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Rödenbeck M, Ayobami O, Eckmanns T, Pletz MW, Bleidorn J, Markwart R. Clinical epidemiology and case fatality due to antimicrobial resistance in Germany: a systematic review and meta-analysis, 1 January 2010 to 31 December 2021. Euro Surveill 2023; 28:2200672. [PMID: 37199987 PMCID: PMC10197495 DOI: 10.2807/1560-7917.es.2023.28.20.2200672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 02/14/2023] [Indexed: 05/19/2023] Open
Abstract
BackgroundAntimicrobial resistance (AMR) is of public health concern worldwide.AimWe aimed to summarise the German AMR situation for clinicians and microbiologists.MethodsWe conducted a systematic review and meta-analysis of 60 published studies and data from the German Antibiotic-Resistance-Surveillance (ARS). Primary outcomes were AMR proportions in bacterial isolates from infected patients in Germany (2016-2021) and the case fatality rates (2010-2021). Random and fixed (common) effect models were used to calculate pooled proportions and pooled case fatality odds ratios, respectively.ResultsThe pooled proportion of meticillin resistance in Staphylococcus aureus infections (MRSA) was 7.9% with a declining trend between 2014 and 2020 (odds ratio (OR) = 0.89; 95% CI: 0.886-0.891; p < 0.0001), while vancomycin resistance in Enterococcus faecium (VRE) bloodstream infections increased (OR = 1.18; (95% CI: 1.16-1.21); p < 0.0001) with a pooled proportion of 34.9%. Case fatality rates for MRSA and VRE were higher than for their susceptible strains (OR = 2.29; 95% CI: 1.91-2.75 and 1.69; 95% CI: 1.22-2.33, respectively). Carbapenem resistance in Gram-negative pathogens (Klebsiella pneumoniae, Acinetobacter baumannii, Enterobacter spp. and Escherichia coli) was low to moderate (< 9%), but resistance against third-generation cephalosporins and fluoroquinolones was moderate to high (5-25%). Pseudomonas aeruginosa exhibited high resistance against carbapenems (17.0%; 95% CI: 11.9-22.8), third-generation cephalosporins (10.1%; 95% CI: 6.6-14.2) and fluoroquinolones (24.9%; 95% CI: 19.3-30.9). Statistical heterogeneity was high (I2 > 70%) across studies reporting resistance proportions.ConclusionContinuous efforts in AMR surveillance and infection prevention and control as well as antibiotic stewardship are needed to limit the spread of AMR in Germany.
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Affiliation(s)
- Maria Rödenbeck
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Olaniyi Ayobami
- Unit for Healthcare Associated Infections, Surveillance of Antimicrobial Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Tim Eckmanns
- Unit for Healthcare Associated Infections, Surveillance of Antimicrobial Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Jutta Bleidorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Robby Markwart
- InfectoGnostics Research Campus Jena, Jena, Germany
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Hashemizadeh Z, Mansouri S, Pahlavanzadeh F, Morones-Ramírez JR, Tabatabaeifar F, Motamedifar M, Gholizadeh A, Kalantar-Neyestanaki D. Evaluation of chromosomally and acquired mechanisms of resistance to carbapenem antibiotics among clinical isolates of Pseudomonas aeruginosa in Kerman, Iran. GENE REPORTS 2020. [DOI: 10.1016/j.genrep.2020.100918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Evaluation of the Xpert Carba-R NxG Assay for Detection of Carbapenemase Genes in a Global Challenge Set of Pseudomonas aeruginosa Isolates. J Clin Microbiol 2020; 58:JCM.01098-20. [PMID: 33115845 DOI: 10.1128/jcm.01098-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/23/2020] [Indexed: 12/28/2022] Open
Abstract
The growing prevalence and diversity of carbapenemase producers among carbapenem-resistant Pseudomonas aeruginosa (CRPA) isolates warrants an expansion of detection capabilities. The purpose of this study was to evaluate the performance of the commercially available Xpert Carba-R (Carba-R) and the research-use-only Xpert Carba-R NxG (Carba-R NxG) in a global collection of P. aeruginosa The challenge set included 123 P. aeruginosa clinical isolates from 12 countries. Isolates were previously categorized via PCR or whole-genome sequencing. Carbapenemase classes tested include VIM, IMP, NDM, SPM, KPC, and GES. Non-carbapenemase (non-CP)-harboring isolates were also tested (negative control). Isolates were tested using the Carba-R NxG and the Carba-R tests per the manufacturer's instructions. Carba-R NxG testing was completed by Cepheid (Sunnyvale, CA), blinded to genotype. Both assays gave negative results for all non-CP isolates and positive results for all VIM, NDM, and KPC isolates. An improvement in IMP detection among isolates was observed (100% detection by Carba-R NxG versus 58% by Carba-R). All SPM and GES isolates, targets not present in commercially available Carba-R, were positive by Carba-R NxG. Two isolates harbored both VIM and GES, while a third isolate contained VIM and NDM. The Carba-R NxG identified both targets in all 3 isolates, while the Carba-R was negative for both GES-containing isolates. Overall, the Carba-R NxG successfully categorized 100% of isolates tested compared with 68% for its predecessor. The Carba-R NxG will expand the detection spectrum of the current Carba-R assay to include SPM, GES, and expanded IMP variants, increasing the global utility of the test.
