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Sengupta M, Sarkar R, Sarkar S, Sengupta M, Ghosh S, Banerjee P. Vancomycin and Linezolid-Resistant Enterococcus Isolates from a Tertiary Care Center in India. Diagnostics (Basel) 2023; 13:diagnostics13050945. [PMID: 36900089 PMCID: PMC10001185 DOI: 10.3390/diagnostics13050945] [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: 01/03/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION There is increasing development of antibiotic resistance among the Enterococcus species. OBJECTIVES This study was performed to determine prevalence and characterize the vancomycin-resistant and linezolid-resistant enterococcus isolates from a tertiary care center. Moreover, the antimicrobial susceptibility pattern of these isolates was also determined. MATERIALS AND METHODS A prospective study was performed in Medical College, Kolkata, India, over a period of two years (from January 2018 to December 2019). After obtaining clearance from the Institutional Ethics Committee, Enterococcus isolates from various samples were included in the present investigation. In addition to the various conventional biochemical tests, the VITEK 2 Compact system was used to identify the Enterococcus species. The isolates were tested for antimicrobial susceptibility to different antibiotics using the Kirby-Bauer disk diffusion method and VITEK 2 Compact to determine the minimum inhibitory concentration (MIC). The Clinical and Laboratory Standards Institute (CLSI) 2017 guidelines were used to interpret susceptibility. Multiplex PCR was performed for genetic characterization of the vancomycin-resistant Enterococcus isolates and sequencing was performed for characterization of the linezolid-resistant Enterococcus isolates. RESULTS During the period of two years, 371 isolates of Enterococcus spp. were obtained from 4934 clinical isolates showing a prevalence of 7.52%. Among these isolates, 239 (64.42%) were Enterococcus faecalis, 114 (30.72%) Enterococcus faecium, and others were Enterococcus durans, Enterococcus casseliflavus, Enterococcus gallinarum, and Enterococcus avium. Among these, 24 (6.47%) were VRE (Vancomycin-Resistant Enterococcus) of which 18 isolates were Van A type and six isolates of Enterococcus casseliflavus and Enterococcus gallinarum were resistant VanC type. There were two linezolid-resistant Enterococcus, and they were found to have the G2576T mutation. Among the 371 isolates, 252 (67.92%) were multi-drug resistant. CONCLUSION This study found an increasing prevalence of vancomycin-resistant Enterococcus isolates. There is also an alarming prevalence of multidrug resistance among these isolates.
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Affiliation(s)
- Mallika Sengupta
- Department of Microbiology, All India Institute of Medical Sciences (AIIMS), Kalyani 741245, India
- Correspondence:
| | - Riya Sarkar
- Vijaya Diagnostics Laboratory, Hyderabad 500029, India
| | - Soma Sarkar
- Department of Microbiology, NRS Medical College, Kolkata 700014, India
| | | | - Sougata Ghosh
- Department of Microbiology, Medical College, Kolkata 700073, India
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Chia M, Naim AN, Tay AS, Lim K, Lee CK, Yow SJ, Chen J, Common JE, Nagarajan N, Tham EH. Shared signatures and divergence in skin microbiomes of children with atopic dermatitis and their caregivers. J Allergy Clin Immunol 2022; 150:894-908. [DOI: 10.1016/j.jaci.2022.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
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Joshi S, Shallal A, Zervos M. Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control. Infect Dis Clin North Am 2021; 35:953-968. [PMID: 34752227 DOI: 10.1016/j.idc.2021.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Vancomycin-resistant enterococcus (VRE) is a pathogen of growing concern due to increasing development of antibiotic resistance, increasing length of hospitalizations and excess mortality. The utility of some infection control practices are debatable, as newer developments in infection prevention strategies continued to be discovered. This article summarizes the significance of VRE and VRE transmission, along with highlighting key changes in infection control practices within the past 5 years.
