoire de Bactériologie et Hygiène, Institut Fédératif de Biologie, 330 Avenue de Grande Bretagne, TSA 40031, 31059 Toulouse Cedex 9, France
| | - François Labaste
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Thierry Seguin
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Olivier Fourcade
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Vincent Minville
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Jean-Marie Conil
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France
| | - Bernard Georges
- 1Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059 Toulouse Cedex 9, France.,3Department of Anesthesiology and Intensive Care Units, University Hospital of Toulouse, 31059 Toulouse Cedex 9, France
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19
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Boutrot M, Azougagh K, Guinard J, Boulain T, Barbier F. Antibiotics with activity against intestinal anaerobes and the hazard of acquired colonization with ceftriaxone-resistant Gram-negative pathogens in ICU patients: a propensity score-based analysis. J Antimicrob Chemother 2019; 74:3095-3103. [DOI: 10.1093/jac/dkz279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Intestinal colonization resistance is mainly exerted by commensal anaerobes.
Objectives
To assess whether exposure to non-carbapenem antibiotics with activity against intestinal anaerobes (namely, piperacillin/tazobactam, amoxicillin/clavulanate and metronidazole) may promote the acquisition of gut colonization with ceftriaxone-resistant Gram-negative bacteria (CFR-GNB) in ICU patients.
Patients and methods
All patients with a first stay >3 days in a single surgical ICU over a 30 month period were retrospectively included. Rectal carriage of CFR-GNB (i.e. ESBL-producing Enterobacteriaceae, AmpC-hyperproducing Enterobacteriaceae, Pseudomonas aeruginosa, Stenotrophomonas maltophilia and CFR Acinetobacter baumannii) was routinely screened for at admission then weekly. The impact of anti-anaerobe antibiotics was investigated in propensity score (PS)-matched cohorts of patients exposed and not exposed to these drugs and through PS-based inverse probability of treatment weighting on the whole study cohort, treating in-ICU death or discharge as competing risks for CFR-GNB acquisition.
Results
Among the 352 included patients [median ICU stay 16 (9–30) days, in-ICU mortality 12.2%], 120 (34.1%) acquired one or more CFR-GNB, mostly AmpC-hyperproducing Enterobacteriaceae (17.6%) and P. aeruginosa (14.8%). Exposure to anti-anaerobe antibiotics was the main predictor of CFR-GNB acquisition in both the PS-matched cohorts [adjusted HR (aHR) 3.92, 95% CI 1.12–13.7, P = 0.03] and the whole study cohort (aHR 4.30, 95% CI 1.46–12.63, P = 0.01). Exposure to other antimicrobials—especially ceftriaxone and imipenem/meropenem—exerted no independent impact on the likelihood of CFR-GNB acquisition.
Conclusions
Exposure to non-carbapenem antibiotics with activity against intestinal anaerobes may predispose to CFR-GNB acquisition in ICU patients. Restricting the use of these drugs appears to be an antibiotic stewardship opportunity.
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Affiliation(s)
- Maxime Boutrot
- Surgical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Khalid Azougagh
- Surgical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Jérôme Guinard
- Department of Microbiology, La Source Hospital, CHR Orléans, Orléans, France
| | - Thierry Boulain
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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20
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Poultry as a vector for emerging multidrug resistant Enterococcus spp.: First report of vancomycin (van) and the chloramphenicol–florfenicol (cat-fex-cfr) resistance genes from pigeon and duck faeces. Microb Pathog 2019; 128:195-205. [DOI: 10.1016/j.micpath.2019.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 12/20/2022]
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21
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Garnier M, Gallah S, Vimont S, Benzerara Y, Labbe V, Constant AL, Siami S, Guerot E, Compain F, Mainardi JL, Montil M, Quesnel C. Multicentre randomised controlled trial to investigate usefulness of the rapid diagnostic βLACTA test performed directly on bacterial cell pellets from respiratory, urinary or blood samples for the early de-escalation of carbapenems in septic intensive care unit patients: the BLUE-CarbA protocol. BMJ Open 2019; 9:e024561. [PMID: 30782909 PMCID: PMC6367973 DOI: 10.1136/bmjopen-2018-024561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/23/2018] [Accepted: 11/29/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The dramatic increase of the incidence of infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has led to an increase of 50% of carbapenem consumption all around Europe in only 5 years. This favours the spread of carbapenem-resistant Gram-negative bacilli (GNB), causing life-threatening infections. In order to limit use of carbapenems for infections actually due to ESBL-PE, health authorities promote the use of rapid diagnostic tests of bacterial resistance. The objective of this work conducted in the intensive care unit (ICU) is to determine whether an early de-escalation of empirical carbapenems guided by the result of the βLACTA test is not inferior to the reference strategy of de-escalating carbapenems after the antibiogram result has been rendered. METHODS AND ANALYSIS This multicentre randomised controlled open-label non-inferiority clinical trial will include patients suffering from respiratory and/or urinary and/or bloodstream infections documented with GNB on direct examination and empirically treated with carbapenems. Empirical carbapenems will be adapted before the second dose depending on the results of the βLACTA test performed directly on the microbiological sample (intervention group) or after 48-72 hours depending on the definite antibiogram (control group). The primary outcome will combine 90-day mortality and percentage of infection recurrence during the ICU stay. The secondary outcomes will include the number of carbapenems defined daily doses and carbapenem-free days after inclusion, the proportion of new infections during ICU stay, new colonisation of patients' digestive tractus with multidrug-resistant GNB, ICU and hospital length of stay and cost-effectiveness ratio. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committee of Paris-Ile-de-France IV, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03147807.
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Affiliation(s)
- Marc Garnier
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
| | - Salah Gallah
- APHP—GHUEP—Microbiology Department, Paris, France
| | - Sophie Vimont
- Paris 6 School of Medicine, Sorbonne University, Paris, France
- APHP—GHUEP—Microbiology Department, Paris, France
| | | | - Vincent Labbe
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
| | - Anne-Laure Constant
- Cardio-thoracic Surgical Intensive Care Unit, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Shidasp Siami
- Polyvalent Intensive Care Unit, Sud Essonne Hospital, Etampes, France
| | - Emmanuel Guerot
- APHP—European Georges Pompidou University Hospital, Medical Intensive Care Unit, Paris, France
| | - Fabrice Compain
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Jean-Luc Mainardi
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Mélissa Montil
- APHP—Clinical Research Platform (URCEst-CRCEst-CRB), St Antoine Hospital, Paris, France
| | - Christophe Quesnel
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
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Ruiz J, Gordon M, Villarreal E, Frasquet J, Sánchez MÁ, Martín M, Castellanos Á, Ramirez P. Influence of antibiotic pressure on multi-drug resistant Klebsiella pneumoniae colonisation in critically ill patients. Antimicrob Resist Infect Control 2019; 8:38. [PMID: 30809381 PMCID: PMC6375121 DOI: 10.1186/s13756-019-0484-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/31/2019] [Indexed: 12/23/2022] Open
Abstract
Background The aim of this study is to evaluate the risk factors for colonisation by multidrug resistant (MDR) K. pneumoniae in a critical care unit and the relationship between colonisation and the antibiotic pressure exerted by the antimicrobial treatments received by patients. Methods A prospective observational was designed. Patients admitted for more than 48 h to an intensive care unit were included. Samples for surveillance cultures were obtained from all the patients upon admission and once a week. The association between risk factors and colonisation by MDR K. pneumoniae was determined by logistic regression. A Cox regression model was used to evaluate the effect of the use of antimicrobials on the colonisation rate. An ARMIA model was used to investigate the association between the incidence of colonisation by MDR strains and the global consumption of antimicrobials in the unit. Results One thousand seven hundred twenty-five patients were included, from which 308 (17.9%) were positive for MDR K. pneumoniae. In the multivariate analysis, hospitalisation for longer than 7 days together with respiratory infection and administration of any antibiotic was associated with increased MR K. pneumoniae colonisation. Patients who received antibiotics for more than 48 h were colonised earlier than patients who did not receive antibiotic treatment [HR: 2.16 (95%CI:1.55–3.03)]. The ARIMA model found a significant association between the monthly colonisation rate for MR K. pneumoniae and the consumption of cephalosporins and carbapenems in the previous month. Conclusion Individual antibiotic administration and the global antibiotic pressure of cephalosporins and carbapenems are associated to an increased colonisation by MDR K. pneumoniae strains.