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Gill CM, Asempa TE, Nicolau DP. Development and Application of a Pragmatic Algorithm to Guide Definitive Carbapenemase Testing to Identify Carbapenemase-Producing Pseudomonas aeruginosa. Antibiotics (Basel) 2020; 9:antibiotics9110738. [PMID: 33120865 PMCID: PMC7693613 DOI: 10.3390/antibiotics9110738] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 02/05/2023] Open
Abstract
A minimum inhibitory concentration (MIC) derived algorithm, predictive of carbapenemase production, was developed using a challenge set (n = 92) of Pseudomonas aeruginosa (PA), including carbapenemase-producing (CP), cephalosporinase and/or efflux/porin mutation, and wild-type isolates. Broth microdilution MICs to clinically relevant anti-pseudomonal agents were utilized. The algorithm was applied to 1209 clinical PA isolates from a US surveillance program. Confirmatory genotypic (Xpert® Carba-R assay) and phenotypic (mCIM/eCIM) testing for carbapenemases was conducted on algorithm-derived isolates. With the algorithm, carbapenem resistance alone resulted in poor specificity to identify CP-PA (54%) within the challenge set of isolates. Inclusion of cefepime, ceftazidime, and piperacillin/tazobactam non-susceptibility resulted in a specificity of 66%. Ceftolozane/tazobactam resistance further improved specificity (89%). Of the 1209 isolates, 116 met criteria (carbapenem-resistant and non-susceptibility to cefepime, ceftazidime, and piperacillin/tazobactam) for confirmatory testing. Carba-R and mCIM/eCIM identified five (all blaVIM-positive) and seven carbapenemase-producing isolates, respectively. This MIC algorithm combined with genotypic/phenotypic carbapenemase testing is a pragmatic and streamlined approach to identify CP-PA.
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Affiliation(s)
- Christian M. Gill
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA; (C.M.G.); (T.E.A.)
| | - Tomefa E. Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA; (C.M.G.); (T.E.A.)
| | - David P. Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA; (C.M.G.); (T.E.A.)
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT 06102, USA
- Correspondence: ; Tel.: +1-860-972-3941
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Garza-González E, Franco-Cendejas R, Morfín-Otero R, Echaniz-Aviles G, Rojas-Larios F, Bocanegra-Ibarias P, Flores-Treviño S, Ponce-de-León A, Rodríguez-Noriega E, Alavez-Ramírez N, Mena-Ramirez JP, Rincón-Zuno J, Fong-Camargo MG, Morales-De-la-Peña CT, Huerta-Baltazar CR, López-Jacome LE, Carnalla-Barajas MN, Soto-Noguerón A, Sanchez-Francia D, Moncada-Barrón D, Ortíz-Brizuela E, García-Mendoza L, Newton-Sánchez OA, Choy-Chang EV, Aviles-Benitez LK, Martínez-Miranda R, Feliciano-Guzmán JM, Peña-Lopez CD, Couoh-May CA, López-Gutiérrez E, Gil-Veloz M, Armenta-Rodríguez LC, Manriquez-Reyes M, Gutierrez-Brito M, López-Ovilla I, Adame-Álvarez C, Barajas-Magallón JM, Aguirre-Burciaga E, Coronado-Ramírez AM, Rosales-García AA, Sida-Rodríguez S, Urbina-Rodríguez RE, López-Moreno LI, Juárez-Velázquez GE, Martínez-Villarreal RT, Canizales-Oviedo JL, Cetina-Umaña CM, Perez-Juárez MM, González-Moreno A, Romero-Romero D, Bello-Pazos FD, Aguilar-Orozco G, Barlandas-Rendón NRE, Maldonado-Anicacio JY, Valadez-Quiroz A, Camacho-Ortiz A. The Evolution of Antimicrobial Resistance in Mexico During the Last Decade: Results from the INVIFAR Group. Microb Drug Resist 2020; 26:1372-1382. [PMID: 32027229 DOI: 10.1089/mdr.2019.0354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Surveillance of antimicrobial resistance (AMR) requires an international approach with national and local strategies. Our aim was to summarize a retrospective 10-year report of antibiotic resistance of gram-positive and gram-negative bacteria in Mexico. Methods: A total of 46 centers from 22 states of Mexico participated. Databases of AMR from January 2009 to December 2018 were included for most species. The 10-year period was divided into five 2-year periods. Results: For Staphylococcus aureus, a decrease in resistance in all specimens was observed for erythromycin and oxacillin (p < 0.0001 for each). For Enterobacter spp., resistance to meropenem increased for urine specimens (p = 0.0042). For Klebsiella spp., increased drug resistance in specimens collected from blood was observed for trimethoprim/sulfamethoxazole, gentamicin, tobramycin (p < 0.0001 for each), meropenem (p = 0.0014), and aztreonam (p = 0.0030). For Acinetobacter baumannii complex, high drug resistance was detected for almost all antibiotics, including carbapenems, except for tobramycin, which showed decreased resistance for urine, respiratory, and blood isolates (p < 0.0001 for each), and for amikacin, which showed a decrease in resistance in urine specimens (p = 0.0002). An increase in resistance to cefepime was found for urine, respiratory, and blood specimens (p < 0.0001 for each). For Pseudomonas aeruginosa, aztreonam resistance increased for isolates recovered from blood (p = 0.0001). Conclusion: This laboratory-based surveillance of antibiotic resistance shows that resistance is increasing for some antibiotics in different bacterial species in Mexico and highlights the need for continuous monitoring of antibiotic resistance.