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Affiliation(s)
- Seema Joshi
- Division of Infectious Diseases, Henry Ford Hospital, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA.
| | - Anita Shallal
- Division of Infectious Diseases, Henry Ford Hospital, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA
| | - Marcus Zervos
- Wayne State University, CFP-3, 2799 W Grand Boulevard, Detroit, MI, USA
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Tien KL, Sheng WH, Shieh SC, Hung YP, Tien HF, Chen YH, Chien LJ, Wang JT, Fang CT, Chen YC. Chlorhexidine Bathing to Prevent Central Line-Associated Bloodstream Infections in Hematology Units: A Prospective, Controlled Cohort Study. Clin Infect Dis 2021; 71:556-563. [PMID: 31504341 DOI: 10.1093/cid/ciz874] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/30/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units. METHODS Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci-related, skin flora-related, or central line-associated bloodstream infection. The negative control outcome was gut-origin bacteremia. RESULTS The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group. CONCLUSIONS CHG bathing could be a highly effective approach for preventing gram-positive cocci-related, skin flora-related, or central line-associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.
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Affiliation(s)
| | | | - Shiouh-Chu Shieh
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Ping Hung
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Yi-Hsuan Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Li-Jung Chien
- Division of Infection Control and Biosafety, Centers for Disease Control, Taipei, Taiwan
| | - Jann-Tay Wang
- Center for Infection Control, Taipei, Taiwan.,Department of Internal Medicine, Taipei, Taiwan
| | - Chi-Tai Fang
- Department of Internal Medicine, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yee-Chun Chen
- Center for Infection Control, Taipei, Taiwan.,Department of Internal Medicine, Taipei, Taiwan
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Central Line Care and Management: Adopting Evidence-Based Nursing Interventions. J Perianesth Nurs 2021; 36:328-333. [PMID: 33771443 DOI: 10.1016/j.jopan.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
Abstract
Central line-associated bloodstream infections occur not only in the intensive care unit but also the non-intensive care units of the hospital. The purpose of this article is to review current evidence to guide perianesthesia nurses in the care of a patient with a central vascular access device (CVAD). The CVAD bundle focuses on five key elements: hand hygiene, maximal sterile barrier, chlorhexidine antiseptic, catheter site selection, and daily evaluation of the need for the device. Once the CVAD is placed, evidence-based care and maintenance are the responsibility of the nurse. Ensuring proper maintenance and care of a CVAD falls within nursing practice and interventions can significantly reduce the patient's risk of central line-associated bloodstream infection. The single most crucial step a nurse can take to help prevent central line-associated bloodstream infections is performing proper hand hygiene. Other interventions focus on dressing management, bathing practices, access of intravenous infusion sets, blood draws, and management of port line occlusions. Familiarity and adoption of best practice interventions in the maintenance and care of patients with CVADs will help the perianesthesia nurse protect patients and prevent harm.
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Morante J, Quispe AM, Ymaña B, Moya-Salazar J, Luque N, Soza G, Ramos Chirinos M, Pons MJ. Tolerance to disinfectants (chlorhexidine and isopropanol) and its association with antibiotic resistance in clinically-related Klebsiella pneumoniae isolates. Pathog Glob Health 2021; 115:53-60. [PMID: 33455564 DOI: 10.1080/20477724.2020.1845479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Disinfectants play an essential role in controlling the dissemination of bacteria in health care settings, but it may also contribute to the selection of antibiotic resistance bacteria. This study looked at Klebsiella pneumoniae isolates collected from three hospitals in Lima, Peru, in order to evaluate: their susceptibility to chlorhexidine [CHG] and isopropanol [ISP]), and their association with antimicrobial susceptibility. We analyzed 59 K. pneumoniae isolates and assessed their CHG and ISP susceptibility by minimum inhibitory concentrations (MICs). Additionally, we performed a regression analysis to assess the association between disinfectant tolerance and antibiotic resistance (measured by the disc diffusion method), colistin resistance (by microdilution), carbapenemases presence (by polymerase chain reaction [PCR]), and clonal relationships (by pulsed-field gel electrophoresis [PFGE]). Eleven K. pneumoniae strains were isolated from fomites, and 48 strains from clinical samples. The MIC range of these isolates was 8-128 µg/ml for CHG and 16-256 mg/ml for ISP. We found that resistance to trimethoprim/sulfamethoxazole (TMP/SMX) was the main factor associated with CHG log2 MIC (ß = 0.65; 95%CI: 0.03, 1.27; R2 = 0.07). In the case of ISP, the log2(MIC) was associated with the institution of origin, showing lower ISP log2(MIC) in fomites compared to clinical samples(ß = -0.77; 95%CI: -1.54, -0.01; R2 = 0.08). Resistance to CHG and ISP among K. pneumoniae isolates found in Peruvian hospitals seems to be elevated and highly variable. Further studies are needed to confirm our results and implement actionable interventions if necessary.