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Affiliation(s)
- Jesus Ruiz
- 1Intensive Care Unit, IIS La FE, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Monica Gordon
- 1Intensive Care Unit, IIS La FE, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Esther Villarreal
- 1Intensive Care Unit, IIS La FE, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan Frasquet
- 2Microbiology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - María Martín
- 1Intensive Care Unit, IIS La FE, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Álvaro Castellanos
- 3Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Paula Ramirez
- 3Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Smoke SM, Abdul W, Grigoriu A, Vasant D. Effect of Carbapenem Selection on Drug Acquisition Costs and Carbapenem Resistance. J Pharm Pract 2019; 32:7-8. [DOI: 10.1177/0897190018766155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Steven M. Smoke
- Department of Pharmacy, Jersey City Medical Center, Jersey City, NJ, USA
| | - Waheed Abdul
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Adriana Grigoriu
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Dhruv Vasant
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
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Telling K, Laht M, Brauer A, Remm M, Kisand V, Maimets M, Tenson T, Lutsar I. Multidrug resistant Pseudomonas aeruginosa in Estonian hospitals. BMC Infect Dis 2018; 18:513. [PMID: 30309321 PMCID: PMC6182868 DOI: 10.1186/s12879-018-3421-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 09/27/2018] [Indexed: 12/23/2022] Open
Abstract
Background We aimed to identify the main spreading clones, describe the resistance mechanisms associated with carbapenem- and/or multidrug-resistant P. aeruginosa and characterize patients at risk of acquiring these strains in Estonian hospitals. Methods Ninety-two non-duplicated carbapenem- and/or multidrug-resistant P. aeruginosa strains were collected between 27th March 2012 and 30th April 2013. Clinical data of the patients was obtained retrospectively from the medical charts. Clonal relationships of the strains were determined by whole genome sequencing and analyzed by multi-locus sequence typing. The presence of resistance genes and beta-lactamases and their origin was determined. Combined-disk method and PCR was used to evaluate carbapenemase and metallo-beta-lactamase production. Results Forty-three strains were carbapenem-resistant, 11 were multidrug-resistant and 38 were both carbapenem- and multidrug-resistant. Most strains (54%) were isolated from respiratory secretions and caused an infection (74%). Over half of the patients (57%) were ≥ 65 years old and 85% had ≥1 co-morbidity; 96% had contacts with healthcare and/or had received antimicrobial treatment in the previous 90 days. Clinically relevant beta-lactamases (OXA-101, OXA-2 and GES-5) were found in 12% of strains, 27% of which were located in plasmids. No Ambler class B beta-lactamases were detected. Aminoglycoside modifying enzymes were found in 15% of the strains. OprD was defective in 13% of the strains (all with CR phenotype); carbapenem resistance triggering mutations (F170 L, W277X, S403P) were present in 29% of the strains. Ciprofloxacin resistance correlated well with mutations in topoisomerase genes gyrA (T83I, D87N) and parC (S87 L). Almost all strains (97%) with these mutations showed ciprofloxacin-resistant phenotype. Multi-locus sequence type analysis indicated high diversity at the strain level – 36 different sequence types being detected. Two sequence types (ST108 (n = 23) and ST260 (n = 18)) predominated. Whereas ST108 was associated with localized spread in one hospital and mostly carbapenem-resistant phenotype, ST260 strains occurred in all hospitals, mostly with multi-resistant phenotype and carried different resistance genotype/machinery. Conclusions Diverse spread of local rather than international P. aeruginosa strains harboring multiple chromosomal mutations, but not plasmid-mediated Ambler class B beta-lactamases, were found in Estonian hospitals. Trial registration This trial was registered retrospectively in ClinicalTrials.gov (NCT03343119). Electronic supplementary material The online version of this article (10.1186/s12879-018-3421-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kaidi Telling
- Department of Microbiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Ravila 19, 50411, Tartu, Estonia.
| | - Mailis Laht
- Institute of Technology, University of Tartu, Tartu, Estonia
| | - Age Brauer
- Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
| | - Maido Remm
- Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
| | - Veljo Kisand
- Institute of Technology, University of Tartu, Tartu, Estonia
| | - Matti Maimets
- Department of Infection Control, Tartu University Hospital, Tartu, Estonia
| | - Tanel Tenson
- Institute of Technology, University of Tartu, Tartu, Estonia
| | - Irja Lutsar
- Department of Microbiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Ravila 19, 50411, Tartu, Estonia
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Woerther PL, Lepeule R, Burdet C, Decousser JW, Ruppé É, Barbier F. Carbapenems and alternative β-lactams for the treatment of infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae: What impact on intestinal colonisation resistance? Int J Antimicrob Agents 2018; 52:762-770. [PMID: 30176355 DOI: 10.1016/j.ijantimicag.2018.08.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/14/2018] [Accepted: 08/25/2018] [Indexed: 12/31/2022]
Abstract
The ongoing pandemic of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) is responsible for a global rise in carbapenem consumption that may hasten the dissemination of carbapenemase-producing Enterobacteriaceae (CPE). Hence, carbapenem sparing through the use of alternative β-lactams is increasingly considered as a potential option in patients with ESBL-E infections. However, at the individual level, this strategy implies an in-depth understanding of how carbapenems and their alternatives impair the gut microbiota, especially the anaerobic bacteria and the colonisation resistance (CR) that it confers. In this review, we sought to appraise the impact of carbapenems and their main alternatives for ESBL-E infections (namely β-lactam/β-lactamase inhibitor combinations, cephamycins and temocillin) on the gut ecosystem and the resulting hazard for acquisition of CPE. Although limited, the available evidence challenges our perception of the ecological side effects of these antimicrobials and highlights knowledge gaps regarding antibiotic-induced alterations in intestinal CR. These alterations may depend not only on anti-anaerobic properties but also on a panel of parameters with marked interindividual variability, such as baseline characteristics of the gut microbiota or the degree of biliary excretion for the considered drug. In the current context of ESBL-E dissemination and increasing opportunities for carbapenem-sparing initiatives, large, comparative, high-quality studies based on new-generation sequencing tools are more than ever warranted to better define the positioning of alternative β-lactams in antimicrobial stewardship programmes.
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Affiliation(s)
- Paul-Louis Woerther
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, APHP, Créteil, France; EA 7380 Dynamyc, EnvA, UPEC, Paris-Est University, Créteil, France.
| | - Raphaël Lepeule
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, APHP, Créteil, France
| | - Charles Burdet
- Diderot-Paris 7 University, Paris, France; INSERM, IAME, UMR 1137, Sorbonne-Paris Cité University, Paris, France; Department of Biostatistics, Epidemiology and Clinical Research, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jean-Winoc Decousser
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, APHP, Créteil, France; EA 7380 Dynamyc, EnvA, UPEC, Paris-Est University, Créteil, France
| | - Étienne Ruppé
- Diderot-Paris 7 University, Paris, France; INSERM, IAME, UMR 1137, Sorbonne-Paris Cité University, Paris, France; Department of Bacteriology, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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A prospective surveillance study for multidrug-resistant bacteria colonization in hospitalized patients at a Thai University Hospital. Antimicrob Resist Infect Control 2018; 7:102. [PMID: 30167108 PMCID: PMC6102905 DOI: 10.1186/s13756-018-0393-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 08/07/2018] [Indexed: 11/10/2022] Open
Abstract
Background Colonization with multidrug-resistant (MDR) bacteria is a major risk factor for developing subsequent MDR infections. Methods We performed a prospective surveillance study in hospitalized patients at Siriraj Hospital. Nasal cavity, throat, inguinal area and rectal swabs were obtained within the first 48-h after admission, on day-5 after hospitalization and then every 7 days until discharge. Target bacteria included extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL), carbapenem-resistant-P.aeruginosa (CR-PA), carbapenem-resistant-A.baumannii (CR-AB) and methicillin-resistant S.aureus (MRSA). Results From January 2013–December 2014, 487 patients were enrolled. The baseline prevalence of colonization by ESBL, CR-PA, CR-AB and MRSA at any site was 52.2%, 6.8%, 4.7% and 7.2%, respectively. After 3-week of hospitalization, the prevalence of colonization by ESBL, CR-PA, CR-AB and MRSA increased to 71.7%, 47.2%, 18.9% and 18.9%, respectively. Multivariable analysis revealed that diabetes mellitus and recent cephalosporin exposure were the independent risk factors for baseline colonization by ESBL. The independent risk factors for CR-AB and/or CR-PA colonization were cerebrovascular diseases, previous hospitalization, transfer from another hospital/a LTCF and previous nasogastric tube use, whereas those for MRSA colonization were previous fluoroquinolone exposure and previous nasogastric tube use. Conclusions The baseline prevalence of colonization by ESBL was relatively high, whereas the baseline prevalence of colonization by CR-PA, CR-AB and MRSA was comparable to previous studies. There was an increasing trend in MDR bacteria colonization after hospitalization.
