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Assaad C, Chaibi K, Jaureguy F, Plésiat P, Carbonnelle E, Cohen Y, Zahar JR, Pilmis B. Risk factors for Pseudomonas aeruginosa VIM colonization or infection in the ICU: Case-control study. Am J Infect Control 2024; 52:1160-1165. [PMID: 38925502 DOI: 10.1016/j.ajic.2024.06.013] [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: 03/25/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Carbapenem-resistant strains of Pseudomonas aeruginosa (CRPA) have become a major health care concern in many countries, against which anti-infective strategies are limited and which require adequate infection control interventions. Knowing the different modes of transmission of CRPA in intensive care units (ICUs) would be helpful to adapt the means of prevention. METHODS The aim of this retrospective case-control study was conducted between January 1, 2017 and February 28, 2022 to identify the risk factors for the acquisition of CRPA in ICUs. RESULTS During the study period, 147 patients were included (49 cases and 98 controls). Among the 49 patients, 31 (63%) acquired CRPA in clusters and 18 (37%) sporadically. A univariate analysis showed that 4 variables were associated with CRPA acquisition, including (1) prior antibiotic prescriptions, (2) admission to rooms 203 and 207, (3) severity of illness at admission, and (4) use of mechanical ventilation. Multivariate analysis identified 3 factors of CRPA acquisition, including admission to room 203 (odds ratio [OR] = 29.5 [3.52-247.09]), previous antibiotic therapy (OR = 3.44 [1.02-11.76]), and severity of condition at admission (OR = 1.02 [1-1.04]). CONCLUSIONS Our study suggests the role of a contaminated environment in the acquisition of CRPA in the ICU, along with antibiotic use.
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Affiliation(s)
- Charbel Assaad
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Khalil Chaibi
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Françoise Jaureguy
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Patrick Plésiat
- Université de Franche-Comté, UMR CNRS 6249 Chrono-Environnement, Besançon, France; Laboratoire Associé du Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Etienne Carbonnelle
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Yves Cohen
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Jean-Ralph Zahar
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France.
| | - Benoit Pilmis
- Service de Microbiologie et Plateforme de Dosage des Anti-infection, Équipe Mobile de Microbiologie Clinique, Hôpitaux Saint-Joseph & Marie Lannelongue, Paris, France; Université Paris-Saclay, INRAE, AgroParisTech, UMR 1319, Micalis Institute, Jouy-en-Josas, France
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2
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Kain T, Dionne JC, Marshall JC. Critical illness and the gut microbiome. Intensive Care Med 2024; 50:1692-1694. [PMID: 38900282 DOI: 10.1007/s00134-024-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Taylor Kain
- Department of Critical Care Medicine, The University of Toronto, Toronto, Canada
- The University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Joanna C Dionne
- Department of Critical Care Medicine, The University of Toronto, Toronto, Canada
- Department of Gastroenterology, McMaster University, Hamilton, ON, Canada
- McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institutee, McMaster University, Hamilton, ON, Canada
| | - John C Marshall
- Department of Gastroenterology, McMaster University, Hamilton, ON, Canada.
- Department of Surgery, The University of Toronto, Toronto, Canada.
- The Li Ka Shing Knowledge Institute, Unity Health Toronto, 4th Floor Bond Wing, Rm. 4-014, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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3
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Wang C, Yang C, Wang D, Wang J, He D, Xu J. Ventilator-associated pneumonia caused by a new-found opportunistic fungal pathogen-Myceliophthora heterothallica: a case report. BMC Geriatr 2024; 24:790. [PMID: 39342216 PMCID: PMC11437987 DOI: 10.1186/s12877-024-05369-4] [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: 06/24/2024] [Accepted: 09/09/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Myceliophthora heterothallica belonging to Myceliophthora is considered as an environmental fungus and has not been reported to be pathogenic or colonizing in recent literature. The present case firstly reports a ventilation-associated pneumonia caused by Myceliophthora heterothallica among the aged adult. CASE PRESENTATION A 67-years-old Asian female patient suffering from a sudden disturbance of consciousness for 3 h was admitted to our hospital. Cardiac arrest occurred during emergency transport, and sinus rhythm was restored after cardiopulmonary resuscitation. Invasive mechanical ventilation was given to this patient for respiratory failure. After mechanical ventilation, the lung CT images showed multiple cuneiform nodules arranging subpleural accompanying with ground-glass opacity. On the 5th day of mechanical ventilation, Myceliophthora heterothallica was cultured from endotracheal aspirates. Two methods, namely automatic microbial identification system and internal transcribed spacer sequencing were employed to identify this fungus. The present case firstly uncovered the colonization ability and pathogenicity of Myceliophthora heterothallica in the respiratory tract. After 28d of treatment with piperacillin-tazobactam, this patient weaned from the ventilator and recovered from consciousness with lung infection disappearance. CONCLUSIONS This is the first case report of ventilation-associated pneumonia in the aged patient caused by Myceliophthora heterothallica. This current case is worth for the clinical diagnosis and treatment of Myceliophthora heterothallica infection, and also enriches new pathogenic species found of thermothelomyces species.
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Affiliation(s)
- Chengxin Wang
- Department of Laboratory Medicine, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun City, Jilin Province, 130021, China
| | - Chun Yang
- Department of Laboratory Medicine, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun City, Jilin Province, 130021, China
| | - Dan Wang
- Pathogenobiology, Jilin University Mycology Research Center, Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, No. 126 Xinmin Street, Changchun City, Jilin Province, 130021, China
| | - Jiayin Wang
- Department of Laboratory Medicine, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun City, Jilin Province, 130021, China
| | - Dan He
- Pathogenobiology, Jilin University Mycology Research Center, Key Laboratory of Pathobiology, Ministry of Education, College of Basic Medical Sciences, Jilin University, No. 126 Xinmin Street, Changchun City, Jilin Province, 130021, China.
| | - Jiancheng Xu
- Department of Laboratory Medicine, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun City, Jilin Province, 130021, China.
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4
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Kullberg RFJ, Wikki I, Haak BW, Kauko A, Galenkamp H, Peters-Sengers H, Butler JM, Havulinna AS, Palmu J, McDonald D, Benchraka C, Abdel-Aziz MI, Prins M, Maitland van der Zee AH, van den Born BJ, Jousilahti P, de Vos WM, Salomaa V, Knight R, Lahti L, Nieuwdorp M, Niiranen T, Wiersinga WJ. Association between butyrate-producing gut bacteria and the risk of infectious disease hospitalisation: results from two observational, population-based microbiome studies. THE LANCET. MICROBE 2024; 5:100864. [PMID: 38909617 DOI: 10.1016/s2666-5247(24)00079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/20/2024] [Accepted: 03/14/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Microbiota alterations are common in patients hospitalised for severe infections, and preclinical models have shown that anaerobic butyrate-producing gut bacteria protect against systemic infections. However, the relationship between microbiota disruptions and increased susceptibility to severe infections in humans remains unclear. We investigated the relationship between gut microbiota and the risk of future infection-related hospitalisation in two large population-based cohorts. METHODS In this observational microbiome study, gut microbiota were characterised using 16S rRNA gene sequencing in independent population-based cohorts from the Netherlands (HELIUS study; derivation cohort) and Finland (FINRISK 2002 study; validation cohort). HELIUS was conducted in Amsterdam, Netherlands, and included adults (aged 18-70 years at inclusion) who were randomly sampled from the municipality register of Amsterdam. FINRISK 2002 was conducted in six regions in Finland and is a population survey that included a random sample of adults (aged 25-74 years). In both cohorts, participants completed questionnaires, underwent a physical examination, and provided a faecal sample at inclusion (Jan 3, 2013, to Nov 27, 2015, for HELIUS participants and Jan 21 to April 19, 2002, for FINRISK participants. For inclusion in our study, a faecal sample needed to be provided and successfully sequenced, and national registry data needed to be available. Primary predictor variables were microbiota composition, diversity, and relative abundance of butyrate-producing bacteria. Our primary outcome was hospitalisation or mortality due to any infectious disease during 5-7-year follow-up after faecal sample collection, based on national registry data. We examined associations between microbiota and infection risk using microbial ecology and Cox proportional hazards. FINDINGS We profiled gut microbiota from 10 699 participants (4248 [39·7%] from the derivation cohort and 6451 [60·3%] from the validation cohort). 602 (5·6%) participants (152 [3·6%] from the derivation cohort; 450 [7·0%] from the validation cohort) were hospitalised or died due to infections during follow-up. Gut microbiota composition of these participants differed from those without hospitalisation for infections (derivation p=0·041; validation p=0·0002). Specifically, higher relative abundance of butyrate-producing bacteria was associated with a reduced risk of hospitalisation for infections (derivation cohort cause-specific hazard ratio 0·75 [95% CI 0·60-0·94] per 10% increase in butyrate producers, p=0·013; validation cohort 0·86 [0·77-0·96] per 10% increase, p=0·0077). These associations remained unchanged following adjustment for demographics, lifestyle, antibiotic exposure, and comorbidities. INTERPRETATION Gut microbiota composition, specifically colonisation with butyrate-producing bacteria, was associated with protection against hospitalisation for infectious diseases in the general population across two independent European cohorts. Further studies should investigate whether modulation of the microbiome can reduce the risk of severe infections. FUNDING Amsterdam UMC, Porticus, National Institutes of Health, Netherlands Organisation for Health Research and Development (ZonMw), and Leducq Foundation.