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Affiliation(s)
- Jasmine Morante
- Escuela de Medicina, Universidad Científica del Sur , Lima, Peru
| | | | - Barbara Ymaña
- Escuela de Medicina, Universidad Científica del Sur , Lima, Peru
| | - Jeel Moya-Salazar
- Hospital Nacional Docente Madre Niño San Bartolomé , Lima, Peru.,Escuela de Posgrado, Universidad Privada San Juan Bautista , Lima, Peru
| | - Néstor Luque
- Médico asistente de UCI. Hospital Nacional Dos de Mayo , Lima, Peru.,Escuela de Medicina Humana. Facultad de Ciencias de la Salud, Universidad Peruana Unión , Lima, Peru
| | | | | | - Maria J Pons
- Escuela de Medicina, Universidad Científica del Sur , Lima, Peru
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Upvall MJ, Bourgault AM, Pigon C, Swartzman CA. Exemplars Illustrating De-implementation of Tradition-Based Practices. Crit Care Nurse 2020; 39:64-69. [PMID: 31961940 DOI: 10.4037/ccn2019534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.
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Affiliation(s)
- Michele J Upvall
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Annette M Bourgault
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Cody Pigon
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
| | - Christine A Swartzman
- Michele J. Upvall is a professor of nursing, University of Central Florida, Orlando, Florida. Annette M. Bourgault is an assistant professor of nursing, University of Central Florida, and a nurse-scientist, Orlando Health, Orlando, Florida. Cody Pigon is clinical nurse IV, Orlando Regional Medical Center, Orlando, Florida. Christine A. Swartzman is a clinical nurse specialist for critical care, South Seminole Hospital, Longwood, Florida
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Abstract
Objective The aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection. Methods We searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words “chlorhexidine bathing” and MeSH terms “cross-infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31. Results Our findings focused on health care–associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means. Conclusions There is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing’s impact on outcomes, such as mortality and length of stay.
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Reitzel RA, Rosenblatt J, Gerges BZ, Jarjour A, Fernández-Cruz A, Raad II. The potential for developing new antimicrobial resistance from the use of medical devices containing chlorhexidine, minocycline, rifampicin and their combinations: a systematic review. JAC Antimicrob Resist 2020; 2:dlaa002. [PMID: 34222960 PMCID: PMC8210168 DOI: 10.1093/jacamr/dlaa002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/04/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background Catheter infections remain one of the most persistent adverse events causing significant morbidity, economic impact and mortality. Several strategies have been proposed to reduce these infections including the use of catheters embedded with antibiotics and/or antiseptics. One reoccurring challenge is the fear that antimicrobial medical devices will induce resistance. The aim of this systematic review is to evaluate the evidence for induced antimicrobial resistance caused by exposure to antimicrobial medical devices. Methods Four electronic databases [MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus] were screened for studies published between 1983 and 2019 regarding assessment of microbial resistance with use of medical devices containing chlorhexidine, minocycline, rifampicin or combinations thereof. Development of new resistance, selection for tolerant organisms and 'no change in resistance' were assessed. Results Forty-four publications, grouped by study type and stratified by drug assessed, were included for analyses. The majority of studies found no change in resistance after exposure to antimicrobial medical devices (13 in vitro, 2 in vivo, 20 clinical). Development of new resistance was commonly reported with the use of rifampicin as a single agent and only reported in one study assessing the minocycline/rifampicin combination (M/R); however, the increase in MIC was well below clinical relevance. Conclusions Emergence of new resistance to combinations of M/R, minocycline/rifampicin/chlorhexidine (M/R/CH) and chlorhexidine/silver sulfadiazine (CHXSS) was rare. No clinical trials confirmed its occurrence and some refuted it. The risk of development of new resistance to these antimicrobial combinations appears more fear-based than substantiated by clinical and experimental evidence but warrants continued surveillance.
