Bacteremia due to Pseudomonas aeruginosa: results from a 3-year national study in the Slovak Republic

Assessment of the Appropriateness of Ceftazidime Use in a Tertiary Teaching Hospital, Northern Ethiopia

Background

Ceftazidime is nowadays one of the most commonly used antibiotics due to its high antibacterial potency, wide spectrum of activity, and low potential for toxicity. However, the global trend shows huge misuse of ceftazidime.

Objective

This study was conducted to assess the appropriateness of ceftazidime use and to identify areas of intervention to prevent inappropriate use in different wards of Ayder Compressive Specialized Hospital, a tertiary teaching Hospital, Mekelle-Ethiopia.

Methods

A facility-based prospective cross-sectional study design was steered on 327 patients who received ceftazidime during their hospitalization in the selected wards from February 1 to April 30, 2019.

Results

In the assessment of the appropriateness of ceftazidime use, 2,084 (70.8%) were appropriate. Appropriateness of indication was 295 (90.2%), the effectiveness of ceftazidime use was 221 (67.6%), correct dose of ceftazidime use was 264 (80.4%), and the correct frequency of ceftazidime use was 230 (70.3%). Its use was empiric in 275 participants (84.1%) and specific in 52 (15.9%) participants. The most common indication for ceftazidime use was uncomplicated pneumonia, at 112 (34.3%). One hundred and seventy-one (52.3%) participants had intervention to prevent inappropriate use of ceftazidime. Changing the drug combination (96, 29.4%), increasing the dose (13, 4%), decreasing the dose (21, 6.4%), holding the (21, 6.4%), and discontinuation of ceftazidime (20, 6.1%) were among the interventions.

Conclusion

This study revealed that more than one-fourth of the ceftazidime use was inappropriate. This may lead to the emergence of resistant pathogens which in turn lead to treatment failure and increased the cost of therapy. Therefore, adherence to current evidence-based guidelines and initiating antimicrobial stewardship are recommended.

Risk factors for pan-resistant Pseudomonas aeruginosa bacteremia and the adequacy of antibiotic therapy

INTRODUCTION

The aim of this study was to determine risk factors for acquiring carbapenem-resistant Pseudomonas aeruginosa bacteremia (CR-PA) and factors associated with in-hospital mortality.

METHODS

Seventy-seven cases of bacteremia caused by P. aeruginosa were evaluated in a hospital with high incidence of CR-PA. Clinical and laboratorial factors, and previous use of antibiotics were also evaluated. In one analysis, CR-PA and carbapenem-susceptible P. aeruginosa (CS-PA) bacteremia were compared. A second analysis compared patients who died with survivors.

RESULTS

Among 77 P. aeruginosa bacteremia, 29 were caused by CR-PA. Admission to the intensive care unit, higher number of total leukocytes, and previous use of carbapenem were statistically associated with CR-PA. In the multivariate analysis, only previous use of carbapenem (including ertapenem) turned out to be a risk factor for CR-PA (p=0.014). The 30-day mortality of patients with P. aeruginosa bloodstream infection was 44.8% for CS-PA and 54.2% for patients with CR-PA (p=0.288). Chronic renal failure, admission to the intensive care unit, mechanical ventilation, and central venous catheter were risk factors for mortality. Incorrect treatment increased mortality of patients with bacteremia caused by CS-PA, but not for CR-SA. The odd ratio of mortality associated with incorrect therapy in patients with CS-PA was 3.30 (1.01-10.82; p=0.043). The mortality of patients with bacteremia caused by CR-PA was unexpectedly similar regardless of antimicrobial treatment adequacy.

CONCLUSION

Appropriate treatment for CS-PA bacteremia initiated within the first 24 hours was associated with lower mortality, but this cannot be extrapolated for CR-PA.

Impact of definitive therapy with beta-lactam monotherapy or combination with an aminoglycoside or a quinolone for Pseudomonas aeruginosa bacteremia

Background

Bacteremia by Pseudomonas aeruginosa represents one severe infection. It is not clear whether beta-lactam monotherapy leads to similar rates of treatment success compared to combinations of beta-lactams with aminoglycosides or quinolones.

Methods

Retrospective cohort study from 3 tertiary hospitals (2 in Greece and 1 in Italy). Pseudomonas aeruginosa isolates were susceptible to a beta-lactam and an aminoglycoside or a quinolone. Patients received appropriate therapy for at least 48 hours. Primary outcome of interest was treatment success in patients with definitive beta-lactam combination therapy compared to monotherapy. Secondary outcomes were treatment success keeping the same empirical and definitive regimen, mortality, and toxicity.