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Osman KM, Kappell AD, Orabi A, Al-Maary KS, Mubarak AS, Dawoud TM, Hemeg HA, Moussa IMI, Hessain AM, Yousef HMY, Hristova KR. Poultry and beef meat as potential seedbeds for antimicrobial resistant enterotoxigenic Bacillus species: a materializing epidemiological and potential severe health hazard. Sci Rep 2018; 8:11600. [PMID: 30072706 PMCID: PMC6072766 DOI: 10.1038/s41598-018-29932-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 07/18/2018] [Indexed: 12/17/2022] Open
Abstract
Although Bacillus cereus is of particular concern in food safety and public health, the role of other Bacillus species was overlooked. Therefore, we investigated the presence of eight enterotoxigenic genes, a hemolytic gene and phenotypic antibiotic resistance profiles of Bacillus species in retail meat samples. From 255 samples, 124 Bacillus isolates were recovered, 27 belonged to B. cereus and 97 were non-B. cereus species. Interestingly, the non-B. cereus isolates carried the virulence genes and exhibited phenotypic virulence characteristics as the B. cereus. However, correlation matrix analysis revealed the B. cereus group positively correlates with the presence of the genes hblA, hblC, and plc, and the detection of hemolysis (p < 0.05), while the other Bacillus sp. groups are negatively correlated. Tests for antimicrobial resistance against ten antibiotics revealed extensive drug and multi-drug resistant isolates. Statistical analyses didn't support a correlation of antibiotic resistance to tested virulence factors suggesting independence of these phenotypic markers and virulence genes. Of special interest was the isolation of Paenibacillus alvei and Geobacillus stearothermophilus from the imported meat samples being the first recorded. The isolation of non-B. cereus species carrying enterotoxigenic genes in meat within Egypt, suggests their impact on food safety and public health and should therefore not be minimised, posing an area that requires further research.
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Affiliation(s)
- Kamelia M Osman
- Department of Microbiology, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt
| | - Anthony D Kappell
- Department of Civil, Construction, and Environmental Engineering, Marquette University, Milwaukee, WI, USA
| | - Ahmed Orabi
- Department of Microbiology, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt
| | - Khalid S Al-Maary
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Ayman S Mubarak
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Turki M Dawoud
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Hassan A Hemeg
- Department of Clinical Laboratory sciences, college of Applied Medical sciences, Taibah University, Taibah, Saudi Arabia
| | - Ihab M I Moussa
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Ashgan M Hessain
- Department of Health Science, College of Applied Studies and Community Service, King Saud University, Riyadh, Saudi Arabia
| | - Hend M Y Yousef
- Central Administration of Preventive Medicine, General Organization for Veterinary Service, Giza, Egypt.
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Raman G, Avendano EE, Chan J, Merchant S, Puzniak L. Risk factors for hospitalized patients with resistant or multidrug-resistant Pseudomonas aeruginosa infections: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2018; 7:79. [PMID: 29997889 PMCID: PMC6032536 DOI: 10.1186/s13756-018-0370-9] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/14/2018] [Indexed: 12/16/2022] Open
Abstract
Background Identifying risk factors predicting acquisition of resistant Pseudomonas aeruginosa will aid surveillance and diagnostic initiatives and can be crucial in early and appropriate antibiotic therapy. We conducted a systematic review examining risk factors of acquisition of resistant P. aeruginosa among hospitalized patients. Methods MEDLINE®, EMBASE®, and Cochrane Central were searched between 2000 and 2016 for studies examining independent risk factors associated with acquisition of resistant P. aeruginosa, among hospitalized patients. Random effects model meta-analysis was conducted when at least three or more studies were sufficiently similar. Results Of the 54 eligible articles, 28 publications (31studies) examined multi-drug resistant (MDR) or extensively drug resistant (XDR) P. aeruginosa and 26 publications (29 studies) examined resistant P. aeruginosa. The acquisition of MDR P. aeruginosa, as compared with non-MDR P. aeruginosa, was significantly associated with intensive care unit (ICU) admission (3 studies: summary adjusted odds ratio [OR] 2.2) or use of quinolones (4 studies: summary adjusted OR 3.59). Acquisition of MDR or XDR compared with susceptible P. aeruginosa was significantly associated with prior hospital stay (4 studies: summary adjusted OR 1.90), use of quinolones (3 studies: summary adjusted OR 4.34), or use of carbapenems (3 studies: summary adjusted OR 13.68). The acquisition of MDR P. aeruginosa compared with non-P. aeruginosa was significantly associated with prior use of cephalosporins (3 studies: summary adjusted OR 3.96), quinolones (4 studies: summary adjusted OR 2.96), carbapenems (6 studies: summary adjusted OR 2.61), and prior hospital stay (4 studies: summary adjusted OR 1.74). The acquisition of carbapenem-resistant P. aeruginosa compared with susceptible P. aeruginosa, was statistically significantly associated with prior use of piperacillin-tazobactam (3 studies: summary adjusted OR 2.64), vancomycin (3 studies: summary adjusted OR 1.76), and carbapenems (7 studies: summary adjusted OR 4.36). Conclusions Prior use of antibiotics and prior hospital or ICU stay was the most significant risk factors for acquisition of resistant P. aeruginosa. These findings provide guidance in identifying patients that may be at an elevated risk for a resistant infection and emphasize the importance of antimicrobial stewardship and infection control in hospitals.
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Affiliation(s)
- Gowri Raman
- 1Center for Clinical Evidence Synthesis, Tufts Medical Center, 800 Washington Street, Box 63, Boston, MA 02111 USA
| | - Esther E Avendano
- 1Center for Clinical Evidence Synthesis, Tufts Medical Center, 800 Washington Street, Box 63, Boston, MA 02111 USA
| | - Jeffrey Chan
- 1Center for Clinical Evidence Synthesis, Tufts Medical Center, 800 Washington Street, Box 63, Boston, MA 02111 USA
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Guidry CA, Shah PM, Dietch ZC, Elwood NR, Krebs ED, Mehaffey JH, Sawyer RG. Recent Anti-Microbial Exposure Is Associated with More Complications after Elective Surgery. Surg Infect (Larchmt) 2018; 19:473-479. [PMID: 29883278 DOI: 10.1089/sur.2018.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Recent anti-microbial exposure has been associated with poor outcomes after infection in a mixed population. We hypothesized that recent anti-microbial exposure would be associated with poor outcomes of elective surgery. METHODS From August 2015 to August 2016, all elective surgical patients were questioned prospectively about anti-microbial exposure during the prior three months. Multivariable models were used to calculate risk-adjusted odds ratios for anti-microbial exposure controlling for surgeon influence. Primary outcomes were any serious complication, any complication, any infection, and surgical site infection. Secondary outcomes were length of stay, C. difficile infection, and death. A separate analysis of patients excluding those having colorectal surgery who had undergone an oral antibiotic bowel preparation also was performed. RESULTS Ninety-four percent of eligible patients (n = 1,538) answered the exposure question, with a three-month anti-microbial exposure rate of 34.1%. Colorectal surgery patients had the highest exposure rate, whereas hernia patients had the lowest. Exposed patients had higher rates of any complication, any infection, and surgical site infection, as well as a median two-day longer hospital stay. There were no differences in C. difficile infection or death between the groups. After risk adjustment, anti-microbial exposure was independently associated with any serious complication for all patients as well as with complications and infection in patients having an operation other than colorectal surgery. CONCLUSION Recent anti-microbial exposure is associated with more complications of elective surgery. Anti-microbial drug-induced alterations in microbiome-related inflammatory responses may play a role, highlighting an opportunity for pre-surgical intervention in this at-risk population.