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Affiliation(s)
- Robert F J Kullberg
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Irina Wikki
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Bastiaan W Haak
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anni Kauko
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Henrike Galenkamp
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hessel Peters-Sengers
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Joe M Butler
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Aki S Havulinna
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland; Institute for Molecular Medicine Finland, FIMM-HiLIFE, Finland
| | - Joonatan Palmu
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland; Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Daniel McDonald
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | | | - Mahmoud I Abdel-Aziz
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Maria Prins
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Bert-Jan van den Born
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Internal Medicine, Division of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Pekka Jousilahti
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Willem M de Vos
- Laboratory of Microbiology, Wageningen University, Wageningen, Netherlands; Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Veikko Salomaa
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Rob Knight
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Leo Lahti
- Department of Computing, University of Turku, Turku, Finland
| | - Max Nieuwdorp
- Department of Internal Medicine, Division of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Teemu Niiranen
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland; Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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5
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Kuo SF, Huang TY, Lee CY, Lee CH. Comparison of the Direct Identification and Short-Term Incubation Methods for Positive Blood Cultures via MALDI-TOF Mass Spectrometry. Diagnostics (Basel) 2024; 14:1611. [PMID: 39125487 PMCID: PMC11311331 DOI: 10.3390/diagnostics14151611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/20/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Timely pathogen identification in bloodstream infections is crucial for patient care. A comparison is made between positive blood culture (BC) pellets from serum separator tubes using a direct identification (DI) method and colonies on agar plates from a short-term incubation (STI) method with a matrix-assisted laser desorption/ionization Biotyper for the evaluation of 354 monomicrobial BCs. Both the DI and STI methods exhibited similar identification rates for different types of bacteria, except for Gram-positive and anaerobic bacteria. The DI method's results aligned closely with the STI method's results for Enterobacterales, glucose-non-fermenting Gram-negative bacilli (GNB), and carbapenem-resistant Enterobacterales. The DI method exhibited high concordance with the conventional method for GNB identification, achieving 88.2 and 87.5% accuracy at the genus and species levels, respectively. Compared with the STI method, the DI method showed a less successful performance for Gram-positive bacterial identification (50.5 vs. 71.3%; p < 0.01). The DI method was useful for anaerobic bacterial identification of slow-growing microorganisms without any need for colony growth, unlike in the STI method (46.7 vs. 13.3%; p = 0.04). However, both methods could not identify yeast in positive BCs. Overall, the DI method provided reliable results for GNB identification, offering many advantages over the STI method by significantly reducing the turnaround time and enabling quicker pathogen identification in positive BCs.
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Affiliation(s)
- Shu-Fang Kuo
- Department of Laboratory Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (S.-F.K.); (C.-Y.L.)
- Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan;
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Microbiology Research and Treatment Center, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Chih-Yi Lee
- Department of Laboratory Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (S.-F.K.); (C.-Y.L.)
- Department of Medical Biotechnology and Laboratory Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan;
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
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6
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Chanderraj R, Admon AJ, He Y, Nuppnau M, Albin OR, Prescott HC, Dickson RP, Sjoding MW. Mortality of Patients With Sepsis Administered Piperacillin-Tazobactam vs Cefepime. JAMA Intern Med 2024; 184:769-777. [PMID: 38739397 PMCID: PMC11091820 DOI: 10.1001/jamainternmed.2024.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/11/2024] [Indexed: 05/14/2024]
Abstract
Importance Experimental and observational studies have suggested that empirical treatment for bacterial sepsis with antianaerobic antibiotics (eg, piperacillin-tazobactam) is associated with adverse outcomes compared with anaerobe-sparing antibiotics (eg, cefepime). However, a recent pragmatic clinical trial of piperacillin-tazobactam and cefepime showed no difference in short-term outcomes at 14 days. Further studies are needed to help clarify the empirical use of these agents. Objective To examine the use of piperacillin-tazobactam compared with cefepime in 90-day mortality in patients treated empirically for sepsis, using instrumental variable analysis of a 15-month piperacillin-tazobactam shortage. Design, Setting, and Participants In a retrospective cohort study, hospital admissions at the University of Michigan from July 1, 2014, to December 31, 2018, including a piperacillin-tazobactam shortage period from June 12, 2015, to September 18, 2016, were examined. Adult patients with suspected sepsis treated with vancomycin and either piperacillin-tazobactam or cefepime for conditions with presumed equipoise between piperacillin-tazobactam and cefepime were included in the study. Data analysis was conducted from December 17, 2022, to April 11, 2023. Main Outcomes and Measures The primary outcome was 90-day mortality. Secondary outcomes included organ failure-free, ventilator-free, and vasopressor-free days. The 15-month piperacillin-tazobactam shortage period was used as an instrumental variable for unmeasured confounding in antibiotic selection. Results Among 7569 patients (4174 men [55%]; median age, 63 [IQR 52-73] years) with sepsis meeting study eligibility, 4523 were treated with vancomycin and piperacillin-tazobactam and 3046 were treated with vancomycin and cefepime. Of patients who received piperacillin-tazobactam, only 152 (3%) received it during the shortage. Treatment groups did not differ significantly in age, Charlson Comorbidity Index score, Sequential Organ Failure Assessment score, or time to antibiotic administration. In an instrumental variable analysis, piperacillin-tazobactam was associated with an absolute mortality increase of 5.0% at 90 days (95% CI, 1.9%-8.1%) and 2.1 (95% CI, 1.4-2.7) fewer organ failure-free days, 1.1 (95% CI, 0.57-1.62) fewer ventilator-free days, and 1.5 (95% CI, 1.01-2.01) fewer vasopressor-free days. Conclusions and Relevance Among patients with suspected sepsis and no clear indication for antianaerobic coverage, administration of piperacillin-tazobactam was associated with higher mortality and increased duration of organ dysfunction compared with cefepime. These findings suggest that the widespread use of empirical antianaerobic antibiotics in sepsis may be harmful.
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Affiliation(s)
- Rishi Chanderraj
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Medicine Service, Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
| | - Andrew J. Admon
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ying He
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Mark Nuppnau
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Owen R. Albin
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
| | - Hallie C. Prescott
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Robert P. Dickson
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor
| | - Michael W. Sjoding
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor
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7
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Ocrospoma S, Restrepo MI. Severe aspiration pneumonia in the elderly. JOURNAL OF INTENSIVE MEDICINE 2024; 4:307-317. [PMID: 39035624 PMCID: PMC11258512 DOI: 10.1016/j.jointm.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/29/2023] [Accepted: 12/30/2023] [Indexed: 07/23/2024]
Abstract
The global population is aging at an unprecedented rate, resulting in a growing and vulnerable elderly population in need of efficient comprehensive healthcare services that include long-term care and skilled nursing facilities. In this context, severe aspiration pneumonia, a condition that carries substantial morbidity, mortality, and financial burden, especially among elderly patients requiring admission to the intensive care unit, has attracted greater concern. Aspiration pneumonia is defined as a pulmonary infection related to aspiration or dysphagia in etiology. Prior episodes of coughing on food or liquid intake, a history of relevant underlying conditions, abnormalities on videofluoroscopy or water swallowing, and gravity-dependent shadow distribution on chest imaging are among the clues that suggest aspiration. Patients with aspiration pneumonia tend to be elderly, frail, and suffering from more comorbidities than those without this condition. Here, we comprehensively address the epidemiology, clinical characteristics, diagnosis, treatment, prevention, and prognosis of severe aspiration community-acquired pneumonia in the elderly to optimize care of this high-risk demographic, enhance outcomes, and minimize the healthcare costs associated with this illness. Emphasizing preventive measures and effective management strategies is vital in ensuring the well-being of our aging population.
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Affiliation(s)
- Sebastian Ocrospoma
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Marcos I. Restrepo
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
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8
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Kitsios GD, Sayed K, Fitch A, Yang H, Britton N, Shah F, Bain W, Evankovich JW, Qin S, Wang X, Li K, Patel A, Zhang Y, Radder J, Dela Cruz C, Okin DA, Huang CY, Van Tyne D, Benos PV, Methé B, Lai P, Morris A, McVerry BJ. Longitudinal multicompartment characterization of host-microbiota interactions in patients with acute respiratory failure. Nat Commun 2024; 15:4708. [PMID: 38830853 PMCID: PMC11148165 DOI: 10.1038/s41467-024-48819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 05/13/2024] [Indexed: 06/05/2024] Open
Abstract
Critical illness can significantly alter the composition and function of the human microbiome, but few studies have examined these changes over time. Here, we conduct a comprehensive analysis of the oral, lung, and gut microbiota in 479 mechanically ventilated patients (223 females, 256 males) with acute respiratory failure. We use advanced DNA sequencing technologies, including Illumina amplicon sequencing (utilizing 16S and ITS rRNA genes for bacteria and fungi, respectively, in all sample types) and Nanopore metagenomics for lung microbiota. Our results reveal a progressive dysbiosis in all three body compartments, characterized by a reduction in microbial diversity, a decrease in beneficial anaerobes, and an increase in pathogens. We find that clinical factors, such as chronic obstructive pulmonary disease, immunosuppression, and antibiotic exposure, are associated with specific patterns of dysbiosis. Interestingly, unsupervised clustering of lung microbiota diversity and composition by 16S independently predicted survival and performed better than traditional clinical and host-response predictors. These observations are validated in two separate cohorts of COVID-19 patients, highlighting the potential of lung microbiota as valuable prognostic biomarkers in critical care. Understanding these microbiome changes during critical illness points to new opportunities for microbiota-targeted precision medicine interventions.
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Affiliation(s)
- Georgios D Kitsios
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Khaled Sayed
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
- Department of Electrical and Computer Engineering & Computer Science, University of New Haven, West Haven, CT, USA
| | - Adam Fitch
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Haopu Yang
- School of Medicine, Tsinghua University, Beijing, China
| | - Noel Britton
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MA, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Veteran's Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - William Bain
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Veteran's Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John W Evankovich
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shulin Qin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xiaohong Wang
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelvin Li
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Asha Patel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josiah Radder
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles Dela Cruz
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel A Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daria Van Tyne
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Barbara Methé
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peggy Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alison Morris
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
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9
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Nohra E, Appelbaum RD, Farrell MS, Carver T, Jung HS, Kirsch JM, Kodadek LM, Mandell S, Nassar AK, Pathak A, Paul J, Robinson B, Cuschieri J, Stein DM. Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9:e001303. [PMID: 38835635 PMCID: PMC11149120 DOI: 10.1136/tsaco-2023-001303] [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: 11/03/2023] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Abstract
The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.