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Affiliation(s)
- Elvira Garza-González
- Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Rafael Franco-Cendejas
- Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ciudad de México, Mexico
| | - Rayo Morfín-Otero
- Hospital Civil de Guadalajara e Instituto de Patología Infecciosa, Universidad de Guadalajara, Guadalajara, Mexico
| | | | | | - Paola Bocanegra-Ibarias
- Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Samantha Flores-Treviño
- Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Alfredo Ponce-de-León
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico
| | - Eduardo Rodríguez-Noriega
- Hospital Civil de Guadalajara e Instituto de Patología Infecciosa, Universidad de Guadalajara, Guadalajara, Mexico
| | - Norma Alavez-Ramírez
- Hospital Regional Tipo B, de Alta Especialidad Bicentenario de La Independencia, Tultitlán de Mariano Escobedo, Mexico
| | - Juan Pablo Mena-Ramirez
- Hospital General de Zona No. 21 IMSS, Centro Universitario de los Altos (CUALTOS), Universidad de Guadalajara, Tepatitlán de Morelos, Mexico
| | - Joaquín Rincón-Zuno
- Hospital Para el Niño de Toluca, Instituto Materno Infantil del Estado De México, Toluca, Mexico
| | | | | | | | - Luis Esau López-Jacome
- Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ciudad de México, Mexico
| | | | | | | | | | - Edgar Ortíz-Brizuela
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jorge Luis Canizales-Oviedo
- Centro Universitario De Salud, Universidad Autónoma de Nuevo León, Laboratorio Pueblo Nuevo, Monterrey, Mexico
| | | | | | | | | | | | | | | | | | | | - Adrián Camacho-Ortiz
- Hospital Universitario Dr. José E. González, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Naylor NR, Atun R, Zhu N, Kulasabanathan K, Silva S, Chatterjee A, Knight GM, Robotham JV. Estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrob Resist Infect Control 2018; 7:58. [PMID: 29713465 PMCID: PMC5918775 DOI: 10.1186/s13756-018-0336-y] [Citation(s) in RCA: 277] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/14/2018] [Indexed: 01/02/2023] Open
Abstract
Background Accurate estimates of the burden of antimicrobial resistance (AMR) are needed to establish the magnitude of this global threat in terms of both health and cost, and to paramaterise cost-effectiveness evaluations of interventions aiming to tackle the problem. This review aimed to establish the alternative methodologies used in estimating AMR burden in order to appraise the current evidence base. Methods MEDLINE, EMBASE, Scopus, EconLit, PubMed and grey literature were searched. English language studies evaluating the impact of AMR (from any microbe) on patient, payer/provider and economic burden published between January 2013 and December 2015 were included. Independent screening of title/abstracts followed by full texts was performed using pre-specified criteria. A study quality score (from zero to one) was derived using Newcastle-Ottawa and Philips checklists. Extracted study data were used to compare study method and resulting burden estimate, according to perspective. Monetary costs were converted into 2013 USD. Results Out of 5187 unique retrievals, 214 studies were included. One hundred eighty-seven studies estimated patient health, 75 studies estimated payer/provider and 11 studies estimated economic burden. 64% of included studies were single centre. The majority of studies estimating patient or provider/payer burden used regression techniques. 48% of studies estimating mortality burden found a significant impact from resistance, excess healthcare system costs ranged from non-significance to $1 billion per year, whilst economic burden ranged from $21,832 per case to over $3 trillion in GDP loss. Median quality scores (interquartile range) for patient, payer/provider and economic burden studies were 0.67 (0.56-0.67), 0.56 (0.46-0.67) and 0.53 (0.44-0.60) respectively. Conclusions This study highlights what methodological assumptions and biases can occur dependent on chosen outcome and perspective. Currently, there is considerable variability in burden estimates, which can lead in-turn to inaccurate intervention evaluations and poor policy/investment decisions. Future research should utilise the recommendations presented in this review. Trial registration This systematic review is registered with PROSPERO (PROSPERO CRD42016037510).