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Affiliation(s)
- Christopher A Guidry
- 1 Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Puja M Shah
- 2 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Zachary C Dietch
- 2 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Nathan R Elwood
- 2 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Elizabeth D Krebs
- 2 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - J Hunter Mehaffey
- 2 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Robert G Sawyer
- 3 Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine , Kalamazoo, Michigan
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30
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Teerawattanapong N, Kengkla K, Dilokthornsakul P, Saokaew S, Apisarnthanarak A, Chaiyakunapruk N. Prevention and Control of Multidrug-Resistant Gram-Negative Bacteria in Adult Intensive Care Units: A Systematic Review and Network Meta-analysis. Clin Infect Dis 2018; 64:S51-S60. [PMID: 28475791 DOI: 10.1093/cid/cix112] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background This study evaluated the relative efficacy of strategies for the prevention of multidrug-resistant gram-negative bacteria (MDR-GNB) in adult intensive care units (ICUs). Methods A systematic review and network meta-analysis was performed; searches of the Cochrane Library, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) included all randomized controlled trials and observational studies conducted in adult patients hospitalized in ICUs and evaluating standard care (STD), antimicrobial stewardship program (ASP), environmental cleaning (ENV), decolonization methods (DCL), or source control (SCT), simultaneously. The primary outcomes were MDR-GNB acquisition, colonization, and infection; secondary outcome was ICU mortality. Results Of 3805 publications retrieved, 42 met inclusion criteria (5 randomized controlled trials and 37 observational studies), involving 62068 patients (median age, 58.8 years; median APACHE [Acute Physiology and Chronic Health Evaluation] II score, 18.9). The majority of studies reported extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and MDR Acinetobacter baumannii. Compared with STD, a 4-component strategy composed of STD, ASP, ENV, and SCT was the most effective intervention (rate ratio [RR], 0.05 [95% confidence interval {CI}, .01-.38]). When ENV was added to STD+ASP or SCT was added to STD+ENV, there was a significant reduction in the acquisition of MDR A. baumannii (RR, 0.28 [95% CI, .18-.43] and 0.48 [95% CI, .35-.66], respectively). Strategies with ASP as a core component showed a statistically significant reduction the acquisition of ESBL-producing Enterobacteriaceae (RR, 0.28 [95% CI, .11-.69] for STD+ASP+ENV and 0.23 [95% CI, .07-.80] for STD+ASP+DCL). Conclusions A 4-component strategy was the most effective intervention to prevent MDR-GNB acquisition. As some strategies were differential for certain bacteria, our study highlighted the need for further evaluation of the most effective prevention strategies.
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Affiliation(s)
| | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and
| | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and.,Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor.,School of Pharmacy, University of Wisconsin- Madison ; and.,School of Population Health, University of Queensland, Brisbane, Australia
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Guidry CA, Sawyer RG. Prevalence of Recent Antimicrobial Exposure among Elective Surgical Patients. Surg Infect (Larchmt) 2017; 18:799-802. [PMID: 28880724 DOI: 10.1089/sur.2017.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The annual prevalence of antimicrobial exposure is high in the outpatient setting and should be a common exposure for surgical patients. Antimicrobials have negative side effects and may be associated with poor outcomes. Logically, one would expect surgical patients to be particularly susceptible to any negative effects of recent antimicrobial exposure. Despite these observations, however, the prevalence of recent antimicrobial exposure among surgical patients remains undefined. The purpose of this study is to define the prevalence of antimicrobial exposure in patients undergoing elective surgical procedures. METHODS Patients presenting for elective operations between August 4, 2015 and August 3, 2016 at our institution were asked prospectively about any antimicrobial exposure in the previous three months. Answers were recorded as either Yes, No, or Unsure. Patients were grouped according to age, American Society of Anesthesiologists (ASA) score, primary operative service, and post-operative destination. Descriptive statistics were employed using simple percentages and chi-square analysis when appropriate. Cochrane-Armitage test was used to evaluate temporal trends. RESULTS There were 21,473 elective surgical procedures performed during the study period across 13 operative services. Answers were recorded for 91.2% cases. The overall prevalence of exposure during this period was 28.6%. Exposure varied with age, ASA score, and surgical specialty. Vascular and transplant operations had the highest prevalence of exposure while ophthalmology and pediatric orthopedic procedures had the lowest. Patients with recent antimicrobial exposure were less likely to be discharged home on the same day and more likely to be admitted to an intensive care or intermediate care unit than those who denied recent exposure. CONCLUSION In this descriptive analysis, the prevalence of recent antimicrobial exposure is overall approximately 28.6% and is higher than anticipated. Further work is needed to determine to what extent, if any, recent antimicrobial exposure impacts post-operative outcomes.
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Affiliation(s)
- Christopher A Guidry
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Robert G Sawyer
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia.,2 Division of Acute Care and Trauma Surgery, The University of Virginia Health System , Charlottesville, Virginia
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Demiraslan H, Cevahir F, Berk E, Metan G, Cetin M, Alp E. Is surveillance for colonization of carbapenem-resistant gram-negative bacteria important in adult bone marrow transplantation units? Am J Infect Control 2017; 45:735-739. [PMID: 28214159 DOI: 10.1016/j.ajic.2017.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to investigate the rate of carbapenem-resistant gram-negative bacilli (CRGNB) colonization and to analyze the risk factors associated with CRGNB colonization. METHODS This prospective study was conducted in adult patients hospitalized in hematopoietic stem cell transplantation (HSCT) units over a period of 8 months. Rectal swab samples were obtained from each participant every Monday, and patients CRGNB positive on admission were excluded. RESULTS Of 185 participants, the median age was 47 years, and 59.5% were men. CRGNB colonization was detected in 21 (11.4%) patients. The most commonly isolated CRGNB were Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Multivariate analysis revealed that busulfan use (11.9 times), fludarabine use (6.4 times), transfer from another hospital (7.8 times), transfer between units (9.3 times), and central venous catheterization (5.1 times) were risk factors for CRGNB colonization. During the study period, febrile neutropenia (FN) developed in 9 (56.2%) of the 21 colonized patients, and 1 patient died. CONCLUSIONS Screening of patients for CRGNB colonization may have a role in preventing the spread of CRGNB. However, the empirical antimicrobial treatment for FN in patients with CRGNB colonization did not change, and their mortality rates were similar.