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Affiliation(s)
- Eden Nohra
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rachel D Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Thomas Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hee Soo Jung
- Department of Surgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jordan Michael Kirsch
- Department of Surgery, Westchester Medical Center/ New York Medical College, Valhalla, NY, USA
| | - Lisa M Kodadek
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samuel Mandell
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aussama Khalaf Nassar
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jasmeet Paul
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland Baltimore, Baltimore, Maryland, USA
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10
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Fernández-Barat L, Torres A. Microbiota Profiling in Endotracheal Aspirates: Are There Differences When Obtained Through Endotracheal Tubes or Tracheostomy Tubes? Chest 2024; 165:1284-1285. [PMID: 38852961 DOI: 10.1016/j.chest.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 06/11/2024] Open
Affiliation(s)
- Laia Fernández-Barat
- Ciberes (CB06/06/0028)-Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain.
| | - Antoni Torres
- Ciberes (CB06/06/0028)-Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Respiratory and Intensive Care Unit, University of Barcelona, Hospital Clinic of Barcelona, Villarroel, Spain
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11
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Dörner PJ, Anandakumar H, Röwekamp I, Fiocca Vernengo F, Millet Pascual-Leone B, Krzanowski M, Sellmaier J, Brüning U, Fritsche-Guenther R, Pfannkuch L, Kurth F, Milek M, Igbokwe V, Löber U, Gutbier B, Holstein M, Heinz GA, Mashreghi MF, Schulte LN, Klatt AB, Caesar S, Wienhold SM, Offermanns S, Mack M, Witzenrath M, Jordan S, Beule D, Kirwan JA, Forslund SK, Wilck N, Bartolomaeus H, Heimesaat MM, Opitz B. Clinically used broad-spectrum antibiotics compromise inflammatory monocyte-dependent antibacterial defense in the lung. Nat Commun 2024; 15:2788. [PMID: 38555356 PMCID: PMC10981692 DOI: 10.1038/s41467-024-47149-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 03/20/2024] [Indexed: 04/02/2024] Open
Abstract
Hospital-acquired pneumonia (HAP) is associated with high mortality and costs, and frequently caused by multidrug-resistant (MDR) bacteria. Although prior antimicrobial therapy is a major risk factor for HAP, the underlying mechanism remains incompletely understood. Here, we demonstrate that antibiotic therapy in hospitalized patients is associated with decreased diversity of the gut microbiome and depletion of short-chain fatty acid (SCFA) producers. Infection experiments with mice transplanted with patient fecal material reveal that these antibiotic-induced microbiota perturbations impair pulmonary defense against MDR Klebsiella pneumoniae. This is dependent on inflammatory monocytes (IMs), whose fatty acid receptor (FFAR)2/3-controlled and phagolysosome-dependent antibacterial activity is compromized in mice transplanted with antibiotic-associated patient microbiota. Collectively, we characterize how clinically relevant antibiotics affect antimicrobial defense in the context of human microbiota, and reveal a critical impairment of IM´s antimicrobial activity. Our study provides additional arguments for the rational use of antibiotics and offers mechanistic insights for the development of novel prophylactic strategies to protect high-risk patients from HAP.
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Affiliation(s)
- Patrick J Dörner
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Harithaa Anandakumar
- Experimental and Clinical Research Center, a cooperation of Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ivo Röwekamp
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Facundo Fiocca Vernengo
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Belén Millet Pascual-Leone
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marta Krzanowski
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Josua Sellmaier
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Brüning
- Metabolomics Platform, Berlin Institute of Health at Charité, Berlin, Germany
| | | | - Lennart Pfannkuch
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Miha Milek
- Core Unit Bioinformatics, Berlin Institute of Health at Charité, Berlin, Germany
| | - Vanessa Igbokwe
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrike Löber
- Experimental and Clinical Research Center, a cooperation of Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Birgitt Gutbier
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Markus Holstein
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gitta Anne Heinz
- German Rheumatism Research Center, a Leibniz Institute, Berlin, Germany
| | | | - Leon N Schulte
- Department of Medicine, Institute for Lung Research, Philipps University Marburg, Marburg, Germany
- German center for lung research (DZL), Marburg, Germany
| | - Ann-Brit Klatt
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra Caesar
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sandra-Maria Wienhold
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan Offermanns
- Max-Planck-Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Matthias Mack
- Department of Nephrology, University Hospital Regensburg, Regensburg, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German center for lung research (DZL), Berlin, Germany
| | - Stefan Jordan
- Institute of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dieter Beule
- Core Unit Bioinformatics, Berlin Institute of Health at Charité, Berlin, Germany
| | - Jennifer A Kirwan
- Metabolomics Platform, Berlin Institute of Health at Charité, Berlin, Germany
| | - Sofia K Forslund
- Experimental and Clinical Research Center, a cooperation of Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Structural and Computational Biology Unit, European Molecular Biology Laboratory (EMBL), Heidelberg, Germany
| | - Nicola Wilck
- Experimental and Clinical Research Center, a cooperation of Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hendrik Bartolomaeus
- Experimental and Clinical Research Center, a cooperation of Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Markus M Heimesaat
- Institute of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bastian Opitz
- Department of Infectious Diseases, Respiratory Medicine and Critical Care, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- German center for lung research (DZL), Berlin, Germany.
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12
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Qian ET, Semler MW, Rice TW. Cefepime vs Piperacillin-Tazobactam for Acute Infection in Hospitalized Adults-Reply. JAMA 2024; 331:709-710. [PMID: 38411646 DOI: 10.1001/jama.2023.27891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Edward T Qian
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Chanderraj R, Dickson RP, Sjoding MW. Cefepime vs Piperacillin-Tazobactam for Acute Infection in Hospitalized Adults. JAMA 2024; 331:707-708. [PMID: 38411650 DOI: 10.1001/jama.2023.27897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Rishi Chanderraj
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Robert P Dickson
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Michael W Sjoding
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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14
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Gupta VK, Rajendraprasad S, Ozkan M, Ramachandran D, Ahmad S, Bakken JS, Laudanski K, Gajic O, Bauer B, Zec S, Freeman DW, Khanna S, Shah A, Skalski JH, Sung J, Karnatovskaia LV. Safety, feasibility, and impact on the gut microbiome of kefir administration in critically ill adults. BMC Med 2024; 22:80. [PMID: 38378568 PMCID: PMC10880344 DOI: 10.1186/s12916-024-03299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Dysbiosis of the gut microbiome is frequent in the intensive care unit (ICU), potentially leading to a heightened risk of nosocomial infections. Enhancing the gut microbiome has been proposed as a strategic approach to mitigate potential adverse outcomes. While prior research on select probiotic supplements has not successfully shown to improve gut microbial diversity, fermented foods offer a promising alternative. In this open-label phase I safety and feasibility study, we examined the safety and feasibility of kefir as an initial step towards utilizing fermented foods to mitigate gut dysbiosis in critically ill patients. METHODS We administered kefir in escalating doses (60 mL, followed by 120 mL after 12 h, then 240 mL daily) to 54 critically ill patients with an intact gastrointestinal tract. To evaluate kefir's safety, we monitored for gastrointestinal symptoms. Feasibility was determined by whether patients received a minimum of 75% of their assigned kefir doses. To assess changes in the gut microbiome composition following kefir administration, we collected two stool samples from 13 patients: one within 72 h of admission to the ICU and another at least 72 h after the first stool sample. RESULTS After administering kefir, none of the 54 critically ill patients exhibited signs of kefir-related bacteremia. No side effects like bloating, vomiting, or aspiration were noted, except for diarrhea in two patients concurrently on laxatives. Out of the 393 kefir doses prescribed for all participants, 359 (91%) were successfully administered. We were able to collect an initial stool sample from 29 (54%) patients and a follow-up sample from 13 (24%) patients. Analysis of the 26 paired samples revealed no increase in gut microbial α-diversity between the two timepoints. However, there was a significant improvement in the Gut Microbiome Wellness Index (GMWI) by the second timepoint (P = 0.034, one-sided Wilcoxon signed-rank test); this finding supports our hypothesis that kefir administration can improve gut health in critically ill patients. Additionally, the known microbial species in kefir were found to exhibit varying levels of engraftment in patients' guts. CONCLUSIONS Providing kefir to critically ill individuals is safe and feasible. Our findings warrant a larger evaluation of kefir's safety, tolerability, and impact on gut microbiome dysbiosis in patients admitted to the ICU. TRIAL REGISTRATION NCT05416814; trial registered on June 13, 2022.
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Affiliation(s)
- Vinod K Gupta
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sanu Rajendraprasad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mahmut Ozkan
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sumera Ahmad
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Section of Infectious Diseases, St Luke's Hospital, Duluth, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brent Bauer
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Simon Zec
- Department of Anesthesiology and Perioperative Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David W Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Sahil Khanna
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph H Skalski
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jaeyun Sung
- Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Surgery Research, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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15
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Cusack R, Little E, Martin-Loeches I. Practical Lessons on Antimicrobial Therapy for Critically Ill Patients. Antibiotics (Basel) 2024; 13:162. [PMID: 38391547 PMCID: PMC10886263 DOI: 10.3390/antibiotics13020162] [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: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis stands as a formidable global health challenge, with persistently elevated mortality rates in recent decades. Each year, sepsis not only contributes to heightened morbidity but also imposes substantial healthcare costs on survivors. This narrative review aims to highlight the targeted measures that can be instituted to alleviate the incidence and impact of sepsis in intensive care. Here we discuss measures to reduce nosocomial infections and the prevention of equipment and patient colonisation by resilient pathogens. The overarching global crisis of bacterial resistance to newly developed antimicrobial agents intensifies the imperative for antimicrobial stewardship and de-escalation. This urgency has been accentuated in recent years, notably during the COVID-19 pandemic, as high-dose steroids and opportunistic infections presented escalating challenges. Ongoing research into airway colonisation's role in influencing disease outcomes among critically ill patients underscores the importance of tailoring treatments to disease endotypes within heterogeneous populations, which are important lessons for intensivists in training. Looking ahead, the significance of novel antimicrobial delivery systems and drug monitoring is poised to increase. This narrative review delves into the multifaceted barriers and facilitators inherent in effectively treating critically ill patients vulnerable to nosocomial infections. The future trajectory of intensive care medicine hinges on the meticulous implementation of vigilant stewardship programs, robust infection control measures, and the continued exploration of innovative and efficient technological solutions within this demanding healthcare landscape.