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Affiliation(s)
- Nichola R. Naylor
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Rifat Atun
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Kavian Kulasabanathan
- Imperial College London, Sir Alexander Fleming Building, South Kensington Campus, London, UK
| | - Sachin Silva
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Anuja Chatterjee
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Gwenan M. Knight
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Julie V. Robotham
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Modelling and Economics Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
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Skariyachan S, Manjunath M, Bachappanavar N. Screening of potential lead molecules against prioritised targets of multi-drug-resistant-Acinetobacter baumannii - insights from molecular docking, molecular dynamic simulations and in vitro assays. J Biomol Struct Dyn 2018. [PMID: 29529934 DOI: 10.1080/07391102.2018.1451387] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acinetobacter baumannii, an opportunistic pathogen, has become multi-drug resistant (MDR) to major classes of antibacterial and poses grave threat to public health. The current study focused to screen novel phytotherapeutics against prioritised targets of Acinetobacter baumannii by computational investigation. Fourteen potential drug targets were screened based on their functional role in various biosynthetic pathways and the 3D structures of 9 targets were retrieved from Protein Data Bank and others were computationally predicted. By extensive literature survey, 104 molecules from 48 herbal sources were screened and subjected to virtual screening. Ten clinical isolates of A. baumannii were tested for antibiotic susceptibility towards clinafloxacin, imipenem and polymyxin-E. Computational screening suggested that Ajmalicine ((19α)-16, 17-didehydro-19-methyloxayohimban-16-carboxylic acid methyl ester from Rauwolfia serpentina), Strictamin (Akuammilan-17-oic acid methyl ester from Alstonia scholaris) and Limonin (7, 16-dioxo-7, 16-dideoxylimondiol from Citrus sps) exhibited promising binding towards multiple drug targets of A. baumannii in comparison with the binding between standard drugs and their targets. Limonin displayed promising binding potential (binding energy -9.8 kcal/mol) towards diaminopimelate epimerase (DapF) and UDP-N-acetylglucosamine 1-carboxyvinyltransferase (MurA). Ajmalicine and Strictamin demonstrated good binding potential (-9.5, -8.5 kcal/mol, respectively) towards MurA and shikimate dehydrogenase (-7.8 kcal/mol). Molecular dynamic simulations further validated the docking results. In vitro assay suggested that the tested isolates exhibited resistance to clinafloxacin, imipenem and polymyxin-E and the herbal preparations (crude extract) demonstrated a significant antibacterial potential (p ≤ .05). The study suggests that the aforementioned lead candidates and targets can be used for structure-based drug screening towards MDR A. baumannii.
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Affiliation(s)
- Sinosh Skariyachan
- a Department of Biotechnology Engineering , Dayananda Sagar Institutions , Bengaluru 560 078 , Karnataka , India.,b Visvesvaraya Technological University , Belagavi , India
| | - Meghna Manjunath
- a Department of Biotechnology Engineering , Dayananda Sagar Institutions , Bengaluru 560 078 , Karnataka , India.,b Visvesvaraya Technological University , Belagavi , India
| | - Nikhil Bachappanavar
- a Department of Biotechnology Engineering , Dayananda Sagar Institutions , Bengaluru 560 078 , Karnataka , India.,b Visvesvaraya Technological University , Belagavi , India
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Rapid and Consistent Evolution of Colistin Resistance in Extensively Drug-Resistant Pseudomonas aeruginosa during Morbidostat Culture. Antimicrob Agents Chemother 2017. [PMID: 28630206 DOI: 10.1128/aac.00043-17] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Colistin is a last-resort antibiotic commonly used against multidrug-resistant strains of Pseudomonas aeruginosa To investigate the potential for in situ evolution of resistance against colistin and to map the molecular targets of colistin resistance, we exposed two P. aeruginosa isolates to colistin using a continuous-culture device known as a morbidostat. As a result, colistin resistance reproducibly increased 10-fold within 10 days and 100-fold within 20 days, along with highly stereotypic yet strain-specific mutation patterns. The majority of mutations hit the pmrAB two-component signaling system and genes involved in lipopolysaccharide (LPS) synthesis, including lpxC, pmrE, and migA We tracked the frequencies of all arising mutations by whole-genome deep sequencing every 3 to 4 days to obtain a detailed picture of the dynamics of resistance evolution, including competition and displacement among multiple resistant subpopulations. In 7 out of 18 cultures, we observed mutations in mutS along with a mutator phenotype that seemed to facilitate resistance evolution.