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Affiliation(s)
- Ruth A Reitzel
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joel Rosenblatt
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bahgat Z Gerges
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Jarjour
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ana Fernández-Cruz
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Wassef M, Mukhtar A, Nabil A, Ezzelarab M, Ghaith D. Care Bundle Approach to Reduce Surgical Site Infections in Acute Surgical Intensive Care Unit, Cairo, Egypt. Infect Drug Resist 2020; 13:229-236. [PMID: 32095080 PMCID: PMC6995287 DOI: 10.2147/idr.s236814] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/14/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Surgical site infections (SSIs) are one of the most frequently reported hospital acquired infections associated with significant spread of antibiotic resistance. Purpose We aimed to evaluate a bundle-based approach in reducing SSI at acute surgical intensive care unit of the Emergency Hospital of Cairo University. Patients and Methods Our prospective study ran from March 2018 to February 2019 and used risk assessment. The study was divided into three phases. Phase I: (pre-bundle phase) for 5 months; data collection, active surveillance of the SSIs, screening for OXA-48 producing Enterobacteriaceae and multidrug resistant Acinetobacter baumannii colonizers using Chrom agars were carried out. Phase II: (bundle-implementation) a 6-S bundle approach included education, training and postoperative bathing with Chlorhexidine Gluconate in collaboration with the infection control team. Finally, Phase III: (post-implementation) for estimation of compliance, rates of colonization, and infection. Results Phase I encompassed 177 patients, while Phase III included 93 patients. A significant reduction of colonization from 24% to 15% (p<0.001) was observed. Similarly, a decrease of SSI from 27% to 15% (p=0.02) was noticed. A logistic regression was performed to adjust for confounding in the implementation of the bundle and we found a 70% reduction of SSI odd's ratio (OR's ratio = 0.3) confidence interval (95% CI 0.14-0.6) with significant Apache II (p=0.04), type of wound; type II (p=0.002), type III (p=0.001) and duration of surgery (p=0.04) as independent risk factors for SSI. Klebsiella pneumoniae was the most prevalent organism during phase I (34.7%). On the other hand, A. baumannii was the commonest organism to be isolated during phase III with (38.5%) preceding K. pneumoniae (30%). Conclusion Our study demonstrated that the implementation of a multidisciplinary bundle containing evidence-based interventions was associated with a significant reduction of colonization and SSIs and was met with staff approval and acceptable compliance.
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Affiliation(s)
- Mona Wassef
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Mukhtar
- Department of Anesthesia and Critical Care, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Nabil
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Moushira Ezzelarab
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Ghaith
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Navel to Knees With Chlorhexidine Gluconate: Preventing Catheter-Associated Urinary Tract Infections. Dimens Crit Care Nurs 2019; 38:236-240. [PMID: 31369441 DOI: 10.1097/dcc.0000000000000371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Urinary tract infections are the most common type of health care-associated infection, and greater than 75% of them are attributed to an indwelling urinary catheter. A catheter-associated urinary infection may lead to a longer hospital length of stay by as many as 4 days. A new patient care standard requiring twice-daily chlorhexidine cleansing from umbilicus to knees was implemented on all patients of the pilot unit with a urinary catheter. This same technique was used after a patient with a urinary catheter had an incontinent bowel movement. The 9-month average catheter-associated urinary infection rate decreased from 3.06/1000 urinary catheter days to 0.46/1000 urinary catheter days after implementation of the new standard. The use of chlorhexidine for routine urinary catheter care and after bowel movements from umbilicus to knees for patients with urinary catheters may significantly decrease catheter-associated urinary tract infections when compared with the standard of care using soap and water. Standards for Quality Improvement Reporting Excellence guidelines were used in reporting these data.