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Affiliation(s)
- Hayati Demiraslan
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University, Melikgazi, Kayseri, Turkey.
| | - Fatma Cevahir
- Infection Control Committee, Erciyes University, Kayseri, Turkey
| | - Elife Berk
- Department of Medical Microbiology, Erciyes University, Kayseri, Turkey
| | - Gokhan Metan
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University, Ankara, Turkey
| | - Mustafa Cetin
- Department of Hematology, Erciyes University, Kayseri, Turkey
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University, Melikgazi, Kayseri, Turkey; Infection Control Committee, Erciyes University, Kayseri, Turkey
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Guidry CA, Hranjec T, Shah PM, Dietch ZC, Hassinger TE, Elwood NR, Sawyer RG. Aggressive Antimicrobial Initiation for Suspected Intensive Care Unit-Acquired Infection Is Associated with Decreased Long-Term Survival after Critical Illness. Surg Infect (Larchmt) 2017; 18:664-669. [PMID: 28557559 DOI: 10.1089/sur.2016.269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The long-term significance of early and prolonged antibiotic use in critically ill patients is yet to be described. Several studies suggest that antimicrobial exposure may have as yet unrecognized long-term effects on clinically meaningful outcomes. Our group previously conducted a quasi-experimental, before and after observational cohort study of hemodynamically stable surgical patients suspected of having an intensive care unit-acquired infection. This study demonstrated that aggressive initiation of antimicrobial therapy was associated with increased 30-day deaths. In a follow-up survival analysis, we hypothesized that aggressive antimicrobial treatment would not be a significant predictor of long-term death. METHODS Survival data for the 201 patients included in the initial study were obtained from our clinical data repository. Univariable analysis, Kaplan-Meier, and Cox proportional hazards models were used. Survival was evaluated at one and four years. Age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and co-morbidities were chosen a priori for potential inclusion in the model. Variables that met the model assumptions after testing were included in the final model. RESULTS Follow-up data were available for 190 patients (95 in each group) representing 94.5% of the initial cohort. Twenty-four (25.3%) patients in the aggressive group had initial APACHE II scores of less than 15 compared with 13 (13.7%) patients in the conservative group (p = 0.04). There was a trend toward higher deaths in the aggressive group at four years (41.1% vs. 30.5%; p = 0.13). Kaplan-Meier analysis demonstrated a difference in survival at one year but not at four years. The Cox proportional hazards model showed a higher long-term death for patients in the aggressive antimicrobial group at both one and four years (hazard rate: 2.26 and 1.70, respectively). CONCLUSION Aggressive initiation of antimicrobial therapy is independently associated with decreased long-term survival after critical illness. While further work is needed to confirm these findings, waiting for evidence of infection before initiation of antibiotic agents may be beneficial.
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Affiliation(s)
- Christopher A Guidry
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Tjasa Hranjec
- 2 Department of Surgery, Memorial Healthcare System , Hollywood, Florida
| | - Puja M Shah
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Zachary C Dietch
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Taryn E Hassinger
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Nathan R Elwood
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Robert G Sawyer
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia.,3 Division of Acute Care and Trauma Surgery, The University of Virginia Health System , Charlottesville, Virginia
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Juan C, Peña C, Oliver A. Host and Pathogen Biomarkers for Severe Pseudomonas aeruginosa Infections. J Infect Dis 2017; 215:S44-S51. [PMID: 28375513 DOI: 10.1093/infdis/jiw299] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Pseudomonas aeruginosa is among the leading causes of severe nosocomial infections, particularly affecting critically ill and immunocompromised patients. Here we review the current knowledge on the factors underlying the outcome of P. aeruginosa nosocomial infections, including aspects related to the pathogen, the host, and treatment. Intestinal colonization and previous use of antibiotics are key risk factors for P. aeruginosa infections, whereas underlying disease, source of infection, and severity of acute presentation are key host factors modulating outcome; delayed adequate antimicrobial therapy is also independently associated with increased mortality. Among pathogen-related factors influencing the outcome of P. aeruginosa infections, antibiotic resistance, and particularly multidrug-resistant profiles, is certainly of paramount relevance, given its obvious effect on the chances of appropriate empirical therapy. However, the direct impact of antibiotic resistance in the severity and outcomes of P. aeruginosa infections is not yet well established. The interplay between antibiotic resistance, virulence, and the concerning international high-risk clones (such as ST111, ST175, and ST235) still needs to be further analyzed. On the other hand, differential presence or expression of virulence factors has been shown to significantly impact disease severity and mortality. The likely more deeply studied P. aeruginosa virulence determinant is the type III secretion system (T3SS); the production of T3SS cytotoxins, and particularly ExoU, has been well established to determine a worse outcome both in respiratory and bloodstream infections. Other relevant pathogen-related biomarkers of severe infections include the involvement of specific clones or O-antigen serotypes, the presence of certain horizontally acquired genomic islands, or the expression of other virulence traits, such as the elastase. Finally, recent data suggest that host genetic factors may also modulate the severity of P. aeruginosa infections.
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Affiliation(s)
- Carlos Juan
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca, and
| | - Carmen Peña
- Servicio de Medicina Interna, Hospital Virgen de los Lirios, Alcoy, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca, and
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Cohen R, Babushkin F, Cohen S, Afraimov M, Shapiro M, Uda M, Khabra E, Adler A, Ben Ami R, Paikin S. A prospective survey of Pseudomonas aeruginosa colonization and infection in the intensive care unit. Antimicrob Resist Infect Control 2017; 6:7. [PMID: 28096975 PMCID: PMC5225573 DOI: 10.1186/s13756-016-0167-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 12/29/2016] [Indexed: 11/18/2022] Open
Abstract
Background Pseudomonas aeruginosa (PA) surveillance may improve empiric antimicrobial therapy, since colonizing strains frequently cause infections. This colonization may be ‘endogenous’ or ‘exogenous’, and the source determines infection control measures. We prospectively investigated the sources of PA, the clinical impact of PA colonization upon admission and the dynamics of colonization at different body sites throughout the intensive care unit stay. Methods Intensive care patients were screened on admission and weekly from the pharynx, endotracheal aspirate, rectum and urine. Molecular typing was performed using Enterobacterial Repetitive Intergenic Consensus Polymerase Chain reaction (ERIC-PCR). Results Between November 2014 and January 2015, 34 patients were included. Thirteen (38%) were colonized on admission, and were at a higher risk for PA-related clinical infection (Hazard Ratio = 14.6, p = 0.0002). Strains were often patient-specific, site-specific and site-persistent. Sixteen out of 17 (94%) clinical isolates were identical to strains found concurrently or previously on screening cultures from the same patient, and none were unique. Ventilator associated pneumonia-related strains were identical to endotracheal aspirates and pharynx screening (87–75% of cases). No clinical case was found among patients with repeated negative screening. Conclusion PA origin in this non-outbreak setting was mainly ‘endogenous’ and PA-strains were generally patient- and site-specific, especially in the gastrointestinal tract. While prediction of ventilator associated pneumonia-related PA-strain by screening was fair, the negative predictive value of screening was very high.
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Affiliation(s)
- Regev Cohen
- Head of Infectious diseases unit, Sanz Medical Center, Laniado hospital, Neytanya, Israel ; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Frida Babushkin
- Infectious diseases unit, Sanz Medical Center, Laniado hospital, Netanya, Israel
| | - Shoshana Cohen
- Infectious diseases unit, Sanz Medical Center, Laniado hospital, Netanya, Israel
| | - Marina Afraimov
- Infectious diseases unit, Sanz Medical Center, Laniado hospital, Netanya, Israel
| | - Maurice Shapiro
- Medical and Surgical intensive care unit, Sanz Medical Center, Laniado hospital, Netanya, Israel
| | - Martina Uda
- Medical and Surgical intensive care unit, Sanz Medical Center, Laniado hospital, Netanya, Israel
| | - Efrat Khabra
- National Center of Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Amos Adler
- National Center of Infection Control, Ministry of Health, Tel Aviv, Israel ; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel ; Infectious diseases unit Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Svetlana Paikin
- Microbiology Laboratory, Sanz Medical Center, Laniado hospital, Netanya, Israel
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Salm F, Deja M, Gastmeier P, Kola A, Hansen S, Behnke M, Gruhl D, Leistner R. Prolonged outbreak of clonal MDR Pseudomonas aeruginosa on an intensive care unit: contaminated sinks and contamination of ultra-filtrate bags as possible route of transmission? Antimicrob Resist Infect Control 2016; 5:53. [PMID: 27980730 PMCID: PMC5139016 DOI: 10.1186/s13756-016-0157-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 11/29/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND We report on an outbreak in a surgical, interdisciplinary intensive care unit (ICU) of a tertiary care hospital. We detected a cluster of ICU patients colonized or infected with multidrug-resistant Pseudomonas aeruginosa. We established an outbreak investigation team, performed an exploratory epidemiological analysis and initiated an epidemiology-based intervention. METHODS As part of the outbreak investigation, we performed microbiological examinations of the sinks in the patient rooms and a retrospective case-control study. All patients admitted to the outbreak ICU between January 2012 and February 2014 were included. Cases were patients colonized with the outbreak strain. Controls were patients with a different Pseudomonas aeruginosa strain. Risk factors were evaluated using multivariable conditional logistic regression analysis. Strain typing was performed using the repetitive element-based polymerase chain reaction (rep-PCR) DiversiLab system. RESULTS The outbreak strain was found in the sinks of five (of 16) patient rooms. Altogether 21 cases and 21 (randomly selected) controls were included. In the univariate analysis, there was no significant difference in baseline data of the patients. In the multivariate analysis, stay in a room with a colonized sink (Odds Ratio[OR] 11.2, p = 0.007) and hemofiltration (OR 21.9, p = 0.020) were independently associated with an elevated risk for colonization or infection by the outbreak strain. In a subsequent evaluation of the work procedures associated with hemofiltration, we found that the ultra-filtrate bags had been on average five times per day emptied in the sinks of the patient rooms and were used multiple for the same patient. We exchanged the traps of the contaminated sinks and eliminated work procedures involving sinks in patient rooms by implementation of single use bags, which are emptied outside patient rooms to reduce splash water at the sinks. In the 20 month follow-up period, the outbreak strain was detected only once, which indicated that the outbreak had been ceased (incidence 0.75% vs. 0.04%, p < 0.001) Furthermore, the incidence of Pseudonomas aeruginosa overall was significantly decreased (2.5% vs. 1.5%, p < 0.001). CONCLUSION In ICUs, limiting work processes involving sinks results in reduced multidrug-resistant Pseudomonas aeruginosa rates. ICUs with high rates of Pseudomonas aeruginosa should consider eliminating work processes that involve sinks and potentially splash water in close proximity to patients. TRIAL REGISTRATION All data were surveillance based data which were obtained within the German Law on Protection against Infection ("Infektionsschutzgesetz"). Therefore a trial registration was not required.