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Michalska-Falkowska A, Sacha PT, Grześ H, Hauschild T, Wieczorek P, Ojdana D, Tryniszewska EA. Emergence of Pseudomonas aeruginosa with class 1 integron carrying blaVIM-2 and blaVIM-4 in the University Clinical Hospital of Bialystok (northeastern Poland). POSTEP HIG MED DOSW 2017; 71:589-594. [DOI: 10.5604/01.3001.0010.3839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effectiveness of carbapenems, considered as last-resort antimicrobials in severe infections, becomes compromised by bacterial resistance. The production of metallo-β-lactamases (MBLs) is the most significant threat to carbapenems activity among Pseudomonas aeruginosa. The aim of this study was to assess the presence and type of MBLs genes in carbapenem-resistant P. aeruginosa clinical strains, to identify the location of MBLs genes and to determine genetic relatedness between MBL-producers using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).The first identified MBL-positive (with blaVIM genes) P. aeruginosa strains were isolated from patients hospitalized in the University Clinical Hospital of Bialystok in the period from September 2012 to December 2013. Variants of MBLs genes and variable integron regions were characterized by PCR and sequencing. PFGE was performed after digesting of bacterial genomes by XbaI enzyme. By MLST seven housekeeping genes were analyzed for the determination of sequence type (ST). Three strains carried the blaVIM-2 gene and one harbored the blaVIM-4 gene. The blaVIM genes resided within class 1 integrons. PCR mapping of integrons revealed the presence of four different cassette arrays. Genetic relatedness analysis by PFGE classified VIM-positive strains into four unrelated pulsotypes (A–D). MLST demonstrated the presence of four (ST 111, ST27, and ST17) different sequence type including one previously undescribed new type of ST 2342. Antimicrobial susceptibility testing showed that VIM-positive strains were resistant to carbapenems, cephalosporins, aminoglycosides, and quinolones, intermediate to aztreonam, and susceptible only to colistin. Integrons mapping, PFGE, and MLST results may point to different origin of these strains and independent introduction into hospitalized patients.
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Affiliation(s)
- Anna Michalska-Falkowska
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Paweł Tomasz Sacha
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Henryk Grześ
- Department of Laboratory Diagnostics, Microbiological Laboratory, University Clinical Hospital of Bialystok, Bialystok, Poland
| | - Tomasz Hauschild
- Department of Microbiology, Institute of Biology, University of Bialystok, Bialystok, Poland
| | - Piotr Wieczorek
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Dominika Ojdana
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
| | - Elżbieta Anna Tryniszewska
- Department of Microbiological Diagnostics and Infectious Immunology, Medical University of Bialystok, Bialystok, Poland
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Evaluation of the Accelerate Pheno System for Fast Identification and Antimicrobial Susceptibility Testing from Positive Blood Cultures in Bloodstream Infections Caused by Gram-Negative Pathogens. J Clin Microbiol 2017; 55:2116-2126. [PMID: 28446572 DOI: 10.1128/jcm.00181-17] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/20/2017] [Indexed: 01/20/2023] Open
Abstract
Bloodstream infections (BSI) are an important cause of morbidity and mortality. Increasing rates of antimicrobial-resistant pathogens limit treatment options, prompting an empirical use of broad-range antibiotics. Fast and reliable diagnostic tools are needed to provide adequate therapy in a timely manner and to enable a de-escalation of treatment. The Accelerate Pheno system (Accelerate Diagnostics, USA) is a fully automated test system that performs both identification and antimicrobial susceptibility testing (AST) directly from positive blood cultures within approximately 7 h. In total, 115 episodes of BSI with Gram-negative bacteria were included in our study and compared to conventional culture-based methods. The Accelerate Pheno system correctly identified 88.7% (102 of 115) of all BSI episodes and 97.1% (102 of 105) of isolates that are covered by the system's identification panel. The Accelerate Pheno system generated an AST result for 91.3% (95 of 104) samples in which the Accelerate Pheno system identified a Gram-negative pathogen. The overall category agreement between the Accelerate Pheno system and culture-based AST was 96.4%, the rates for minor discrepancies 1.4%, major discrepancies 2.3%, and very major discrepancies 1.0%. Of note, ceftriaxone, piperacillin-tazobactam, and carbapenem resistance was correctly detected in blood culture specimens with extended-spectrum beta-lactamase-producing Escherichia coli (n = 7) and multidrug-resistant Pseudomonas aeruginosa (n = 3) strains. The utilization of the Accelerate Pheno system reduced the time to result for identification by 27.49 h (P < 0.0001) and for AST by 40.39 h (P < 0.0001) compared to culture-based methods in our laboratory setting. In conclusion, the Accelerate Pheno system provided fast, reliable results while significantly improving turnaround time in blood culture diagnostics of Gram-negative BSI.
