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Spiliopoulou A, Giannopoulou I, Assimakopoulos SF, Jelastopulu E, Bartzavali C, Marangos M, Paliogianni F, Kolonitsiou F. Laboratory Surveillance of Acinetobacter spp. Bloodstream Infections in a Tertiary University Hospital during a 9-Year Period. Trop Med Infect Dis 2023; 8:503. [PMID: 37999622 PMCID: PMC10674392 DOI: 10.3390/tropicalmed8110503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/12/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023] Open
Abstract
Multidrug-resistant Acinetobacter baumannii infections have become a threat for public health worldwide. The aim of the present study was to follow-up resistance patterns of Acinetobacter spp. bloodstream isolates in a Tertiary University Hospital over the last nine years, from 2014 to 2022. Susceptibility patterns were followed for the following antimicrobial agents: amikacin, gentamicin, tobramycin, ciprofloxacin, levofloxacin, imipenem, meropenem, tigecycline, trimethoprim/sulfamethoxazole, and colistin. Minimal inhibitory concentration (MIC) values to ampicillin/sulbactam, cefepime, ceftazidime, minocycline, piperacillin/tazobactam were evaluated from 2020 to 2023. During the study period, 853 Acinetobacter spp. bloodstream infections (BSIs) were recorded, accounting for 5.36% of all BSIs. A. baumannii was isolated in 795 cases (93.2%), during the study period. Most BSIs were recorded in adult intensive care units (ICU) (46.2%) and medical wards (42%). Among A. baumannii isolates, 4.5% were multidrug-resistant, 84.7% were extensively drug-resistant, and 8.5% were pandrug-resistant. Resistance to carbapenems was over 95%. Resistance to tigecycline increased significantly during the last years of the study (2020-2022); A. baumannii isolates with MIC ≤ 2 μg/mL accounted for 28.5% of all isolates. Resistance to colistin exhibited an increasing pattern up to 42.2% in 2022. Increasing resistance rates and the evolution of pandrug-resistant isolates call for the urgent application of preventive and response actions.
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Affiliation(s)
- Anastasia Spiliopoulou
- Department of Microbiology, University Hospital of Patras, 265 04 Rio, Greece (C.B.); (F.P.); (F.K.)
| | - Ioanna Giannopoulou
- Department of Microbiology, University Hospital of Patras, 265 04 Rio, Greece (C.B.); (F.P.); (F.K.)
| | - Stelios F. Assimakopoulos
- Department of Infectious Diseases, University Hospital of Patras, 265 04 Rio, Greece; (S.F.A.); (M.M.)
| | - Eleni Jelastopulu
- Department of Public Health, School of Medicine, University of Patras, 265 04 Patras, Greece;
| | - Christina Bartzavali
- Department of Microbiology, University Hospital of Patras, 265 04 Rio, Greece (C.B.); (F.P.); (F.K.)
| | - Markos Marangos
- Department of Infectious Diseases, University Hospital of Patras, 265 04 Rio, Greece; (S.F.A.); (M.M.)
| | - Fotini Paliogianni
- Department of Microbiology, University Hospital of Patras, 265 04 Rio, Greece (C.B.); (F.P.); (F.K.)
| | - Fevronia Kolonitsiou
- Department of Microbiology, University Hospital of Patras, 265 04 Rio, Greece (C.B.); (F.P.); (F.K.)