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Hashemi MM, Holden BS, Coburn J, Taylor MF, Weber S, Hilton B, Zaugg AL, McEwan C, Carson R, Andersen JL, Price JC, Deng S, Savage PB. Proteomic Analysis of Resistance of Gram-Negative Bacteria to Chlorhexidine and Impacts on Susceptibility to Colistin, Antimicrobial Peptides, and Ceragenins. Front Microbiol 2019; 10:210. [PMID: 30833936 PMCID: PMC6388577 DOI: 10.3389/fmicb.2019.00210] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/24/2019] [Indexed: 12/19/2022] Open
Abstract
Use of chlorhexidine in clinical settings has led to concerns that repeated exposure of bacteria to sub-lethal doses of chlorhexidine might result in chlorhexidine resistance and cross resistance with other cationic antimicrobials including colistin, endogenous antimicrobial peptides (AMPs) and their mimics, ceragenins. We have previously shown that colistin-resistant Gram-negative bacteria remain susceptible to AMPs and ceragenins. Here, we investigated the potential for cross resistance between chlorhexidine, colistin, AMPs and ceragenins by serial exposure of standard strains of Gram-negative bacteria to chlorhexidine to generate resistant populations of organisms. Furthermore, we performed a proteomics study on the chlorhexidine-resistant strains and compared them to the wild-type strains to find the pathways by which bacteria develop resistance to chlorhexidine. Serial exposure of Gram-negative bacteria to chlorhexidine resulted in four- to eight-fold increases in minimum inhibitory concentrations (MICs). Chlorhexidine-resistant organisms showed decreased susceptibility to colistin (8- to 32-fold increases in MICs) despite not being exposed to colistin. In contrast, chlorhexidine-resistant organisms had the same MICs as the original strains when tested with representative AMPs (LL-37 and magainin I) and ceragenins (CSA-44 and CSA-131). These results imply that there may be a connection between the emergence of highly colistin-resistant Gram-negative pathogens and the prevalence of chlorhexidine usage. Yet, use of chlorhexidine may not impact innate immune defenses (e.g., AMPs) and their mimics (e.g., ceragenins). Here, we also show that chlorhexidine resistance is associated with upregulation of proteins involved in the assembly of LPS for outer membrane biogenesis and virulence factors in Pseudomonas aeruginosa. Additionally, resistance to chlorhexidine resulted in elevated expression levels of proteins associated with chaperones, efflux pumps, flagella and cell metabolism. This study provides a comprehensive overview of the evolutionary proteomic changes in P. aeruginosa following exposure to chlorhexidine and colistin. These results have important clinical implications considering the continuous application of chlorhexidine in hospitals that could influence the emergence of colistin-resistant strains.
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Affiliation(s)
- Marjan M Hashemi
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Brett S Holden
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Jordan Coburn
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Maddison F Taylor
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Scott Weber
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Brian Hilton
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Aaron L Zaugg
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Colten McEwan
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Richard Carson
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Joshua L Andersen
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - John C Price
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Shenglou Deng
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
| | - Paul B Savage
- Department of Chemistry and Biochemistry, Brigham Young University, Provo, UT, United States
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DeSimone DC, Chahal AA, DeSimone CV, Asirvatham SJ, Friedman PA, Baddour LM, Sohail MR. International survey of knowledge, attitudes, and practices of cardiologists regarding prevention and management of cardiac implantable electronic device infections. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1260-1268. [PMID: 28846153 DOI: 10.1111/pace.13183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/10/2017] [Accepted: 07/14/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular implantable electronic devices (CIEDs) can be life-saving. However, complications from CIED infection can be life-threatening, often requiring device removal. Despite publication of CIED infection management guidelines, there remains marked variation in clinical practice. OBJECTIVE To better understand and quantify these differences, we conducted a multinational survey of practitioners of CIED management. METHODS An electronic survey was sent to Heart Rhythm Society members, spanning 70 countries across six continents. All responses were collected anonymously. RESULTS 227 out of 3,600 (6.3%) responded to the survey. The majority of surveys were completed by practitioners from the United States (168; 68.3%) and 53.8% of these practiced in academic medical centers. The large majority (92.7%) of sites had protocols to ensure appropriate timing of prophylactic antibiotics. Superficial (incisional) site infections were treated with antibiotics alone 52.5% of the time (consistent with guidelines); in contrast, deep pocket infections were treated with antibiotics (with device removal) in accordance to guidelines only 37.4% of the time. Almost all providers (98.7%) were inclined to perform complete hardware removal in cases of CIED-related endocarditis. In contrast, 82.2% of survey participants suggested complete CIED system removal in patients with an occult Gram-positive bacteremia, 65.5% with occult Gram-negative bacteremia, and 59.3% with prolonged bacteremia due to a source other than CIED. CONCLUSIONS These data suggest wide variability in clinical practice in managing CIED infection with significant deviations from published guidelines. There is critical need to increase awareness and develop institutional protocols to ensure adherence with evidence-based guidelines to optimize outcomes.
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Affiliation(s)
| | - Anwar A Chahal
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA.,Mayo Graduate School, Mayo Clinic, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - M Rizwan Sohail
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
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