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Antibacterial Effects of Zataria multiflora, Ziziphus, Chamomile and Myrtus communis Methanolic Extracts on IMP-Type Metallo-Beta-Lactamase-Producing Pseudomonas aeruginosa. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2016. [DOI: 10.5812/archcid.32413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Clonal Relatedness among Imipenem-Resistant Pseudomonas aeruginosa Isolated from ICU-Hospitalized Patients. Crit Care Res Pract 2015; 2015:983207. [PMID: 26798509 PMCID: PMC4698532 DOI: 10.1155/2015/983207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 11/18/2022] Open
Abstract
Imipenem-resistant Pseudomonas aeruginosa (P. aeruginosa) has become an increasingly important problem in healthcare settings worldwide. The aim of the present study was to evaluate clonal spread among imipenem-resistant P. aeruginosa isolated from ICU-hospitalized patients. Totally, 150 wound specimens were analyzed. Antibiotic resistance profiles and clonal diversity were evaluated using Kirby-Bauer's disk diffusion method and Random Amplified Polymorphic DNA- (RAPD-) PCR, respectively. The isolates showed a high frequency of antibiotic resistance against meropenem, and imipenem (100%) followed by ciprofloxacin, and ceftazidime (90%); meanwhile resistance to polymyxin B was not observed. Eighteen (40%) of P. aeruginosa isolates were MBL-positive via ethylenediaminetetraacetic acid (EDTA) combined disk test. Our findings showed high genetic diversity, with 37 different RAPD types detected. RAPD typing results showed cross-acquisition of P. aeruginosa in investigated hospital, suggesting failure in infection control practices. Incidence of MBL-positive isolates is high and should be regarded as a threat to hospitalized patients.
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Seboxa T, Amogne W, Abebe W, Tsegaye T, Azazh A, Hailu W, Fufa K, Grude N, Henriksen TH. High Mortality from Blood Stream Infection in Addis Ababa, Ethiopia, Is Due to Antimicrobial Resistance. PLoS One 2015; 10:e0144944. [PMID: 26670718 PMCID: PMC4682922 DOI: 10.1371/journal.pone.0144944] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 11/26/2015] [Indexed: 01/21/2023] Open
Abstract
Background Managing blood stream infection in Africa is hampered by lack of bacteriological support needed for antimicrobial stewardship, and background data needed for empirical treatment. A combined pro- and retrospective approach was used to overcome thresholds in clinical research in Africa. Methods Outcome and characteristics including age, HIV infection, pancytopenia and bacteriological results were studied in 292 adult patients with two or more SIRS criteria using univariate and confirming multivariate logistic regression models. Expected randomly distributed resistance covariation was compared with observed co-resistance among gram-negative enteric bacteria in 92 paediatric blood culture isolates that had been harvested in the same hospital during the same period of time. Results Mortality was fivefold increased among patients with positive blood culture results [50.0% vs. 9.8%; OR 11.24 (4.38–25.88), p < 0.0001], and for this group of patients mortality was significantly associated with antimicrobial resistance [OR 23.28 (3.3–164.4), p = 0.002]. All 11 patients with Enterobacteriaceae resistant to 3rd. generation cephalosporins died. Eighty-nine patients had pancytopenia grade 3–4. Among patients with negative blood culture results, mortality was significantly associated with pancytopenia [OR 3.12 (1.32–7.39), p = 0.01]. HIV positivity was not associated with increased mortality. Antimicrobial resistance that concerned gram-negative enteric bacteria, regardless of species, was characterized by co-resistance between third generation cephalosporins, gentamicin, chloramphenicol, and co-trimoxazole. Conclusion Mortality was strongly associated with growth of bacteria resistant to empirical treatment, and these patients were dead or dying when bacteriological reports arrived. Because of co-resistance, alternative efficient antibiotics would not have been available in Ethiopia for 8/11 Enterobacteriaceae-infected patients with isolates resistant to third generation cephalosporins. Strong and significant resistance covariation between 3rd. generation cephalosporins, chloramphenicol, gentamicin, and co-trimoxazole was identified. Pronounced pancytopenia was common and associated with increased mortality. HIV positive patients had no excess mortality.