Results

Out of 92 bacteremias there were 54 evaluable episodes for the primary outcome (20 received monotherapy). Treatment success was higher with combination therapy (85%) compared to beta-lactam monotherapy (65%), however not statistically significantly [Odds ratio (OR) 3.1; 95% Confidence Interval (CI) 0.69–14.7, p = 0.1]. Very long (>2 months) hospitalisation before bacteremia was the only factor independently associated with treatment success (OR 0.73; 95% CI 0.01–0.95, p = 0.046), however this result entailed few episodes. All-cause mortality did not differ significantly between combination therapy [6/31 (19%)] and monotherapy [8/19 (42%)], p = 0.11. Only Charlson comorbidity index was associated with excess mortality (p = 0.03).

Conclusion

Our study, in accordance with previous ones, indicates that the choice between monotherapy and combination therapy may not affect treatment success significantly. However, our study does not have statistical power to identify small or moderate differences. A large randomized controlled trial evaluating this issue is justified.

Population-based study of the epidemiology and the risk factors for Pseudomonas aeruginosa bloodstream infection

BACKGROUND

Detailed population-based data on the epidemiology of Pseudomonas aeruginosa bloodstream infections are sparse. We sought to describe the incidence rate, risk factors, and outcomes associated with P. aeruginosa bacteremia in a large Canadian health region.

PATIENTS AND METHODS

A retrospective population-based surveillance for P. aeruginosa bacteremia was conducted in the Calgary Health Region (CHR, population:approx. 1.2 million) during the period from 2000 to 2006.

RESULTS

A total of 284 incident cases of P. aeruginosa bacteremia were identified in CHR residents, corresponding to an annual incidence rate of 3.6/100,000.Nosocomial acquisition accounted for 45% of cases,healthcare-associated community onset for 34% of cases,and community-acquired (CA) cases for 21%. Relative to the general population, risk factors for blood stream infection included male sex, increasing age, hemodialysis,solid organ transplant, diagnosis of cancer, heart disease, HIV infection, diabetes mellitus, and/or chronic obstructive airway disease (COPD). Overall mortality was 29%. Factors associated with mortality in univariate analysis included pulmonary focus of infection and co-morbidities, including chronic liver disease, substance abuse, heart disease, COPD, and cancer, and increased with the burden of co-morbidities. Despite those patients with CA disease having fewer co-morbidities,they had a significantly higher mortality rate than either healthcare-associated cases or nosocomial cases(RR 1.88, p = 0.05).

CONCLUSIONS

This study documents that P. aeruginosa bacteremic disease is responsible for a significant burden of illness in general populations and identifies those groups at increased risk of infection and subsequent mortality. This information can be used to identify those individuals likely to benefit from empiric anti-pseudomonal therapies.

Incidence of Pseudomonas aeruginosa bacteremia: a population-based study

BACKGROUND

The incidence of Pseudomonas aeruginosa bacteremia has not been defined in a population-based investigation.

METHODS

We performed a retrospective, population-based incidence study using resources of the Rochester Epidemiology Project of Olmsted County, Minnesota. We identified all Olmsted County residents with P. aeruginosa bacteremia between January 1, 1997, and December 31, 2006, by microbiology records in the only 2 laboratories in the county. Medical records were reviewed to confirm diagnosis, residency status, and clinical characteristics.

RESULTS

Age-adjusted incidence per 100,000 person-years was 10.8 (95% confidence interval [CI], 7.5-14.0) in men and 3.7 (95% CI, 2.2-5.2) in women for total P. aeruginosa bacteremia, and 8.4 (95% CI, 5.5-11.2) in men and 2.5 (95% CI, 1.3-3.8) in women for monomicrobial P. aeruginosa bacteremia. There was no significant change in incidence of total P. aeruginosa bacteremia during the past decade (P=.418). Incidence increased exponentially with age, with a greater magnitude of increase in men compared with women for total and monomicrobial P. aeruginosa bacteremia (P=.007 and P=.015, respectively). In patients with monomicrobial P. aeruginosa bacteremia, the median age was 69 years, and 78.4% of cases were either nosocomial or health care associated. Most patients had multiple comorbid conditions. The urinary tract was the most common primary source of infection. The 28-day all-cause mortality of monomicrobial P. aeruginosa bacteremia was 25.5%. In vitro susceptibility to ciprofloxacin was 95.3%.

CONCLUSION

To our knowledge, this is the first population-based incidence study of P. aeruginosa bacteremia. The incidence of P. aeruginosa bacteremia has remained stable during the past decade. Fluoroquinolone susceptibility is high among local P. aeruginosa bacteremia isolates.