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Affiliation(s)
- Rachael Cusack
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Elizabeth Little
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
- Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, 08180 Barcelona, Spain
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16
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Sung J, Rajendraprasad SS, Philbrick KL, Bauer BA, Gajic O, Shah A, Laudanski K, Bakken JS, Skalski J, Karnatovskaia LV. The human gut microbiome in critical illness: disruptions, consequences, and therapeutic frontiers. J Crit Care 2024; 79:154436. [PMID: 37769422 PMCID: PMC11034825 DOI: 10.1016/j.jcrc.2023.154436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/23/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
With approximately 39 trillion cells and over 20 million genes, the human gut microbiome plays an integral role in both health and disease. Modern living has brought a widespread use of processed food and beverages, antimicrobial and immunomodulatory drugs, and invasive procedures, all of which profoundly disrupt the delicate homeostasis between the host and its microbiome. Of particular interest is the human gut microbiome, which is progressively being recognized as an important contributing factor in many aspects of critical illness, from predisposition to recovery. Herein, we describe the current understanding of the adverse impacts of standard intensive care interventions on the human gut microbiome and delve into how these microbial alterations can influence patient outcomes. Additionally, we explore the potential association between the gut microbiome and post-intensive care syndrome, shedding light on a previously underappreciated avenue that may enhance patient recuperation following critical illness. There is an impending need for future epidemiological studies to encompass detailed phenotypic analyses of gut microbiome perturbations. Interventions aimed at restoring the gut microbiome represent a promising therapeutic frontier in the quest to prevent and treat critical illnesses.
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Affiliation(s)
- Jaeyun Sung
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Brent A Bauer
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Department of Infectious Diseases, St Luke's Hospital, Duluth, MN, United States of America
| | - Joseph Skalski
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
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17
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Drigot ZG, Clark SE. Insights into the role of the respiratory tract microbiome in defense against bacterial pneumonia. Curr Opin Microbiol 2024; 77:102428. [PMID: 38277901 PMCID: PMC10922932 DOI: 10.1016/j.mib.2024.102428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/28/2024]
Abstract
The respiratory tract microbiome (RTM) is a microbial ecosystem inhabiting different niches throughout the airway. A critical role for the RTM in dictating lung infection outcomes is underlined by recent efforts to identify community members benefiting respiratory tract health. Obligate anaerobes common in the oropharynx and lung such as Prevotella and Veillonella are associated with improved pneumonia outcomes and activate several immune defense pathways in the lower airway. Colonizers of the nasal cavity, including Corynebacterium and Dolosigranulum, directly impact the growth and virulence of lung pathogens, aligning with robust clinical correlations between their upper airway abundance and reduced respiratory tract infection risk. Here, we highlight recent work identifying respiratory tract bacteria that promote airway health and resilience against disease, with a focus on lung infections and the underlying mechanisms driving RTM-protective benefits.
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Affiliation(s)
- Zoe G Drigot
- University of Colorado School of Medicine, Department of Otolaryngology, Aurora, CO 80045, USA
| | - Sarah E Clark
- University of Colorado School of Medicine, Department of Otolaryngology, Aurora, CO 80045, USA.
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18
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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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19
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Baindara P, Mandal SM. Gut-Antimicrobial Peptides: Synergistic Co-Evolution with Antibiotics to Combat Multi-Antibiotic Resistance. Antibiotics (Basel) 2023; 12:1732. [PMID: 38136766 PMCID: PMC10740742 DOI: 10.3390/antibiotics12121732] [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: 11/29/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Due to huge diversity and dynamic competition, the human gut microbiome produces a diverse array of antimicrobial peptides (AMPs) that play an important role in human health. The gut microbiome has an important role in maintaining gut homeostasis by the AMPs and by interacting with other human organs via established connections such as the gut-lung, and gut-brain axis. Additionally, gut AMPs play a synergistic role with other gut microbiota and antimicrobials to maintain gut homeostasis by fighting against multi-antibiotic resistance (MAR) bacteria. Further, conventional antibiotics intake creates a synergistic evolutionary pressure for gut AMPs, where antibiotics and gut AMPs fight synergistically against MAR. Overall, gut AMPs are evolving under a complex and highly synergistic co-evolutionary pressure created by the various interactions between gut microbiota, gut AMPs, and antibiotics; however, the complete mechanism is not well understood. The current review explores the synergistic action of gut AMPs and antibiotics along with possibilities to fight against MAR bacteria.
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Affiliation(s)
- Piyush Baindara
- Radiation Oncology, NextGen Precision Health, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - Santi M. Mandal
- Department of Biotechnology, Indian Institute of Technology Kharagpur, Kharagpur 721302, India;
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20
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Mo S, Thursky K, Chronas A, Hall L, James R, Ierano C. Metronidazole prescribing practices in Australian hospitals: Measuring guideline compliance and appropriateness to support antimicrobial stewardship. J Infect Public Health 2023; 16 Suppl 1:90-96. [PMID: 37926594 DOI: 10.1016/j.jiph.2023.10.039] [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: 09/28/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Metronidazole is a commonly prescribed antimicrobial in Australian hospitals. Inappropriate use may increase risks to patient care, such as toxicities and antimicrobial resistance. To date, there is limited information on the quality of metronidazole prescriptions to inform antimicrobial stewardship and quality improvement initiatives. This study aims to describe the quality of metronidazole prescribing practices in Australian hospitals. METHODS Retrospective data analysis of the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Data were collected by auditors at each participating hospital using a standardised auditing tool. All data from 2013 to 2021 were de-identified and analysed descriptively. Variables included were antimicrobial prescribed, indication, guideline compliance and appropriateness. RESULTS Metronidazole was the fifth most prescribed antimicrobial in the Hospital NAPS dataset (2013-2021), accounting for 5.7 % (n = 14,197) of all antimicrobial prescriptions (n = 250,863). The proportion of metronidazole prescriptions declined by 2 % from 2013 to 2021 (p < 0.001). The most common indications were surgical prophylaxis (15.3 %), diverticulitis (9.4 %), aspiration pneumonia (7.3 %). Over half (53.5 %) of metronidazole prescriptions were deemed compliant with prescribing guidelines and 67.8 % were deemed appropriate. These rates were comparatively lower than the overall results of all antimicrobials. The primary documented reason for inappropriateness was that the spectrum was too broad (34.2 %). Surgical prophylaxis had the lowest rates of guideline compliance (53.8 %) and appropriateness (54.3 %). CONCLUSIONS Metronidazole remains widely used in Australian hospitals with suboptimal rates of guideline compliance and appropriateness. A noted area for improvement that we identified was using metronidazole when its spectrum was too broad, possibly when anaerobic therapy is unnecessary. With increasing international adoption of the Hospital NAPS programme, future comparative studies will be critical to identify global trends of antimicrobial prescribing quality. Antimicrobial stewardship (AMS) programmes have proven to be effective in improving prescribing quality and should be considered to specifically target improvements in metronidazole prescribing.
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Affiliation(s)
- Simone Mo
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Alexandros Chronas
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Lisa Hall
- Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia; School of Public Health, The University of Queensland, 266 Herston Rd, Herston, Queensland, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Courtney Ierano
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia.
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21
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Zinter MS, Dvorak CC, Mayday MY, Reyes G, Simon MR, Pearce EM, Kim H, Shaw PJ, Rowan CM, Auletta JJ, Martin PL, Godder K, Duncan CN, Lalefar NR, Kreml EM, Hume JR, Abdel-Azim H, Hurley C, Cuvelier GDE, Keating AK, Qayed M, Killinger JS, Fitzgerald JC, Hanna R, Mahadeo KM, Quigg TC, Satwani P, Castillo P, Gertz SJ, Moore TB, Hanisch B, Abdel-Mageed A, Phelan R, Davis DB, Hudspeth MP, Yanik GA, Pulsipher MA, Sulaiman I, Segal LN, Versluys BA, Lindemans CA, Boelens JJ, DeRisi JL. Pulmonary microbiome and transcriptome signatures reveal distinct pathobiologic states associated with mortality in two cohorts of pediatric stem cell transplant patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.29.23299130. [PMID: 38077035 PMCID: PMC10705623 DOI: 10.1101/2023.11.29.23299130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Lung injury is a major determinant of survival after pediatric hematopoietic cell transplantation (HCT). A deeper understanding of the relationship between pulmonary microbes, immunity, and the lung epithelium is needed to improve outcomes. In this multicenter study, we collected 278 bronchoalveolar lavage (BAL) samples from 229 patients treated at 32 children's hospitals between 2014-2022. Using paired metatranscriptomes and human gene expression data, we identified 4 patient clusters with varying BAL composition. Among those requiring respiratory support prior to sampling, in-hospital mortality varied from 22-60% depending on the cluster (p=0.007). The most common patient subtype, Cluster 1, showed a moderate quantity and high diversity of commensal microbes with robust metabolic activity, low rates of infection, gene expression indicating alveolar macrophage predominance, and low mortality. The second most common cluster showed a very high burden of airway microbes, gene expression enriched for neutrophil signaling, frequent bacterial infections, and moderate mortality. Cluster 3 showed significant depletion of commensal microbes, a loss of biodiversity, gene expression indicative of fibroproliferative pathways, increased viral and fungal pathogens, and high mortality. Finally, Cluster 4 showed profound microbiome depletion with enrichment of Staphylococci and viruses, gene expression driven by lymphocyte activation and cellular injury, and the highest mortality. BAL clusters were modeled with a random forest classifier and reproduced in a geographically distinct validation cohort of 57 patients from The Netherlands, recapitulating similar cluster-based mortality differences (p=0.022). Degree of antibiotic exposure was strongly associated with depletion of BAL microbes and enrichment of fungi. Potential pathogens were parsed from all detected microbes by analyzing each BAL microbe relative to the overall microbiome composition, which yielded increased sensitivity for numerous previously occult pathogens. These findings support personalized interpretation of the pulmonary microenvironment in pediatric HCT, which may facilitate biology-targeted interventions to improve outcomes.