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Affiliation(s)
- Teshale Seboxa
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workeabeba Abebe
- Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tewodros Tsegaye
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aklilu Azazh
- Department of Emergency and Critical Care Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workagegnehu Hailu
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kebede Fufa
- Department of Microbiology, Black Lion Hospital, Addis Ababa, Ethiopia
| | - Nils Grude
- Department of Microbiology, Vestfold Hospital Trust, Tönsberg, Norway
| | - Thor-Henrik Henriksen
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
- Medical Department, Vestfold Hospital Trust, Tönsberg, Norway
- * E-mail:
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Oliver A, Mulet X, López-Causapé C, Juan C. The increasing threat of Pseudomonas aeruginosa high-risk clones. Drug Resist Updat 2015; 21-22:41-59. [PMID: 26304792 DOI: 10.1016/j.drup.2015.08.002] [Citation(s) in RCA: 391] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 08/04/2015] [Indexed: 01/01/2023]
Abstract
The increasing prevalence of chronic and hospital-acquired infections produced by multidrug-resistant (MDR) or extensively drug-resistant (XDR) Pseudomonas aeruginosa strains is associated with significant morbidity and mortality. This growing threat results from the extraordinary capacity of this pathogen for developing resistance through chromosomal mutations and from the increasing prevalence of transferable resistance determinants, particularly those encoding carbapenemases or extended-spectrum β-lactamases (ESBLs). P. aeruginosa has a nonclonal epidemic population structure, composed of a limited number of widespread clones which are selected from a background of a large quantity of rare and unrelated genotypes that are recombining at high frequency. Indeed, recent concerning reports have provided evidence of the existence of MDR/XDR global clones, denominated high-risk clones, disseminated in hospitals worldwide; ST235, ST111, and ST175 are likely those more widespread. Noteworthy, the vast majority of infections by MDR, and specially XDR, strains are produced by these and few other clones worldwide. Moreover, the association of high-risk clones, particularly ST235, with transferable resistance is overwhelming; nearly 100 different horizontally-acquired resistance elements and up to 39 different acquired β-lactamases have been reported so far among ST235 isolates. Likewise, MDR internationally-disseminated epidemic strains, such as the Liverpool Epidemic Strain (LES, ST146), have been noted as well among cystic fibrosis patients. Here we review the population structure, epidemiology, antimicrobial resistance mechanisms and virulence of the P. aeruginosa high-risk clones. The phenotypic and genetic factors potentially driving the success of high-risk clones, the aspects related to their detection in the clinical microbiology laboratory and the implications for infection control and public health are also discussed.
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Affiliation(s)
- Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Ctra. Valldemossa 79, 07010 Palma de Mallorca, Spain.
| | - Xavier Mulet
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Ctra. Valldemossa 79, 07010 Palma de Mallorca, Spain
| | - Carla López-Causapé
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Ctra. Valldemossa 79, 07010 Palma de Mallorca, Spain
| | - Carlos Juan
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Ctra. Valldemossa 79, 07010 Palma de Mallorca, Spain
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Willmann M, Bezdan D, Zapata L, Susak H, Vogel W, Schröppel K, Liese J, Weidenmaier C, Autenrieth IB, Ossowski S, Peter S. Analysis of a long-term outbreak of XDR Pseudomonas aeruginosa: a molecular epidemiological study. J Antimicrob Chemother 2015; 70:1322-30. [PMID: 25583750 DOI: 10.1093/jac/dku546] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/05/2014] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Here we report on a long-term outbreak from 2009 to 2012 with an XDR Pseudomonas aeruginosa on two wards at a university hospital in southern Germany. METHODS Whole-genome sequencing was performed on the outbreak isolates and a core genome was constructed for molecular epidemiological analysis. We applied a time-place-sequence algorithm to improve estimation of transmission probabilities. RESULTS By using conventional infection control methods we identified 49 P. aeruginosa strains, including eight environmental isolates that belonged to ST308 (by MLST) and carried the metallo-β-lactamase IMP-8. Phylogenetic analysis on the basis of a non-recombinant core genome that contained 22 outbreak-specific SNPs revealed a pattern of four dominant clades with a strong phylogeographic structure and allowed us to determine the potential temporal origin of the outbreak to July 2008, 1 year before the index case was diagnosed. Superspreaders at the root of clades exhibited a high number of probable and predicted transmissions, indicating their exceptional position in the outbreak. CONCLUSIONS Our results suggest that the initial expansion of dominant sublineages was driven by a few superspreaders, while environmental contamination seemed to sustain the outbreak for a long period despite regular environmental control measures.