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Sodeifian F, Zangiabadian M, Arabpour E, Kian N, Yazarlou F, Goudarzi M, Centis R, Seghatoleslami ZS, Kameh MC, Danaei B, Goudarzi H, Nasiri MJ, Sotgiu G, Migliori GB. Tigecycline-Containing Regimens and Multi Drug-Resistant Acinetobacter baumannii: A Systematic Review and Meta-Analysis. Microb Drug Resist 2023. [PMID: 37192494 DOI: 10.1089/mdr.2022.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Introduction: The use of tigecycline (TG) for the treatment of Acinetobacter baumannii is controversial. In this systematic review and meta-analysis, we aimed to better explore the safety and efficacy of TG for the treatment of multi drug-resistant (MDR) Acinetobacter. Methods: We searched PubMed/MEDLINE, Scopus, Cochrane Central, and Web of Science to identify studies reporting the clinical and microbiological efficacy and safety of regimens containing TG in patients with drug susceptibility testing (DST)-confirmed MDR A. baumannii, published until December 30, 2022. Observational studies were included if they reported clinical and microbiological efficacy of TG-based regimens. The Newcastle-Ottawa Scale (NOS) and Joana Briggs Institute (JBI) critical appraisal tool were used to assess the quality of included studies. Results: There were 30 observational studies, of which 19 studies were cohort and 11 studies were single group studies. Pooled clinical response and failure rates in the TG-containing regimens group were 58.1 (95% confidence interval [CI] 49.2-66.6) and 40.2 (95% CI 31.1-50.0), respectively. The pooled microbiological response rate was 32.1 (95% CI 19.8-47.5), and the pooled all-cause mortality rate was 41.1 (95% CI 34.1-48.4). Pooled clinical response and failure rates in the colistin-based regimens group were 52.7 (42.7-62.5) and 43.1 (33.1-53.8), respectively. The pooled microbiological response rate was 42.9 (16.2-74.5), and the pooled all-cause mortality rate was 34.3 (26.1-43.5). Conclusions: According to our results, the efficacy of the TG-based regimen is the same as other antibiotics. However, our study showed a high mortality rate and a lower rate of microbiological eradication for TG compared with colistin-based regimen. Therefore, our study does not recommend it for the treatment of MDR A. baumannii. However, this was a prevalence meta-analysis of observational studies, and for better conclusion experimental studies are required.
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Affiliation(s)
- Fatemeh Sodeifian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Erfan Arabpour
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naghmeh Kian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fartous Yazarlou
- Department of Pharmacy, Comenius University Bratislava, Bratislava, Slovakia
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | | | - Mahdis Chahar Kameh
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bardia Danaei
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
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Elarabi MA. Answers to the authors of the "Letter to the Editor": A comparative study between non colistin based combinations for treatment of infections caused by extensive drug resistant Acinetobacter baumannii: comments. Int J Clin Pharm 2021; 43:1149-1151. [PMID: 33411179 DOI: 10.1007/s11096-020-01214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gilani M, Latif M, Gilani M, Saad N, Ansari M, Gilani M, Waseem H, Naeem A. Efficacy of Antimicrobials Against Multidrug-Resistant Acinetobacter baumannii from Patients in a Tertiary Care Hospital. Microb Drug Resist 2019; 26:681-684. [PMID: 31829792 DOI: 10.1089/mdr.2019.0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: In just two decades Acinetobacter baumannii has attained considerable importance, evolving from an insignificant organism to a leading pathogen especially in intensive care unit settings globally. Treatment options are already very limited and have almost run out due to the rapid emergence of antimicrobial resistance. Evaluation of antimicrobials that are currently in use to determine their effectiveness against multidrug-resistant (MDR) strains and developing newer options is of utmost importance. We thus set out to determine the efficacy of routinely used antibiotics against MDR A. baumannii. Materials and Methods: This was a cross-sectional study conducted at the Department of Microbiology, Army Medical College, National University of Medical Sciences (Rawalpindi, Pakistan) from December 2015 to June 2016. The organisms were identified on the basis of colony morphology, gram staining, catalase, oxidase, motility test, and API (analytical profile index) 20NE. The organisms were considered to be MDR when the isolate was found to be resistant to at least one agent in more than three antimicrobial groups. Antibiotic sensitivity was determined using the modified Kirby-Bauer disc diffusion method according to Clinical Laboratory Standards Institute (CLSI) guidelines. Results: The 77 isolates were found to have good sensitivity to tigecycline (94.8%) and minocycline (80.5%). Most of the isolates were resistant to other routinely used antibiotics. Conclusion: A few antibiotics, tigecycline and minocycline, are still effective against these MDR A. baumannii. We need to remain up to date regarding the efficacy of antibiotics to effectively treat patients with these MDR bacteria.