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Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher C Dvorak
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Madeline Y Mayday
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Departments of Laboratory Medicine and Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Gustavo Reyes
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Miriam R Simon
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Emma M Pearce
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Hanna Kim
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Peter J Shaw
- The Children`s Hospital at Westmead, Sydney, Australia
| | - Courtney M Rowan
- Indiana University, Department of Pediatrics, Division of Critical Care Medicine, Indianapolis, IN, USA
| | - Jeffrey J Auletta
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Paul L Martin
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Kamar Godder
- Cancer and Blood Disorders Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Christine N Duncan
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Nahal R Lalefar
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, University of California San Francisco, Oakland, CA, USA
| | - Erin M Kreml
- Department of Child Health, Division of Critical Care Medicine, University of Arizona, Phoenix, AZ, USA
| | - Janet R Hume
- University of Minnesota, Department of Pediatrics, Division of Critical Care Medicine, Minneapolis, MN, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Division of Hematology/Oncology and Transplant and Cell Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Loma Linda University School of Medicine, Cancer Center, Children Hospital and Medical Center, Loma Linda, CA, USA
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Geoffrey D E Cuvelier
- CancerCare Manitoba, Manitoba Blood and Marrow Transplant Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amy K Keating
- Center for Cancer and Blood Disorders, Children's Hospital Colorado and University of Colorado, Aurora, CO, USA
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - James S Killinger
- Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Rabi Hanna
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kris M Mahadeo
- Department of Pediatrics, Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX, USA
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Troy C Quigg
- Pediatric Blood and Marrow Transplantation Program, Texas Transplant Institute, Methodist Children's Hospital, San Antonio, TX, USA
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, NY, USA
| | - Paul Castillo
- University of Florida, Gainesville, UF Health Shands Children's Hospital, Gainesville, FL, USA
| | - Shira J Gertz
- Department of Pediatrics, Division of Critical Care Medicine, Joseph M Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ, USA
- Department of Pediatrics, St. Barnabas Medical Center, Livingston, NJ, USA
| | - Theodore B Moore
- Department of Pediatric Hematology-Oncology, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - Benjamin Hanisch
- Children's National Hospital, Washington, District of Columbia, USA
| | - Aly Abdel-Mageed
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Rachel Phelan
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dereck B Davis
- Department of Pediatrics, Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle P Hudspeth
- Adult and Pediatric Blood & Marrow Transplantation, Pediatric Hematology/Oncology, Medical University of South Carolina Children's Hospital/Hollings Cancer Center, Charleston, SC, USA
| | - Greg A Yanik
- Pediatric Blood and Bone Marrow Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Pulsipher
- Division of Hematology, Oncology, Transplantation, and Immunology, Primary Children's Hospital, Huntsman Cancer Institute, Spense Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Imran Sulaiman
- Departments of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Leopoldo N Segal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Birgitta A Versluys
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Caroline A Lindemans
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jaap J Boelens
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
- Transplantation and Cellular Therapy, MSK Kids, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
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22
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Montassier E, Kitsios GD, Radder JE, Le Bastard Q, Kelly BJ, Panzer A, Lynch SV, Calfee CS, Dickson RP, Roquilly A. Robust airway microbiome signatures in acute respiratory failure and hospital-acquired pneumonia. Nat Med 2023; 29:2793-2804. [PMID: 37957375 DOI: 10.1038/s41591-023-02617-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/27/2023] [Indexed: 11/15/2023]
Abstract
Respiratory microbial dysbiosis is associated with acute respiratory distress syndrome (ARDS) and hospital-acquired pneumonia (HAP) in critically ill patients. However, we lack reproducible respiratory microbiome signatures that can increase our understanding of these conditions and potential treatments. Here, we analyze 16S rRNA sequencing data from 2,177 respiratory samples collected from 1,029 critically ill patients (21.7% with ARDS and 26.3% with HAP) and 327 healthy controls, sourced from 17 published studies. After data harmonization and pooling of individual patient data, we identified microbiota signatures associated with ARDS, HAP and prolonged mechanical ventilation. Microbiota signatures for HAP and prolonged mechanical ventilation were characterized by depletion of a core group of microbes typical of healthy respiratory samples, and the ARDS microbiota signature was distinguished by enrichment of potentially pathogenic respiratory microbes, including Pseudomonas and Staphylococcus. Using machine learning models, we identified clinically informative, three- and four-factor signatures that predicted ARDS, HAP and prolonged mechanical ventilation with relatively high accuracy (area under the curve of 0.751, 0.72 and 0.727, respectively). We validated the signatures in an independent prospective cohort of 136 patients on mechanical ventillation and found that patients with microbiome signatures associated with ARDS, HAP or prolonged mechanical ventilation had longer times to successful extubation than patients lacking these signatures (hazard ratios of 1.56 (95% confidence interval (CI) 1.07-2.27), 1.51 (95% CI 1.02-2.23) and 1.50 (95% CI 1.03-2.18), respectively). Thus, we defined and validated robust respiratory microbiome signatures associated with ARDS and HAP that may help to identify promising targets for microbiome therapeutic modulation in critically ill patients.
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Affiliation(s)
- Emmanuel Montassier
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université, Inserm, CHU Nantes, Nantes, France.
- Service des Urgences, Nantes Université, CHU Nantes, Nantes, France.
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josiah E Radder
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Brendan J Kelly
- Department of Medicine, Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, USA
| | - Ariane Panzer
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Susan V Lynch
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | - Robert P Dickson
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Antoine Roquilly
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université, Inserm, CHU Nantes, Nantes, France.
- Service d'Anesthesie Réanimation, Nantes Université, CHU Nantes, Nantes, France.
- Department of Microbiology and Immunology, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
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23
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Kitsios GD, Sayed K, Fitch A, Yang H, Britton N, Shah F, Bain W, Evankovich JW, Qin S, Wang X, Li K, Patel A, Zhang Y, Radder J, Dela Cruz C, Okin DA, Huang CY, van Tyne D, Benos PV, Methé B, Lai P, Morris A, McVerry BJ. Prognostic Insights from Longitudinal Multicompartment Study of Host-Microbiota Interactions in Critically Ill Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.25.23296086. [PMID: 37808745 PMCID: PMC10557814 DOI: 10.1101/2023.09.25.23296086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Critical illness can disrupt the composition and function of the microbiome, yet comprehensive longitudinal studies are lacking. We conducted a longitudinal analysis of oral, lung, and gut microbiota in a large cohort of 479 mechanically ventilated patients with acute respiratory failure. Progressive dysbiosis emerged in all three body compartments, characterized by reduced alpha diversity, depletion of obligate anaerobe bacteria, and pathogen enrichment. Clinical variables, including chronic obstructive pulmonary disease, immunosuppression, and antibiotic exposure, shaped dysbiosis. Notably, of the three body compartments, unsupervised clusters of lung microbiota diversity and composition independently predicted survival, transcending clinical predictors, organ dysfunction severity, and host-response sub-phenotypes. These independent associations of lung microbiota may serve as valuable biomarkers for prognostication and treatment decisions in critically ill patients. Insights into the dynamics of the microbiome during critical illness highlight the potential for microbiota-targeted interventions in precision medicine.
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Affiliation(s)
- Georgios D. Kitsios
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Khaled Sayed
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
- Department of Electrical and Computer Engineering & Computer Science, University of New Haven, West Haven, CT, USA
| | - Adam Fitch
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Haopu Yang
- School of Medicine, Tsinghua University, Beijing, China
| | - Noel Britton
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - William Bain
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John W. Evankovich
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shulin Qin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xiaohong Wang
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelvin Li
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Asha Patel
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josiah Radder
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles Dela Cruz
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel A Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daria van Tyne
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Barbara Methé
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peggy Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alison Morris
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA, USA
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24
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Widere JC, Davis CL, Loomba JJ, Bell TD, Enfield KB, Barros AJ. Early Empiric Antibiotic Use in Patients Hospitalized With COVID-19: A Retrospective Cohort Study. Crit Care Med 2023; 51:1168-1176. [PMID: 37125800 PMCID: PMC10426778 DOI: 10.1097/ccm.0000000000005901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To investigate temporal trends and outcomes associated with early antibiotic prescribing in patients hospitalized with COVID-19. DESIGN Retrospective propensity-matched cohort study using the National COVID Cohort Collaborative (N3C) database. SETTING Sixty-six health systems throughout the United States that were contributing to the N3C database. Centers that had fewer than 500 admissions in their dataset were excluded. PATIENTS Patients hospitalized with COVID-19 were included. Patients were defined to have early antibiotic use if they received at least 3 calendar days of intravenous antibiotics within the first 5 days of admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 322,867 qualifying first hospitalizations, 43,089 patients received early empiric antibiotics. Antibiotic use declined across all centers in the data collection period, from March 2020 (23%) to June 2022 (9.6%). Average rates of early empiric antibiotic use (EEAU) also varied significantly between centers (deviance explained 7.33% vs 20.0%, p < 0.001). Antibiotic use decreased slightly by day 2 of hospitalization and was significantly reduced by day 5. Mechanical ventilation before day 2 (odds ratio [OR] 3.57; 95% CI, 3.42-3.72), extracorporeal membrane oxygenation before day 2 (OR 2.14; 95% CI, 1.75-2.61), and early vasopressor use (OR 1.85; 95% CI, 1.78-1.93) but not region of residence was associated with EEAU. After propensity matching, EEAU was associated with an increased risk for in-hospital mortality (OR 1.27; 95% CI, 1.23-1.33), prolonged mechanical ventilation (OR 1.65; 95% CI, 1.50-1.82), late broad-spectrum antibiotic exposure (OR 3.24; 95% CI, 2.99-3.52), and late Clostridium difficile infection (OR 1.60; 95% CI, 1.37-1.87). CONCLUSIONS Although treatment of COVID-19 patients with empiric antibiotics has declined during the pandemic, the frequency of use remains high. There is significant inter-center variation in antibiotic prescribing practices and evidence of potential harm. Our findings are hypothesis-generating and future work should prospectively compare outcomes and adverse events.