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Affiliation(s)
- Florian Salm
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Maria Deja
- Department of Anesthesiology and Intensive Care, Charité Universitaetsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Axel Kola
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Sonja Hansen
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Michael Behnke
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Désirée Gruhl
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Rasmus Leistner
- Institute of Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of nosocomial Infections, Charité Universitaetsmedizin Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
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Bassetti M, Carnelutti A, Peghin M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther 2016; 15:55-65. [PMID: 27766913 DOI: 10.1080/14787210.2017.1251840] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The isolation of multi-drug-resistant gram-negative (MDRGN) pathogens has progressively increased worldwide and has been associated with important delays in the prescription of an adequate antibiotic treatment, resulting in increased mortality rates. Patient's stratification for MDRGN infections to optimize the prescription of an adequate empiric antimicrobial regimen is crucial. Areas covered: This article covers MDRGN epidemiology, with a specific focus on risk factors for harbouring infections sustained by extended-spectrum-Beta-lactamase (ESBL), carbapenem resistant Enterobacteriacae (CRE), MDR Pseudomonas aeruginosa and MDR Acinetobacter baumanii. Moreover, we will propose an algorithm for the choice of empiric treatment when a MDRGN infection is suspected. Expert commentary: Although in clinical practice, a patient's stratification represents a challenge, whenever a MDRGN pathogen is suspected broad-spectrum, combination empiric treatment should be promptly started, looking for a balance between the prescription of an adequate empiric treatment and the risk of resistance selection.
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Affiliation(s)
- Matteo Bassetti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Alessia Carnelutti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Maddalena Peghin
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
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Gómez-Zorrilla S, Morandeira F, Castro MJ, Tubau F, Periche E, Cañizares R, Dominguez MA, Ariza J, Peña C. Acute Inflammatory Response of Patients with Pseudomonas aeruginosa Infections: A Prospective Study. Microb Drug Resist 2016; 23:523-530. [PMID: 27754817 DOI: 10.1089/mdr.2016.0144] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The severity of Pseudomonas aeruginosa (PA) infection may be determined by the interaction with the host immune system. We designed a prospective study to assess the relationship between the inflammatory response and the clinical presentation and outcome of PA infection. We also investigated whether there are differences in the inflammatory response depending on the resistance profile of PA. Interleukin-6 (IL-6), IL-10, procalcitonin (PCT), and C-reactive protein (CRP) were measured. Sixty-nine infection episodes were recorded; 40 caused by non-multidrug-resistant (non-MDR) strains [29 (73%) respiratory; 8 (20%) bacteremia], 12 by MDR non-extensively drug-resistant (MDR-non-XDR) [9 (75%) respiratory; 3 (25%) bacteremia], and 17 by XDR strains [9 (53%) respiratory; 7 (41%) bacteremia]. All inflammatory parameters were significantly higher in patients who developed acute organ dysfunction and bacteremia. PCT levels were higher in patients with early mortality [p = 0.050]. Inflammatory biomarkers were higher in patients with XDR than in those with non-MDR PA [IL-6 430 (67-951) vs. 77 (34-216), p = 0.02; IL-10 3.3 (1.5-16.3) vs. 1.3 (0-3.9), p = 0.02; and PCT 1.1 (0.6-5.2) vs. 0.3 (0.1-1.0), p = 0.008]. The intensity of inflammatory response was associated with the severity of PA infection, particularly if bacteremia occurred. Only PCT was documented useful to predict the outcome. XDR infections presented a higher inflammatory response; related in part to the larger number of bloodstream infections in this group.
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Affiliation(s)
- Silvia Gómez-Zorrilla
- 1 Infectious Diseases Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Francisco Morandeira
- 2 Immunology Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - María José Castro
- 3 Clinical Biochemistry Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Fe Tubau
- 4 Microbiology Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Elisabet Periche
- 5 Intensive Care Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Rosario Cañizares
- 5 Intensive Care Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - María Angeles Dominguez
- 4 Microbiology Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Javier Ariza
- 1 Infectious Diseases Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
| | - Carmen Peña
- 1 Infectious Diseases Service, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona , Barcelona, Spain
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IV Immunoglobulin for Acute Lung Injury and Bacteremia in Pseudomonas aeruginosa Pneumonia. Crit Care Med 2016; 44:e12-24. [PMID: 26317571 DOI: 10.1097/ccm.0000000000001271] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Virulent and multidrug-resistant Pseudomonas aeruginosa causes a lethal pneumonia, especially in patients who are artificially ventilated. It has been reported that the virulence mechanism used by P. aeruginosa, which is linked to acute lung injury, is strongly associated with the type III secretion system, and specific antibodies targeting this system have shown a protective effect in both experimental and clinical settings. We investigated the effect of administering IV immunoglobulins on P. aeruginosa pneumonia, including its associated bacteremia and mortality, although focusing especially on type III secretion system-associated P. aeruginosa virulence. DESIGN Prospective randomized and controlled animal study. SETTING University laboratory. SUBJECTS Male ICR mice. INTERVENTIONS Mice were infected intratracheally with a lethal dose of the virulent P. aeruginosa PA103 strain. IV immunoglobulin administration was examined in three different settings: 1) premixed; 2) pre-IV, prophylactic administration before bacterial infection; and 3) post-IV, therapeutic administration after bacterial infection. The effect of specific antigen titer depletion of IV immunoglobulins was also examined. MEASUREMENTS AND MAIN RESULTS Survival and body temperature were monitored for 24 hours. Bacteremia, cytokine concentration, myeloperoxidase activity, WBC counts in the blood, and lung bacterial load were evaluated. Survival improved significantly in mice that received IV immunoglobulins (p < 0.05). Lung edema, lung bacteriologic load, and bacteremia decreased significantly in the IV immunoglobulin-treated mice (p < 0.05). The mechanism of protection was associated with the presence of antibodies against both PcrV and some bacterial surface antigens in the IV immunoglobulins. CONCLUSIONS IV immunoglobulin administration had a significantly protective effect against lethal infection from virulent P. aeruginosa. Prophylactic IV immunoglobulin administration at the highest dose was comparable with that achieved by administrating a specific anti-PcrV polyclonal IgG into the mice. The mechanism of protection is likely to involve the synergic action of anti-PcrV titers and antibodies against some surface antigen(s) that block the type III secretion system-associated virulence of P. aeruginosa.