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Affiliation(s)
- Mehreen Gilani
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mahwish Latif
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mehwish Gilani
- Armed Forces Institute of Pathology, Rawalpindi, Pakistan
| | - Nadia Saad
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Maliha Ansari
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
| | | | - Hafsa Waseem
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Afnan Naeem
- Department of Microbiology, Army Medical College, National University of Medical Sciences, Rawalpindi, Pakistan
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Comparison of tigecycline susceptibility testing methods for multidrug-resistant Acinetobacter baumannii. Diagn Microbiol Infect Dis 2018; 91:360-362. [PMID: 29778562 DOI: 10.1016/j.diagmicrobio.2018.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/19/2018] [Indexed: 01/20/2023]
Abstract
Automated systems Vitek 2, BD Phoenix, MicroScan WalkAway and gradient diffusion assays Etest and MIC Test Strip were compared against broth microdilution for susceptibility testing of tigecycline against Acinetobacter baumannii. BD Phoenix and MIC Test Strip seemed to provide the most accurate determination of tigecycline susceptibility.
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Bloodstream infections caused by Acinetobacter species with reduced susceptibility to tigecycline: clinical features and risk factors. Int J Infect Dis 2017; 62:26-31. [PMID: 28676346 DOI: 10.1016/j.ijid.2017.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/02/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION During recent decades, the rates of multidrug resistance, including resistance to carbapenems, have increased dramatically among Acinetobacter species. Tigecycline has activity against multidrug-resistant Acinetobacter spp, including carbapenem-resistant isolates. However, reports of tigecycline-resistant Acinetobacter spp are emerging from different parts of the world. The purpose of this study was to evaluate potential risk factors associated with tigecycline non-susceptible Acinetobacter bacteremia. METHODS The medical records of 152 patients with Acinetobacter bacteremia attending Samsung Medical Center between January 2010 and December 2014 were reviewed. Non-susceptibility to tigecycline was defined as a minimum inhibitory concentration (MIC) of tigecycline ≥4μg/ml. Cases were patients with tigecycline non-susceptible Acinetobacter bacteremia and controls were those with tigecycline-susceptible Acinetobacter bacteremia. RESULTS Of the 152 patients included in the study, 61 (40.1%) had tigecycline non-susceptible Acinetobacter bacteremia (case group). These patients were compared to 91 patients with tigecycline-susceptible Acinetobacter bacteremia (control group). The case group showed high resistance to other antibiotics (>90%) except colistin (6.6%) and minocycline (9.8%) when compared to the control group, which exhibited relatively low resistance to other antibiotics (<50%). Multivariate analysis showed that recent exposure to corticosteroids (minimum 20mg per day for more than 5 days within 2 weeks) (adjusted odds ratio (OR) 2.887, 95% confidence interval (CI) 1.170-7.126) and carbapenems (within 2 weeks) (adjusted OR 4.437, 95% CI 1.970-9.991) were significantly associated with tigecycline non-susceptible Acinetobacter bacteremia. Although prior exposure to tigecycline was more common in the case group than in the control group (9.8%, 6/61 vs. 2.2%, 2/91; p=0.046), this variable was found not to be a significant factor associated with tigecycline non-susceptibility after adjustment for other variables (adjusted OR 1.884, 95% CI 0.298-11.920; p=0.501). CONCLUSIONS These data suggest that tigecycline non-susceptible Acinetobacter spp have emerged and disseminated in the hospital in association with a recent exposure to carbapenems and an immunosuppressed state. This indicates that the rational use of antibiotics through a comprehensive antimicrobial stewardship program, especially in immunosuppressed patients, may be essential in limiting the emergence and spread of multidrug-resistant organisms such as tigecycline-resistant Acinetobacter spp, which are difficult to treat.