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Affiliation(s)
| | - Claire Leilani Davis
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Johanna Jean Loomba
- Integrated Translational Health Research Institute of Virginia, University of Virginia, Charlottesville, VA
| | - Taison D Bell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Kyle B Enfield
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Andrew Julio Barros
- Division of Pulmonary and Critical Care, Department of Medicine, University of Virginia, Charlottesville, VA
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25
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Ray A, Kale SL, Ramonell RP. Bridging the Gap between Innate and Adaptive Immunity in the Lung: Summary of the Aspen Lung Conference 2022. Am J Respir Cell Mol Biol 2023; 69:266-280. [PMID: 37043828 PMCID: PMC10503303 DOI: 10.1165/rcmb.2023-0057ws] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/12/2023] [Indexed: 04/14/2023] Open
Abstract
Although significant strides have been made in the understanding of pulmonary immunology, much work remains to be done to comprehensively explain coordinated immune responses in the lung. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic only served to highlight the inadequacy of current models of host-pathogen interactions and reinforced the need for current and future generations of immunologists to unravel complex biological questions. As part of that effort, the 64th Annual Thomas L. Petty Aspen Lung Conference was themed "Bridging the Gap between Innate and Adaptive Immunity in the Lung" and featured exciting work from renowned immunologists. This report summarizes the proceedings of the 2022 Aspen Lung Conference, which was convened to discuss the roles played by innate and adaptive immunity in disease pathogenesis, evaluate the interface between the innate and adaptive immune responses, assess the role of adaptive immunity in the development of autoimmunity and autoimmune lung disease, discuss lessons learned from immunologic cancer treatments and approaches, and define new paradigms to harness the immune system to prevent and treat lung diseases.
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Affiliation(s)
- Anuradha Ray
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sagar L. Kale
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and
| | - Richard P. Ramonell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, and
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Abstract
Emerging evidence suggest a major role for the gut microbiome in wound infections. A Trojan Horse mechanism of surgical site infections has been hypothesized to occur when pathogens in the gut, gums, and periodontal areas enter an immune cell and silently travel to the wound site where they release their infectious payload. Genetic tracking of microbes at the strain level is now possible with genetic sequencing techniques and can clarify the origin of microbes that cause wound infections. An emerging field of dietary prehabilitation to modulate the microbiome before surgery is being described to improve infection-related outcomes from surgery.
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Affiliation(s)
- Sanjiv Hyoju
- Department of Surgery, University of Chicago, Pritzker School of Medicine, 5841 South Maryland, Chicago, IL 60637, USA
| | - Kaylie Machutta
- University of Nevada, Reno School of Medicine, 1664 North Virginia Street, Reno, NV 89557, USA
| | - Monika A Krezalek
- Northshore University Health Systems, 1000 Central Street Suite 800, Evanston, IL 60201, USA
| | - John C Alverdy
- Department of Surgery, University of Chicago, Pritzker School of Medicine, 5841 South Maryland, Chicago, IL 60637, USA.
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27
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Wiersinga WJ. Selective digestive decontamination- Not sure. Intensive Care Med 2023; 49:984-986. [PMID: 37336865 DOI: 10.1007/s00134-023-07115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/28/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Willem Joost Wiersinga
- Division of Infectious Diseases and Center for Experimental and Molecular Medicine, Department of Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105 AZ, Amsterdam, The Netherlands.
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28
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Kreitmann L, Jermoumi S, Vasseur M, Chabani M, Nourry E, Richard JC, Wallet F, Garçon P, Kachmar S, Zerbib Y, Van Grunderbeeck N, Vinsonneau C, Duhamel A, Labreuche J, Nseir S. Relationship between COVID-19 and ICU-acquired colonization and infection related to multidrug-resistant bacteria: a prospective multicenter before-after study. Intensive Care Med 2023; 49:796-807. [PMID: 37326645 DOI: 10.1007/s00134-023-07109-5] [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: 03/06/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE Patients presenting the most severe form of coronavirus disease 2019 (COVID-19) pneumonia, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have a prolonged intensive care unit (ICU) stay and are exposed to broad-spectrum antibiotics, but the impact of COVID-19 on antimicrobial resistance is unknown. METHODS Observational prospective before-after study in 7 ICUs in France. All consecutive patients with an ICU stay > 48 h and a confirmed SARS-CoV-2 infection were included prospectively and followed for 28 days. Patients underwent systematic screening for colonization with multidrug-resistant (MDR) bacteria upon admission and every week subsequently. COVID-19 patients were compared to a recent prospective cohort of control patients from the same ICUs. The primary objective was to investigate the association of COVID-19 with the cumulative incidence of a composite outcome including ICU-acquired colonization and/or infection related to MDR bacteria (ICU-MDR-col and ICU-MDR-inf, respectively). RESULTS From February 27th, 2020 to June 2nd, 2021, 367 COVID-19 patients were included, and compared to 680 controls. After adjustment for prespecified baseline confounders, the cumulative incidence of ICU-MDR-col and/or ICU-MDR-inf was not significantly different between groups (adjusted sub-hazard ratio [sHR] 1.39, 95% confidence interval [CI] 0.91-2.09). When considering both outcomes separately, COVID-19 patients had a higher incidence of ICU-MDR-inf than controls (adjusted sHR 2.50, 95% CI 1.90-3.28), but the incidence of ICU-MDR-col was not significantly different between groups (adjusted sHR 1.27, 95% CI 0.85-1.88). CONCLUSION COVID-19 patients had an increased incidence of ICU-MDR-inf compared to controls, but the difference was not significant when considering a composite outcome including ICU-MDR-col and/or ICU-MDR-inf.
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Affiliation(s)
- Louis Kreitmann
- Médecine Intensive Réanimation, Hôpital R. Salengro, CHU de Lille, Rue E. Laine, 59037, Lille Cedex, France
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Sonia Jermoumi
- Médecine Intensive Réanimation, Hôpital R. Salengro, CHU de Lille, Rue E. Laine, 59037, Lille Cedex, France
| | - Margot Vasseur
- Médecine Intensive Réanimation, Hôpital R. Salengro, CHU de Lille, Rue E. Laine, 59037, Lille Cedex, France
| | - Myriam Chabani
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Emilie Nourry
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Jean-Christophe Richard
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital de la Croix Rousse, 69004, Lyon, France
| | - Florent Wallet
- Service de Réanimation, Hospices Civils de Lyon, Groupement Hospitalier Sud, 69637, Pierre Bénite, France
- Centre International de Recherche en Infectiologie (CIRI), INSERM U1111, CNRS UMR5308, ENS Lyon, Université Claude Bernard Lyon, Lyon, France
| | - Pierre Garçon
- Réanimation, Grand Hôpital de l'Est Francilien, Site de Marne-la-Vallée, Jossigny, France
| | - Safaâ Kachmar
- Réanimation, Grand Hôpital de l'Est Francilien, Site de Marne-la-Vallée, Jossigny, France
| | - Yoann Zerbib
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | | | | | - Alain Duhamel
- Department of Biostatistics, CHU Lille, 59000, Lille, France
| | | | - Saad Nseir
- Médecine Intensive Réanimation, Hôpital R. Salengro, CHU de Lille, Rue E. Laine, 59037, Lille Cedex, France.
- Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, 59000, Lille, France.
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29
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Kitsios GD, Nguyen VD, Sayed K, Al-Yousif N, Schaefer C, Shah FA, Bain W, Yang H, Fitch A, Li K, Wang X, Qin S, Gentry H, Zhang Y, Varon J, Arciniegas Rubio A, Englert JA, Baron RM, Lee JS, Methé B, Benos PV, Morris A, McVerry BJ. The upper and lower respiratory tract microbiome in severe aspiration pneumonia. iScience 2023; 26:106832. [PMID: 37250794 PMCID: PMC10212968 DOI: 10.1016/j.isci.2023.106832] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/24/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Uncertainty persists whether anaerobic bacteria represent important pathogens in aspiration pneumonia. In a nested case-control study of mechanically ventilated patients classified as macro-aspiration pneumonia (MAsP, n = 56), non-macro-aspiration pneumonia (NonMAsP, n = 91), and uninfected controls (n = 11), we profiled upper (URT) and lower respiratory tract (LRT) microbiota with bacterial 16S rRNA gene sequencing, measured plasma host-response biomarkers, analyzed bacterial communities by diversity and oxygen requirements, and performed unsupervised clustering with Dirichlet Multinomial Models (DMM). MAsP and NonMAsP patients had indistinguishable microbiota profiles by alpha diversity and oxygen requirements with similar host-response profiles and 60-day survival. Unsupervised DMM clusters revealed distinct bacterial clusters in the URT and LRT, with low-diversity clusters enriched for facultative anaerobes and typical pathogens, associated with higher plasma levels of SPD and sCD14 and worse 60-day survival. The predictive inter-patient variability in these bacterial profiles highlights the importance of microbiome study in patient sub-phenotyping and precision medicine approaches for severe pneumonia.