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Abdalhamid B, Elhadi N, Alabdulqader N, Alsamman K, Aljindan R. Rates of gastrointestinal tract colonization of carbapenem-resistant Enterobacteriaceae and Pseudomonas aeruginosa in hospitals in Saudi Arabia. New Microbes New Infect 2016; 10:77-83. [PMID: 26933499 PMCID: PMC4765740 DOI: 10.1016/j.nmni.2016.01.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 11/26/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-resistant Pseudomonas aeruginosa (CRPAE) are globally a major medical issue, especially in intensive care units. The digestive tract is the main reservoir for these isolates; therefore, rectal swab surveillance is highly recommended. The purpose of this study was to detect the prevalence of gastrointestinal tract colonization of CRE and CRPAE in patients admitted to intensive care units in Saudi Arabia. This project also aimed to characterize carbapenem-hydrolyzing enzyme production in these isolates. From February to May 2015, 200 rectal swab specimens were screened by CHROMagar KPC. Organism identification and susceptibility testing were performed using the Vitek 2 system. One CRE and 13 CRPAE strains were identified, for a prevalence of 0.5% (1/200) and 6.5% (13/200) respectively. Strains showed high genetic diversity using enterobacterial repetitive intergenic consensus sequence-based PCR. NDM type and VIM type were detected by PCR in four and one CRPAE isolates respectively. ampC overexpression was detected in eight CRPAE isolates using Mueller-Hinton agar containing 1000 μg/mL cloxacillin. CTX-M-15 type was detected in 1 CRE by PCR. The prevalence of CRE strain colonization was lower than that of CRPAE isolates. The detection of NDM and VIM in the colonizing CRPAE strains is a major infection control concern. To our knowledge, this is the first study in Saudi Arabia and the gulf region focusing on digestive tract colonization of CRE and CRPAE organisms and characterizing the mechanisms of carbapenem resistance.
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Affiliation(s)
- B Abdalhamid
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - N Elhadi
- Department of Clinical Laboratory Science, College of Applied Medical Science, Saudi Arabia
| | - N Alabdulqader
- Department of Pathology and Laboratory Medicine, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - K Alsamman
- Department of Clinical Laboratory Science, College of Applied Medical Science, Saudi Arabia
| | - R Aljindan
- Department of Microbiology, College of Medicine, University of Dammam, AlKhobar, Saudi Arabia
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Buhl M, Peter S, Willmann M. Prevalence and risk factors associated with colonization and infection of extensively drug-resistant Pseudomonas aeruginosa: a systematic review. Expert Rev Anti Infect Ther 2015; 13:1159-70. [PMID: 26153817 DOI: 10.1586/14787210.2015.1064310] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative human pathogen with extensively drug-resistant (XDR) strains emerging in hospitals across the globe. This systematic review is focused on the worldwide prevalence of XDR P. aeruginosa (XDR-PA) and on the risk factors associated with its colonization and infection, based on literature available through PubMed, Web of Science and BioMed Central databases. An overview of surveillance systems is provided as well as a synopsis on the prevalence of XDR-PA, showing an increase in recent reports. Risk factors independently associated with XDR-PA colonization or infections are described in four groups with reference to antimicrobial therapy, medical devices as well as patient- and hospital environment-related factors.
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Affiliation(s)
- Michael Buhl
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
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Prospective observational study of prior rectal colonization status as a predictor for subsequent development of Pseudomonas aeruginosa clinical infections. Antimicrob Agents Chemother 2015; 59:5213-9. [PMID: 26077248 DOI: 10.1128/aac.04636-14] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 06/06/2015] [Indexed: 01/17/2023] Open
Abstract
The potential role of Pseudomonas aeruginosa (PA) intestinal colonization in the subsequent development of infections has not been thoroughly investigated. The aims of this study were to assess the role of PA intestinal colonization as a predictor of subsequent infections and to investigate the risk factors associated with the development of PA infection in patients in the intensive care unit (ICU). For this purpose, a prospective study was conducted that included (i) active surveillance of PA rectal colonization at ICU admission and weekly until ICU discharge, (ii) detection of PA clinical infections, and (iii) genotypic analysis by pulsed-field gel electrophoresis (PFGE). A total of 414 patients were included, of whom 179 (43%) were colonized with PA. Among the 77 patients who developed PA infection, 69 (90%) had prior PA colonization, and 60 (87%) of these showed genotyping concordance between rectal and clinical isolates. The probability of PA infection 14 days after ICU admission was 26% for carriers versus 5% for noncarriers (P < 0.001). Cox regression analysis identified prior PA rectal colonization as the main predictor of PA infection (hazard ratio [HR], 15.23; 95% confidence interval [CI], 6.9 to 33.7; P < 0.001). Prior use of nonantipseudomonal penicillins was also identified as an independent variable associated with PA infection (HR, 2.15; 95% CI, 1.3 to 3.55; P < 0.003). Our study demonstrated that prior PA rectal colonization is a key factor for developing PA infection.
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Skalweit MJ. Profile of ceftolozane/tazobactam and its potential in the treatment of complicated intra-abdominal infections. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2919-25. [PMID: 26082619 PMCID: PMC4461093 DOI: 10.2147/dddt.s61436] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drug-resistant pathogens have gained a foothold especially in the most vulnerable patient populations, hospitalized and immunocompromised individuals. Furthermore, extended-spectrum β-lactamase and carbapenemase-producing organisms are finding their way even into the community, with patients presenting to the hospital with established colonization and infection with resistant Enterobacteriaceae in particular. Recently, a novel antipseudomonal cephalosporin in combination with an established Class A β-lactamase inhibitor, ceftolozane/tazobactam has been approved by the FDA for use in the treatment of complicated urinary tract infections and complicated intra-abdominal infections. Ceftolozane is a uniquely potent antipseudomonal cephalosporin because of its high affinity for the penicillin-binding proteins of Pseudomonas aeruginosa, its low affinity for the intrinsic Class C β-lactamases of P. aeruginosa, its ability to enter P. aeruginosa through the outer membrane without the utilization of OprD protein, and the fact that it is not a substrate of the often upregulated MexAB/OprM efflux system of P. aeruginosa. The biological chemistry, pharmacokinetics/pharmacodynamics, microbiologic spectrum, and clinical trials that led to the approval of ceftolozane is reviewed. A discussion regarding its potential role in the treatment of complicated intra-abdominal infections and other infectious disease syndromes associated with drug-resistant pathogens follows.
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Affiliation(s)
- Marion J Skalweit
- Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs and Case Western Reserve University School of Medicine, Cleveland, OH, USA ; Department of Biochemistry, Louis Stokes Cleveland Department of Veterans Affairs and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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The role of systemic antibiotics in acquiring respiratory tract colonization with gram-negative bacteria in intensive care patients: a nested cohort study. Crit Care Med 2015; 43:774-80. [PMID: 25493969 DOI: 10.1097/ccm.0000000000000768] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Colonization of the respiratory tract with Gram-negative bacteria in intensive care patients increases the risk of subsequent infections. Application of systemic antibiotics may prevent colonization with Gram-negative bacteria, but this effect has never been quantified. The objective of this study was to determine associations between systemic antibiotic use and acquisition of respiratory tract colonization with Gram-negative bacteria in ICUs. DESIGN A nested cohort study. SETTING A university hospital and a teaching hospital. PATIENTS Patients with ICU stay of more than 48 hours and absence of respiratory tract colonization with Gram-negative bacteria on ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Acquisition was determined through protocolized surveillance. Associations were investigated with Cox regression models with antibiotics as a time-dependent covariate. In all, 250 of 481 patients (52%) acquired respiratory tract colonization with Gram-negative bacteria after a median of 5 days (interquartile range, 3-8 d) (acquisition rate, 77.1/1,000 patient-days at risk). Antibiotic exposure during ICU admission was present in 78% and 72% of the patients with and without acquired Gram-negative bacteria colonization, respectively. In Kaplan-Meier curve analysis, the median times to acquisition of Gram-negative bacteria were 9 days (95% CI, 7.9-10.1) and 6 days (95% CI, 4.8-7.2) in patients receiving and not receiving antibiotics, respectively. In time varying Cox regression analysis, however, the association between acquired colonization and systemic antibiotics was not statistically significant (hazard ratio, 0.90; 95% CI, 0.70-1.16). CONCLUSIONS Among patients not colonized with Gram-negative bacteria in the respiratory tract at admission to ICU, systemic antibiotics during ICU stay were not associated with a reduction in acquisition of Gram-negative bacteria carriage in the respiratory tract during the ICU stay.