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Maraki S, Mantadakis E, Mavromanolaki VE, Kofteridis DP, Samonis G. A 5-year Surveillance Study on Antimicrobial Resistance of Acinetobacter baumannii Clinical Isolates from a Tertiary Greek Hospital. Infect Chemother 2016; 48:190-198. [PMID: 27659437 PMCID: PMC5048000 DOI: 10.3947/ic.2016.48.3.190] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/17/2016] [Indexed: 11/24/2022] Open
Abstract
Background Acinetobacter baumannii has emerged as a major cause of nosocomial outbreaks. It is particularly associated with nosocomial pneumonia and bloodstream infections in immunocompromised and debilitated patients with serious underlying pathologies. Over the last two decades, a remarkable rise in the rates of multidrug resistance to most antimicrobial agents that are active against A. baumannii has been noted worldwide. We evaluated the rates of antimicrobial resistance and changes in resistance over a 5-year period (2010–2014) in A. baumannii strains isolated from hospitalized patients in a tertiary Greek hospital. Materials and Methods Identification of A. baumannii was performed by standard biochemical methods and the Vitek 2 automated system, which was also used for susceptibility testing against 18 antibiotics: ampicillin/sulbactam, ticarcillin, ticarcillin/clavulanic acid, piperacillin, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, imipenem, meropenem, gentamicin, amikacin, tobramycin, ciprofloxacin, tetracycline, tigecycline, trimethoprim/sulfamethoxazole, and colistin. Interpretation of susceptibility results was based on the Clinical and Laboratory Standards Institute criteria, except for tigecycline, for which the Food and Drug Administration breakpoints were applied. Multidrug resistance was defined as resistance to ≥3 classes of antimicrobial agents. Results Overall 914 clinical isolates of A. baumannii were recovered from the intensive care unit (ICU) (n = 493), and medical (n = 252) and surgical (n = 169) wards. Only 4.9% of these isolates were fully susceptible to the antimicrobials tested, while 92.89% of them were multidrug resistant (MDR), i.e., resistant to ≥3 classes of antibiotics. ICU isolates were the most resistant followed by isolates from surgical and medical wards. The most effective antimicrobial agents were, in descending order: colistin, amikacin, trimethoprim/sulfamethoxazole, tigecycline, and tobramycin. Nevertheless, with the exception of colistin, no antibiotic was associated with a susceptibility rate >40% for the entire study period. The most common phenotype showed resistance against ampicillin/sulbactam, cephalosporins, carbapenems, aminoglycosides, ciprofloxacin, and tigecycline. An extremely concerning increase in colistin-resistant isolates (7.9%) was noted in 2014, the most recent study year. Conclusion The vast majority of A. baumannii clinical isolates in our hospital are MDR. The remaining therapeutic options for critically ill patients who suffer from MDR A. baumannii infections are severely limited, with A. baumannii beginning to develop resistance even against colistin. Scrupulous application of infection control practices should be implemented in every hospital unit. Lastly, given the lack of available therapeutic options for MDR A. baumannii infections, well-controlled clinical trials of combinations of existing antibiotics are clearly needed.
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Affiliation(s)
- Sofia Maraki
- Department of Clinical Microbiology, University Hospital of Heraklion, Crete, Greece.