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Affiliation(s)
- Georgios D. Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Vi D. Nguyen
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- University of California Los Angeles, Department of Medicine, Internal Medicine Residency Program, Los Angeles, CA90095, USA
| | - Khaled Sayed
- University of PittsburghDepartment of Computational & Systems Biology, Pittsburgh, PA15213, USA
- Department of Epidemiology, University of Florida, Gainesville, FL32611, USA
| | - Nameer Al-Yousif
- University of Pittsburgh Medical Center Mercy, Department of Medicine, Pittsburgh, PA15219, USA
| | - Caitlin Schaefer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Faraaz A. Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
- Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA15240, USA
| | - William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
- Veteran’s Affairs Pittsburgh Healthcare System, Pittsburgh, PA15240, USA
| | - Haopu Yang
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- School of Medicine, Tsinghua University, Beijing, China
| | - Adam Fitch
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Kelvin Li
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Xiaohong Wang
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
| | - Shulin Qin
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Heather Gentry
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Jack Varon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA02115, USA
| | - Antonio Arciniegas Rubio
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA02115, USA
| | - Joshua A. Englert
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH43210, USA
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA02115, USA
| | - Janet S. Lee
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO63110, USA
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
| | - Panayiotis V. Benos
- Department of Epidemiology, University of Florida, Gainesville, FL32611, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA15213, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA15213, USA
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, PA15213, USA
- Acute Lung Injury Center for Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, PA15213, USA
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Zijlstra GJ, de Grooth HJS. Anti-anaerobic antibiotics: indication is key. Eur Respir J 2023; 61:61/5/2300318. [PMID: 37169380 DOI: 10.1183/13993003.00318-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 05/13/2023]
Affiliation(s)
- G Jan Zijlstra
- Department of Intensive Care, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands
| | - Harm-Jan S de Grooth
- Department of Intensive Care, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands
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31
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Kullberg RFJ, Schinkel M, Wiersinga WJ. Empiric anti-anaerobic antibiotics are associated with adverse clinical outcomes in emergency department patients. Eur Respir J 2023; 61:61/5/2300413. [PMID: 37169379 DOI: 10.1183/13993003.00413-2023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Robert F J Kullberg
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- These authors contributed equally
| | - Michiel Schinkel
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- These authors contributed equally
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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32
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Chanderraj R, Baker JM, Kay SG, Brown CA, Hinkle KJ, Fergle DJ, McDonald RA, Falkowski NR, Metcalf JD, Kaye KS, Woods RJ, Prescott HC, Sjoding MW, Dickson RP. Reply to: Anti-anaerobic antibiotics: indication is key. Eur Respir J 2023; 61:61/5/2300492. [PMID: 37169381 DOI: 10.1183/13993003.00492-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Rishi Chanderraj
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Medicine Service, Infectious Diseases Section, Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer M Baker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephen G Kay
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Christopher A Brown
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Research on Innovation and Science, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Kevin J Hinkle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel J Fergle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Roderick A McDonald
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicole R Falkowski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joseph D Metcalf
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Robert J Woods
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Medicine Service, Infectious Diseases Section, Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, MI, USA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, MI, USA
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Bongers KS, Chanderraj R, Woods RJ, McDonald RA, Adame MD, Falkowski NR, Brown CA, Baker JM, Winner KM, Fergle DJ, Hinkle KJ, Standke AK, Vendrov KC, Young VB, Stringer KA, Sjoding MW, Dickson RP. The Gut Microbiome Modulates Body Temperature Both in Sepsis and Health. Am J Respir Crit Care Med 2023; 207:1030-1041. [PMID: 36378114 PMCID: PMC10112447 DOI: 10.1164/rccm.202201-0161oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: Among patients with sepsis, variation in temperature trajectories predicts clinical outcomes. In healthy individuals, normal body temperature is variable and has decreased consistently since the 1860s. The biologic underpinnings of this temperature variation in disease and health are unknown. Objectives: To establish and interrogate the role of the gut microbiome in calibrating body temperature. Methods: We performed a series of translational analyses and experiments to determine whether and how variation in gut microbiota explains variation in body temperature in sepsis and in health. We studied patient temperature trajectories using electronic medical record data. We characterized gut microbiota in hospitalized patients using 16S ribosomal RNA gene sequencing. We modeled sepsis using intraperitoneal LPS in mice and modulated the microbiome using antibiotics, germ-free, and gnotobiotic animals. Measurements and Main Results: Consistent with prior work, we identified four temperature trajectories in patients hospitalized with sepsis that predicted clinical outcomes. In a separate cohort of 116 hospitalized patients, we found that the composition of patients' gut microbiota at admission predicted their temperature trajectories. Compared with conventional mice, germ-free mice had reduced temperature loss during experimental sepsis. Among conventional mice, heterogeneity of temperature response in sepsis was strongly explained by variation in gut microbiota. Healthy germ-free and antibiotic-treated mice both had lower basal body temperatures compared with control animals. The Lachnospiraceae family was consistently associated with temperature trajectories in hospitalized patients, experimental sepsis, and antibiotic-treated mice. Conclusions: The gut microbiome is a key modulator of body temperature variation in both health and critical illness and is thus a major, understudied target for modulating physiologic heterogeneity in sepsis.
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Affiliation(s)
| | - Rishi Chanderraj
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Medicine Service, Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Robert J. Woods
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Medicine Service, Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Center for Computational Medicine and Bioinformatics and
| | | | - Mark D. Adame
- Division of Pulmonary and Critical Care Medicine and
| | | | - Christopher A. Brown
- Division of Pulmonary and Critical Care Medicine and
- Institute for Research on Innovation and Science, Institute for Social Research
| | - Jennifer M. Baker
- Division of Pulmonary and Critical Care Medicine and
- Department of Microbiology and Immunology, Medical School
| | - Katherine M. Winner
- Division of Pulmonary and Critical Care Medicine and
- Department of Microbiology and Immunology, Medical School
| | | | | | - Alexandra K. Standke
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Kimberly C. Vendrov
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Vincent B. Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Department of Microbiology and Immunology, Medical School
| | - Kathleen A. Stringer
- Division of Pulmonary and Critical Care Medicine and
- Department of Clinical Pharmacy, College of Pharmacy, and
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
| | - Michael W. Sjoding
- Division of Pulmonary and Critical Care Medicine and
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; and
- Weil Institute for Critical Care Research & Innovation, Ann Arbor, Michigan
| | - Robert P. Dickson
- Division of Pulmonary and Critical Care Medicine and
- Department of Microbiology and Immunology, Medical School
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; and
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34
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Schlechte J, Zucoloto AZ, Yu IL, Doig CJ, Dunbar MJ, McCoy KD, McDonald B. Dysbiosis of a microbiota-immune metasystem in critical illness is associated with nosocomial infections. Nat Med 2023; 29:1017-1027. [PMID: 36894652 PMCID: PMC10115642 DOI: 10.1038/s41591-023-02243-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/30/2023] [Indexed: 03/11/2023]
Abstract
Critically ill patients in intensive care units experience profound alterations of their gut microbiota that have been linked to a high risk of hospital-acquired (nosocomial) infections and adverse outcomes through unclear mechanisms. Abundant mouse and limited human data suggest that the gut microbiota can contribute to maintenance of systemic immune homeostasis, and that intestinal dysbiosis may lead to defects in immune defense against infections. Here we use integrated systems-level analyses of fecal microbiota dynamics in rectal swabs and single-cell profiling of systemic immune and inflammatory responses in a prospective longitudinal cohort study of critically ill patients to show that the gut microbiota and systemic immunity function as an integrated metasystem, where intestinal dysbiosis is coupled to impaired host defense and increased frequency of nosocomial infections. Longitudinal microbiota analysis by 16s rRNA gene sequencing of rectal swabs and single-cell profiling of blood using mass cytometry revealed that microbiota and immune dynamics during acute critical illness were highly interconnected and dominated by Enterobacteriaceae enrichment, dysregulated myeloid cell responses and amplified systemic inflammation, with a lesser impact on adaptive mechanisms of host defense. Intestinal Enterobacteriaceae enrichment was coupled with impaired innate antimicrobial effector responses, including hypofunctional and immature neutrophils and was associated with an increased risk of infections by various bacterial and fungal pathogens. Collectively, our findings suggest that dysbiosis of an interconnected metasystem between the gut microbiota and systemic immune response may drive impaired host defense and susceptibility to nosocomial infections in critical illness.
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Affiliation(s)
- Jared Schlechte
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amanda Z Zucoloto
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian-Ling Yu
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary J Dunbar
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathy D McCoy
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Kreitmann L, Vasseur M, Labreuche J, Nseir S. Relationship of multidrug-resistant bacterial colonization and immune status of patients in the ICU. Author's reply. Intensive Care Med 2023; 49:481-482. [PMID: 36912965 DOI: 10.1007/s00134-023-07016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Louis Kreitmann
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France
- Médecine Intensive Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France
| | - Margot Vasseur
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France
| | | | - Saad Nseir
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France.
- Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, 59000, Lille, France.