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Cobos-Trigueros N, Solé M, Castro P, Torres JL, Hernández C, Rinaudo M, Fernández S, Soriano Á, Nicolás JM, Mensa J, Vila J, Martínez JA. Acquisition of Pseudomonas aeruginosa and its resistance phenotypes in critically ill medical patients: role of colonization pressure and antibiotic exposure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:218. [PMID: 25936721 PMCID: PMC4432505 DOI: 10.1186/s13054-015-0916-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/10/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The objective of this work was to investigate the risk factors for the acquisition of Pseudomonas aeruginosa and its resistance phenotypes in critically ill patients, taking into account colonization pressure. METHODS We conducted a prospective cohort study in an 8-bed medical intensive care unit during a 35-month period. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48 hours of admission and thrice weekly thereafter. During the study, a policy of consecutive mixing and cycling periods of three classes of antipseudomonal antibiotics was followed in the unit. RESULTS Of 850 patients admitted for ≥ 3 days, 751 (88.3%) received an antibiotic, 562 of which (66.1%) were antipseudomonal antibiotics. A total of 68 patients (8%) carried P. aeruginosa upon admission, and among the remaining 782, 104 (13%) acquired at least one strain of P. aeruginosa during their stay. Multivariate analysis selected shock (odds ratio (OR) = 2.1; 95% confidence interval (CI), 1.2 to 3.7), intubation (OR = 3.6; 95% CI, 1.7 to 7.5), enteral nutrition (OR = 3.6; 95% CI, 1.8 to 7.6), parenteral nutrition (OR = 3.9; 95% CI, 1.6 to 9.6), tracheostomy (OR = 4.4; 95% CI, 2.3 to 8.3) and colonization pressure >0.43 (OR = 4; 95% CI, 1.2 to 5) as independently associated with the acquisition of P. aeruginosa, whereas exposure to fluoroquinolones for >3 days (OR = 0.4; 95% CI, 0.2 to 0.8) was protective. In the whole series, prior exposure to carbapenems was independently associated with carbapenem resistance, and prior amikacin use predicted piperacillin-tazobactam, fluoroquinolone and multiple-drug resistance. CONCLUSIONS In critical care settings with a high rate of antibiotic use, colonization pressure and non-antibiotic exposures may be the crucial factors for P. aeruginosa acquisition, whereas fluoroquinolones may actually decrease its likelihood. For the acquisition of strains resistant to piperacillin-tazobactam, fluoroquinolones and multiple drugs, exposure to amikacin may be more relevant than previously recognized.
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Affiliation(s)
- Nazaret Cobos-Trigueros
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Mar Solé
- ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Jorge Luis Torres
- Department of Internal Medicine, University Hospital of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.
| | - Cristina Hernández
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Mariano Rinaudo
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Álex Soriano
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - José María Nicolás
- Medical Intensive Care Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - Jordi Vila
- ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic, University of Barcelona, Barcelona, Spain. .,Department of Clinical Microbiology, Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain.
| | - José Antonio Martínez
- Department of Infectious Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
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Sahuquillo-Arce JM, Hernández-Cabezas A, Yarad-Auad F, Ibáñez-Martínez E, Falomir-Salcedo P, Ruiz-Gaitán A. Carbapenemases: A worldwide threat to antimicrobial therapy. World J Pharmacol 2015; 4:75-95. [DOI: 10.5497/wjp.v4.i1.75] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/07/2014] [Accepted: 12/01/2014] [Indexed: 02/07/2023] Open
Abstract
Carbapenems are potent β-lactams with activity against extended-spectrum cephalosporinases and β-lactamases. These antibiotics, derived from thienamycn, a carbapenem produced by the environmental bacterium Streptomyces cattleya, were initially used as last-resort treatments for severe Gram-negative bacterial infections presenting resistance to most β-lactams but have become an empirical option in countries with high prevalence of Extended Spectrum β-lactamase-producing bacterial infections. Imipenem, the first commercially available carbapenem, was approved for clinical use in 1985. Since then, a wide variety of carbapenem-resistant bacteria has appeared, primarily Enterobacteriaceae such as Escherichia coli or Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa and Acinetobacter baumannii, presenting different resistance mechanisms. The most relevant mechanism is the production of carbapenem-hydrolyzing β-lactamases, also known as carbapenemases. These enzymes also inactivate all known β-lactams, and some of these enzymes can be acquired through horizontal gene transfer. Moreover, plasmids, transposons and integrons harboring these genes typically carry other resistance determinants, rendering the recipient bacteria resistant to almost all currently used antimicrobials, as is the case for K. pneumoniae carbapenemase - or New Delhi metallo-β-lactamases-type enzymes. The recent advent of these enzymes in the health landscape presents a serious challenge. First, the emergence of carbapenemases limits the currently available treatment options; second, these enzymes pose a risk to patients, as some studies have demonstrated high mortality associated with carbapenemase-producing bacterial infections; and third, these circumstances require an extra cost to sanitary systems, which are particularly cumbersome in developing countries. Therefore, emphasis should be placed on the early detection of these enzymes, the prevention of the spread of carbapenemase-producing bacteria and the development of new drugs resistant to carbapenemase hydrolysis.
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Genome Sequence of a Pandrug-Resistant Pseudomonas aeruginosa Strain, YN-1. GENOME ANNOUNCEMENTS 2014; 2:2/6/e01280-14. [PMID: 25540339 PMCID: PMC4276817 DOI: 10.1128/genomea.01280-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A highly rampant multidrug-resistant strain of Pseudomonas aeruginosa appeared in a hospital in Yunnan Province, China. Here, we report the genome sequence of the pandrug-resistant (PDR) P. aeruginosa strain recovered from a patient in 2013.
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Willmann M, Klimek AM, Vogel W, Liese J, Marschal M, Autenrieth IB, Peter S, Buhl M. Clinical and treatment-related risk factors for nosocomial colonisation with extensively drug-resistant Pseudomonas aeruginosa in a haematological patient population: a matched case control study. BMC Infect Dis 2014; 14:650. [PMID: 25490897 PMCID: PMC4266216 DOI: 10.1186/s12879-014-0650-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 11/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to investigate risk factors for colonisation with extensively drug-resistant P. aeruginosa (XDR-PA) in immunocompromised patients and to build a clinical risk score (CRS) based on these results. Methods We conducted a matched case–control study with 31 cases and 93 controls (1:3). Cases were colonised with XDR-PA during hospitalisation. Independent risk factors were determined using a three step conditional logistic regression procedure. A CRS was built with respect to the corresponding risk fraction of each risk factor, and its discriminatory power was estimated by receiver operating characteristic (ROC) analysis. Results The presence of a central venous catheter (OR 7.41, P = 0.0008), the presence of a urinary catheter (OR 21.04, P < 0.0001), CRP > 10 mg/dl (OR 7.36, P = 0.0015), and ciprofloxacin administration (OR 5.53, P = 0.025) were independent risk factors. The CRS exhibited a high discriminatory power, defining a high risk population with an approximately fourteen times greater risk for XDR-PA colonisation. Conclusions Unnecessary use of antibiotics, particularly ciprofloxacin should be avoided, and a high standard of infection control measures must be achieved when using medical devices. A CRS can be used for adaptation of the active screening culture policy to the local setting. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0650-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Willmann
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Anna M Klimek
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Wichard Vogel
- Medical Center, Department of Hematology, Oncology, Immunology, Rheumatology & Pulmonology, University of Tübingen, Tübingen, Germany.
| | - Jan Liese
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Matthias Marschal
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Ingo B Autenrieth
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Silke Peter
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Michael Buhl
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
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