| | - Elpis Mantadakis
- Department of Pediatrics, Democritus University of Thrace Faculty of Medicine and University General District Hospital of Evros, Alexandroupolis, Thrace, Greece
| | | | - Diamantis P Kofteridis
- Department of Internal Medicine, Infectious Diseases Unit, University of Crete Medical School, Heraklion, Crete, Greece
| | - George Samonis
- Department of Internal Medicine, Infectious Diseases Unit, University of Crete Medical School, Heraklion, Crete, Greece
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In Vitro Activity of Tigecycline Against Acinetobacter baumannii: Global Epidemiology and Resistance Mechanisms. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 897:1-14. [DOI: 10.1007/5584_2015_5001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rynga D, Shariff M, Deb M. Phenotypic and molecular characterization of clinical isolates of Acinetobacter baumannii isolated from Delhi, India. Ann Clin Microbiol Antimicrob 2015; 14:40. [PMID: 26338039 PMCID: PMC4559170 DOI: 10.1186/s12941-015-0101-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/19/2015] [Indexed: 11/22/2022] Open
Abstract
Background Acinetobacter has gained importance as a multi-drug resistant and hence a difficult to treat pathogen. This study was done to characterize our isolates with respect to drug resistance and presence of beta-lactamases which is a major mechanism of resistance and to type using RAPD and MLST so that comparison of our clones can be made with the existing international clones. Methods 100 isolates recovered from clinical samples from two hospitals in Delhi were tested for their susceptibility against major groups of antimicrobials. The resistant isolates were screened and confirmed phenotypically for presence of ESBL, MBL and AmpC and MBLs also by PCR. The isolates were typed by RAPD and MLST. Results Out of the 100 isolates, 91, 78 and 2 % were MDR, XDR and PDR respectively. 97, 100 and 85 were screen positive for ESBL, AmpC and MBL respectively. Of these, 38.1 % were confirmed phenotypically to produce ESBL, 99 % produced AmpC and 29.4 % produced MBL comprising of GIM, VIM, SIM and IMP. MLST showed known STs 110, 188, 146, 69, 103, 108 and 194. Eight new STs were encountered. The RAPD showed a high degree of genetic variability among the isolates. Conclusion Majority of our isolates were MDR, producing one or more types of beta-lactamases. We encountered drug resistant international clones by MLST which are found in other continents there by confirming their spread to Indian sub continent. No data on ST types of other Indian isolates is available in the MLST database and hence comparison is not possible.
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Affiliation(s)
- Dabet Rynga
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India. .,Department of Microbiology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
| | - Malini Shariff
- Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India.
| | - Monorama Deb
- Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India.
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Papadimitriou-Olivgeris M, Spiliopoulou A, Fligou F, Manolopoulou P, Spiliopoulou I, Vrettos T, Dodou V, Filos KS, Anastassiou ED, Marangos M, Christofidou M. Association of KPC-producing Klebsiella pneumoniae colonization or infection with Candida isolation and selection of non-albicans species. Diagn Microbiol Infect Dis 2014; 80:227-32. [PMID: 25175179 DOI: 10.1016/j.diagmicrobio.2014.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 07/17/2014] [Accepted: 07/18/2014] [Indexed: 01/08/2023]
Abstract
Clinical specimens from 565 patients hospitalized in 2 intensive care units (ICUs A and B) during a 28-month period were cultured on appropriate media for isolation of Candida. Forty-nine (9%) patients had at least a Candida spp.-positive sample. Candida albicans was the predominant species isolated from 26 (53%) patients. Seventeen patients (3%) developed candidemia. Multivariate analysis showed that obesity, female gender, hospitalization during summer months, admission at ICU B, parenteral nutrition, administration of metronidazole, transplantation, and KPC-producing Klebsiella pneumoniae (KPC-Kp) infection were independently associated with Candida spp. isolation. Candidemia was associated with cortisone administration, KPC-Kp infection, and presence of colostomy or abdominal catheter. Administration of fluconazole was a protective factor for both Candida spp. isolation and infection, leading to selection of Candida non-albicans species. Among several risk factors, KPC-Kp infection and colonization are identified as statistically significant factors associated with Candida isolation, especially of non-albicans species.
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Affiliation(s)
| | | | - Fotini Fligou
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | | | - Iris Spiliopoulou
- Department of Microbiology, School of Medicine, University of Patras, Patras, Greece
| | - Theofanis Vrettos
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | - Vasiliki Dodou
- Intensive Care Unit, Saint Andrew's General Hospital of Patras, Patras, Greece
| | - Kriton S Filos
- Division of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Patras, Patras, Greece
| | | | - Markos Marangos
- Division of Infectious Diseases, School of Medicine, University of Patras, Patras, Greece
| | - Myrto Christofidou
- Department of Microbiology, School of Medicine, University of Patras, Patras, Greece
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