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Qian ET, Casey JD, Wright A, Wang L, Siemann J, Dear ML, Stollings J, Lloyd BD, Seitz K, Nelson G, Wright P, Siew ED, Dennis B, Wrenn J, Andereck J, Self WH, Semler MW, Rice TW. Protocol and statistical analysis plan for the Antibiotic Choice On ReNal outcomes (ACORN) randomised clinical trial. BMJ Open 2023; 13:e066995. [PMID: 36898748 PMCID: PMC10008324 DOI: 10.1136/bmjopen-2022-066995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/02/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Antibiotics are time-critical in the management of sepsis. When infectious organisms are unknown, patients are treated with empiric antibiotics to include coverage for gram-negative organisms, such as antipseudomonal cephalosporins and penicillins. However, in observational studies, some antipseudomonal cephalosporins (eg, cefepime) are associated with neurologic dysfunction while the most common antipseudomonal penicillin (piperacillin-tazobactam) is associated with acute kidney injury (AKI). No randomised control trials have compared these regimens. This manuscript describes the protocol and analysis plan for a trial designed to compare the effects of antipseudomonal cephalosporins and antipseudomonal penicillins among acutely ill patients receiving empiric antibiotics. METHODS AND ANALYSIS The Antibiotic Choice On ReNal outcomes trial is a prospective, single-centre, non-blinded randomised trial being conducted at Vanderbilt University Medical Center. The trial will enrol 2500 acutely ill adults receiving gram-negative coverage for treatment of infection. Eligible patients are randomised 1:1 to receive cefepime or piperacillin-tazobactam on first order entry of a broad-spectrum antibiotic covering gram-negative organisms. The primary outcome is the highest stage of AKI and death occurring between enrolment and 14 days after enrolment. This will be compared between patients randomised to cefepime and randomised to piperacillin-tazobactam using an unadjusted proportional odds regression model. The secondary outcomes are major adverse kidney events through day 14 and number of days alive and free of delirium and coma in 14 days after enrolment. Enrolment began on 10 November 2021 and is expected to be completed in December 2022. ETHICS AND DISSEMINATION The trial was approved by the Vanderbilt University Medical Center institutional review board (IRB#210591) with a waiver of informed consent. Results will be submitted to a peer-reviewed journal and presented at scientific conferences. TRIAL REGISTRATION NUMBER NCT05094154.
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Affiliation(s)
- Edward Tang Qian
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Justin Siemann
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joanna Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bradley Daniel Lloyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin Seitz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - George Nelson
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patty Wright
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bradley Dennis
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jesse Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Andereck
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Yoshimatsu Y, Aga M, Komiya K, Haranaga S, Numata Y, Miki M, Higa F, Senda K, Teramoto S. The Clinical Significance of Anaerobic Coverage in the Antibiotic Treatment of Aspiration Pneumonia: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:1992. [PMID: 36902779 PMCID: PMC10004249 DOI: 10.3390/jcm12051992] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
INTRODUCTION Aspiration pneumonia is increasingly recognised as a common condition. While antibiotics covering anaerobes are thought to be necessary based on old studies reporting anaerobes as causative organisms, recent studies suggest that it may not necessarily benefit prognosis, or even be harmful. Clinical practice should be based on current data reflecting the shift in causative bacteria. The aim of this review was to investigate whether anaerobic coverage is recommended in the treatment of aspiration pneumonia. METHODS A systematic review and meta-analysis of studies comparing antibiotics with and without anaerobic coverage in the treatment of aspiration pneumonia was performed. The main outcome studied was mortality. Additional outcomes were resolution of pneumonia, development of resistant bacteria, length of stay, recurrence, and adverse effects. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS From an initial 2523 publications, one randomised control trial and two observational studies were selected. The studies did not show a clear benefit of anaerobic coverage. Upon meta-analysis, there was no benefit of anaerobic coverage in improving mortality (Odds ratio 1.23, 95% CI 0.67-2.25). Studies reporting resolution of pneumonia, length of hospital stay, recurrence of pneumonia, and adverse effects showed no benefit of anaerobic coverage. The development of resistant bacteria was not discussed in these studies. CONCLUSION In the current review, there are insufficient data to assess the necessity of anaerobic coverage in the antibiotic treatment of aspiration pneumonia. Further studies are needed to determine which cases require anaerobic coverage, if any.
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Affiliation(s)
- Yuki Yoshimatsu
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London SE18 4QH, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London SE9 2HB, UK
| | - Masaharu Aga
- Department of Respiratory Medicine, Yokohama Municipal Citizen’s Hospital, Yokohama 221-0855, Japan
| | - Kosaku Komiya
- Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu 879-5593, Japan
| | - Shusaku Haranaga
- Comprehensive Health Professions Education Center, University Hospital, University of the Ryukyus, Okinawa 903-0125, Japan
| | - Yuka Numata
- Department of Respiratory Medicine, Nagaoka Red Cross Hospital, Nagaoka 940-2085, Japan
| | - Makoto Miki
- Department of Respiratory Medicine, Japanese Red Cross Sendai Hospital, Sendai 982-0801, Japan
| | - Futoshi Higa
- Department of Respiratory Medicine, National Hospital Organization Okinawa National Hospital, Okinawa 901-2214, Japan
| | - Kazuyoshi Senda
- Department Pharmacy, Kinjo Gakuin University, Nagoya 463-8521, Japan
| | - Shinji Teramoto
- Department of Respiratory Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo 160-0023, Japan
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Trøseid M, Holter JC, Holm K, Vestad B, Sazonova T, Granerud BK, Dyrhol-Riise AM, Holten AR, Tonby K, Kildal AB, Heggelund L, Tveita A, Bøe S, Müller KE, Jenum S, Hov JR, Ueland T. Gut microbiota composition during hospitalization is associated with 60-day mortality after severe COVID-19. Crit Care 2023; 27:69. [PMID: 36814280 PMCID: PMC9946863 DOI: 10.1186/s13054-023-04356-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/12/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Gut microbiota alterations have been reported in hospitalized COVID-19 patients, with reduced alpha diversity and altered microbiota composition related to respiratory failure. However, data regarding gut microbiota and mortality are scarce. METHODS Rectal swabs for gut microbiota analyses were collected within 48 h after hospital admission (baseline; n = 123) and three-month post-admission (n = 50) in a subset of patients included in the Norwegian SARS-CoV2 cohort study. Samples were analysed by sequencing the 16S rRNA gene. Gut microbiota diversity and composition at baseline were assessed in relation to need for intensive care unit (ICU) admission during hospitalization. The primary objective was to investigate whether the ICU-related gut microbiota was associated with 60-day mortality. RESULTS Gut microbiota diversity (Shannon index) at baseline was lower in COVID-19 patients requiring ICU admission during hospitalization than in those managed in general wards. A dysbiosis index representing a balance of enriched and reduced taxa in ICU compared with ward patients, including decreased abundance of butyrate-producing microbes and enrichment of a partly oral bacterial flora, was associated with need of ICU admission independent of antibiotic use, dexamethasone use, chronic pulmonary disease, PO2/FiO2 ratio, C-reactive protein, neutrophil counts or creatinine levels (adjusted p < 0.001). The ICU-related dysbiosis index at baseline correlated with systemic inflammation and was associated with 60-day mortality in univariate analyses (Hazard ratio 3.70 [2.00-8.6], p < 0.001), as well as after separate adjustment for covariates. At the three-month follow-up, the dysbiosis index remained elevated in ICU patients compared with ward patients (adjusted p = 0.007). CONCLUSIONS Although our data should be regarded as exploratory due to low number of clinical end points, they suggest that gut microbiota alterations during hospitalization could be related to poor prognosis after severe COVID-19. Larger studies of gut involvement during COVID-19 in relation to long-term clinical outcome are warranted. Trial registration NCT04381819 . Retrospectively registered May 11, 2020.
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Affiliation(s)
- Marius Trøseid
- Research Institute of Internal Medicine, Oslo University Hospital, 0424, Oslo, Norway. .,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, 0424, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, 0315, Oslo, Norway.
| | - Jan Cato Holter
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Microbiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Kristian Holm
- grid.55325.340000 0004 0389 8485Research Institute of Internal Medicine, Oslo University Hospital, 0424 Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital, Oslo, Norway
| | - Beate Vestad
- grid.55325.340000 0004 0389 8485Research Institute of Internal Medicine, Oslo University Hospital, 0424 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital, Oslo, Norway
| | - Taisiia Sazonova
- grid.55325.340000 0004 0389 8485Research Institute of Internal Medicine, Oslo University Hospital, 0424 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital, Oslo, Norway
| | - Beathe K. Granerud
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Microbiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Anne Ma Dyrhol-Riise
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway
| | - Aleksander R. Holten
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Kristian Tonby
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway
| | - Anders Benjamin Kildal
- grid.412244.50000 0004 4689 5540Department of Anesthesiology and Intensive Care, University Hospital of North Norway, 9019 Tromsö, Norway ,grid.10919.300000000122595234Department of Clinical Medicine, Faculty of Health Sciences, UIT – The Arctic University of Norway, 9019 Tromsö, Norway
| | - Lars Heggelund
- grid.470118.b0000 0004 0627 3835Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, 3004 Drammen, Norway ,grid.7914.b0000 0004 1936 7443Department of Clinical Science, Faculty of Medicine, University of Bergen, 5009 Bergen, Norway
| | - Anders Tveita
- grid.55325.340000 0004 0389 8485Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway ,grid.414168.e0000 0004 0627 3595Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, 1346 Gjettum, Norway
| | - Simen Bøe
- Department of Anesthesiology and Intensive Care, Hammerfest County Hospital, Hammerfest, Norway
| | - Karl Erik Müller
- grid.470118.b0000 0004 0627 3835Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, 3004 Drammen, Norway
| | - Synne Jenum
- grid.55325.340000 0004 0389 8485Department of Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway
| | - Johannes R. Hov
- grid.55325.340000 0004 0389 8485Research Institute of Internal Medicine, Oslo University Hospital, 0424 Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital, Oslo, Norway ,grid.55325.340000 0004 0389 8485Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Thor Ueland
- grid.55325.340000 0004 0389 8485Research Institute of Internal Medicine, Oslo University Hospital, 0424 Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway ,grid.10919.300000000122595234K.G. Jebsen-Thrombosis Research and Expertise Center (TREC), UIT – The Arctic University of Norway, Tromsö, Norway
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Bongers KS, Stringer KA, Dickson RP. The gut microbiome in ARDS: from the "whether" and "what" to the "how". Eur Respir J 2023; 61:2202233. [PMID: 36796848 DOI: 10.1183/13993003.02233-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/07/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Kale S Bongers
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kathleen A Stringer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
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40
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Affiliation(s)
- Alexa A. Pragman
- Infectious Disease SectionMinneapolis Veterans Affairs Health Care SystemMinneapolis, Minnesota,Division of Infectious Diseases and International MedicineUniversity of MinnesotaMinneapolis, Minnesota
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