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Affiliation(s)
- Matthias Willmann
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Daniela Bezdan
- Genomic and Epigenomic Variation in Disease Group, Centre for Genomic Regulation (CRG), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Luis Zapata
- Genomic and Epigenomic Variation in Disease Group, Centre for Genomic Regulation (CRG), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Hana Susak
- Genomic and Epigenomic Variation in Disease Group, Centre for Genomic Regulation (CRG), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Wichard Vogel
- Medical Center, Department of Hematology, Oncology, Immunology, Rheumatology & Pulmonology, University of Tübingen, Tübingen, Germany
| | - Klaus Schröppel
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - Jan Liese
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Christopher Weidenmaier
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Ingo B Autenrieth
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
| | - Stephan Ossowski
- Genomic and Epigenomic Variation in Disease Group, Centre for Genomic Regulation (CRG), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Silke Peter
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany
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Willmann M, Klimek AM, Vogel W, Liese J, Marschal M, Autenrieth IB, Peter S, Buhl M. Clinical and treatment-related risk factors for nosocomial colonisation with extensively drug-resistant Pseudomonas aeruginosa in a haematological patient population: a matched case control study. BMC Infect Dis 2014; 14:650. [PMID: 25490897 PMCID: PMC4266216 DOI: 10.1186/s12879-014-0650-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 11/21/2014] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to investigate risk factors for colonisation with extensively drug-resistant P. aeruginosa (XDR-PA) in immunocompromised patients and to build a clinical risk score (CRS) based on these results. Methods We conducted a matched case–control study with 31 cases and 93 controls (1:3). Cases were colonised with XDR-PA during hospitalisation. Independent risk factors were determined using a three step conditional logistic regression procedure. A CRS was built with respect to the corresponding risk fraction of each risk factor, and its discriminatory power was estimated by receiver operating characteristic (ROC) analysis. Results The presence of a central venous catheter (OR 7.41, P = 0.0008), the presence of a urinary catheter (OR 21.04, P < 0.0001), CRP > 10 mg/dl (OR 7.36, P = 0.0015), and ciprofloxacin administration (OR 5.53, P = 0.025) were independent risk factors. The CRS exhibited a high discriminatory power, defining a high risk population with an approximately fourteen times greater risk for XDR-PA colonisation. Conclusions Unnecessary use of antibiotics, particularly ciprofloxacin should be avoided, and a high standard of infection control measures must be achieved when using medical devices. A CRS can be used for adaptation of the active screening culture policy to the local setting. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0650-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Willmann
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Anna M Klimek
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Wichard Vogel
- Medical Center, Department of Hematology, Oncology, Immunology, Rheumatology & Pulmonology, University of Tübingen, Tübingen, Germany.
| | - Jan Liese
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Matthias Marschal
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Ingo B Autenrieth
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Silke Peter
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
| | - Michael Buhl
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany. .,German Center for Infection Research (DZIF), partner site Tübingen, Tübingen, Germany.
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Nathwani D, Raman G, Sulham K, Gavaghan M, Menon V. Clinical and economic consequences of hospital-acquired resistant and multidrug-resistant Pseudomonas aeruginosa infections: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2014; 3:32. [PMID: 25371812 PMCID: PMC4219028 DOI: 10.1186/2047-2994-3-32] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 09/22/2014] [Indexed: 12/16/2022] Open
Abstract
Background Increasing rates of resistant and multidrug-resistant (MDR) P. aeruginosa in hospitalized patients constitute a major public health threat. We present a systematic review of the clinical and economic impact of this resistant pathogen. Methods Studies indexed in MEDLINE and Cochrane databases between January 2000-February 2013, and reported all-cause mortality, length of stay, hospital costs, readmission, or recurrence in at least 20 hospitalized patients with laboratory confirmed resistant P. aeruginosa infection were included. We accepted individual study definitions of MDR, and assessed study methodological quality. Results The most common definition of MDR was resistance to more than one agent in three or more categories of antibiotics. Twenty-three studies (7,881 patients with susceptible P. aeruginosa, 1,653 with resistant P. aeruginosa, 559 with MDR P. aeruginosa, 387 non-infected patients without P. aeruginosa) were analyzed. A random effects model meta-analysis was feasible for the endpoint of all-cause in-hospital mortality. All-cause mortality was 34% (95% confidence interval (CI) 27% – 41%) in patients with any resistant P. aeruginosa compared to 22% (95% CI 14% – 29%) with susceptible P. aeruginosa. The meta-analysis demonstrated a > 2-fold increased risk of mortality with MDR P. aeruginosa (relative risk (RR) 2.34, 95% CI 1.53 – 3.57) and a 24% increased risk with resistant P. aeruginosa (RR 1.24, 95% CI 1.11 – 1.38), compared to susceptible P. aeruginosa. An adjusted meta-analysis of data from seven studies demonstrated a statistically non-significant increased risk of mortality in patients with any resistant P. aeruginosa (adjusted RR 1.24, 95% CI 0.98 – 1.57). All three studies that reported infection-related mortality found a statistically significantly increased risk in patients with MDR P. aeruginosa compared to those with susceptible P. aeruginosa. Across studies, hospital length of stay (LOS) was higher in patients with resistant and MDR P. aeruginosa infections, compared to susceptible P. aeruginosa and control patients. Limitations included heterogeneity in MDR definition, restriction to nosocomial infections, and potential confounding in analyses. Conclusions Hospitalized patients with resistant and MDR P. aeruginosa infections appear to have increased all-cause mortality and LOS. The negative clinical and economic impact of these pathogens warrants in-depth evaluation of optimal infection prevention and stewardship strategies. Electronic supplementary material The online version of this article (doi:10.1186/2047-2994-3-32) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dilip Nathwani
- Ninewells Hospital and Medical School, Dundee, Scotland DD19SY UK
| | - Gowri Raman
- Tufts Medical Center for Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, 800 Washington Street, Box 63, Boston, MA 02111 USA
| | | | - Meghan Gavaghan
- GfK Market Access, LLC, 21 Cochituate Rd, Wayland, MA 01778 USA
| | - Vandana Menon
- Cubist Pharmaceuticals, 65 Hayden Ave, Lexington, MA 02421 USA
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