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Reisinger M, Kachel M, George I. Emerging and Re-Emerging Pathogens in Valvular Infective Endocarditis: A Review. Pathogens 2024; 13:543. [PMID: 39057770 PMCID: PMC11279809 DOI: 10.3390/pathogens13070543] [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: 06/01/2024] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
Infective endocarditis (IE) is a microbial infection of the endocardial surface, most commonly affecting native and prosthetic valves of the heart. The epidemiology and etiology of the disease have evolved significantly over the last decades. With a growing elderly population, the incidence of degenerative valvopathies and the use of prosthetic heart valves have increased, becoming the most important predisposing risk factors. This change in the epidemiology has caused a shift in the underlying microbiology of the disease, with Staphylococci overtaking Streptococci as the main causative pathogens. Other rarer microbes, including Streptococcus agalactiae, Pseudomonas aeruginosa, Coxiella burnetti and Brucella, have also emerged or re-emerged. Valvular IE caused by these pathogens, especially Staphylococcus aureus, is often associated with a severe clinical course, leading to high rates of morbidity and mortality. Therefore, prompt diagnosis and management are crucial. Due to the high virulence of these pathogens and an increased incidence of antimicrobial resistances, surgical valve repair or replacement is often necessary. As the epidemiology and etiology of valvular IE continue to evolve, the diagnostic methods and therapies need to be progressively advanced to ensure satisfactory clinical outcomes.
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Affiliation(s)
- Maximilian Reisinger
- Division of Cardiac, Thoracic & Vascular Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Mateusz Kachel
- Division of Cardiac, Thoracic & Vascular Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
- Center for Cardiovascular Research and Development, American Heart of Poland, 40-028 Katowice, Poland
| | - Isaac George
- Division of Cardiac, Thoracic & Vascular Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
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2
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Naeem A, Kansakar S, Basnet A, Naeem M, Sharma N, Paul S, Khan MH. A Hole in the Heart, a Hole in the Defenses: A Case of Pseudomonas Endocarditis. Cureus 2024; 16:e62373. [PMID: 39006685 PMCID: PMC11246778 DOI: 10.7759/cureus.62373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/16/2024] Open
Abstract
Infective endocarditis (IE) is a rare but serious infection of the cardiac endothelium. This case report presents a rare instance of left-sided Pseudomonas aeruginosa endocarditis in an immunocompetent patient without traditional risk factors for IE. Pseudomonas endocarditis is uncommon and usually associated with specific factors. The patient in this case was a 30-year-old male with end-stage renal disease, receiving hemodialysis through a tunneled dialysis catheter, who developed a fever. Blood cultures confirmed P. aeruginosa as the causative agent, which prompted the administration of appropriate antibiotics and the removal of the catheter. However, subsequent imaging revealed significant damage to the mitral valve. Despite timely mitral valve replacement and aggressive medical treatment, the patient's condition worsened, and he ultimately succumbed to the infection. This case also emphasizes the necessity of timely diagnosis and intervention. In this patient, by the time it was diagnosed and managed, significant mitral valve damage had already occurred. Therefore, it should be considered a differential diagnosis even in patients with no risk factors and should be managed vigorously. Pseudomonas endocarditis is associated with high mortality, and successful treatment often requires a combination of antipseudomonal antibiotics due to the organism's ability to develop resistance. Surgical intervention, such as valve replacement, is frequently necessary. This case underscores the importance of considering P. aeruginosa infection, even in patients without traditional risk factors for IE. Early diagnosis, appropriate antibiotic therapy, and timely surgical intervention are critical for improving outcomes in Pseudomonas endocarditis cases.
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Affiliation(s)
- Azka Naeem
- Internal Medicine, Maimonides Medical Center, New York, USA
- General Surgery, King Edward Medical University, Lahore, PAK
- General Surgery, Lahore General Hospital, Lahore, PAK
| | - Sajog Kansakar
- Internal Medicine, Maimonides Medical Center, New York, USA
| | - Arjun Basnet
- Internal Medicine, Maimonides Medical Center, New York, USA
| | - Muzamil Naeem
- Internal Medicine, Gujranwala Medical College, Gujranwala, PAK
| | - Neha Sharma
- Internal Medicine, Maimonides Medical Center, New York, USA
| | - Saunders Paul
- Cardiothoracic Surgery, Maimonides Medical Center, New York, USA
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3
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Lynch JP, Zhanel GG. Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy. Semin Respir Crit Care Med 2022; 43:191-218. [PMID: 35062038 DOI: 10.1055/s-0041-1740109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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4
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FERREIRA AI, GOMES C, ENES J, FERREIRA E, ALMEIDA J. Pseudomonas aeruginosa bacteremia in a patient with cardiac pacemaker and prosthetic valves. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2021. [DOI: 10.23736/s0393-3660.21.04601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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5
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Terasawa Y, Sataka C, Sato T, Yamamoto K, Fukushima Y, Nakajima C, Suzuki Y, Katsuyama A, Matsumaru T, Yakushiji F, Yokota SI, Ichikawa S. Elucidating the Structural Requirement of Uridylpeptide Antibiotics for Antibacterial Activity. J Med Chem 2020; 63:9803-9827. [PMID: 32787111 DOI: 10.1021/acs.jmedchem.0c00973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The synthesis and biological evaluation of analogues of uridylpeptide antibiotics were described, and the molecular interaction between the 3'-hydroxy analogue of mureidomycin A (3'-hydroxymureidomycin A) and its target enzyme, phospho-MurNAc-pentapeptide transferase (MraY), was analyzed in detail. The structure-activity relationship (SAR) involving MraY inhibition suggests that the side chain at the urea-dipeptide moiety does not affect the MraY inhibition. However, the anti-Pseudomonas aeruginosa activity is in great contrast and the urea-dipeptide motif is a key contributor. It is also suggested that the nucleoside peptide permease NppA1A2BCD is responsible for the transport of 3'-hydroxymureidomycin A into the cytoplasm. A systematic SAR analysis of the urea-dipeptide moiety of 3'-hydroxymureidomycin A was further conducted and the antibacterial activity was determined. This study provides a guide for the rational design of analogues based on uridylpeptide antibiotics.
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Affiliation(s)
- Yuma Terasawa
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Chisato Sataka
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Toyotaka Sato
- Department of Microbiology, Sapporo Medical University School of Medicine, South-1, West-17, Chuo-ku, Sapporo 060-8556, Japan
| | - Kazuki Yamamoto
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Yukari Fukushima
- Division of Bioresources, Hokkaido University Research Center for Zoonosis Control, Sapporo 001-0020, Japan
| | - Chie Nakajima
- Division of Bioresources, Hokkaido University Research Center for Zoonosis Control, Sapporo 001-0020, Japan.,Global Station for Zoonosis Control, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Kita-20, Nishi-10, Kita-ku, Sapporo 001-0020, Japan
| | - Yasuhiko Suzuki
- Division of Bioresources, Hokkaido University Research Center for Zoonosis Control, Sapporo 001-0020, Japan.,Global Station for Zoonosis Control, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Kita-20, Nishi-10, Kita-ku, Sapporo 001-0020, Japan
| | - Akira Katsuyama
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan.,Center for Research and Education on Drug Discovery, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Takanori Matsumaru
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan.,Center for Research and Education on Drug Discovery, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Fumika Yakushiji
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan.,Center for Research and Education on Drug Discovery, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Shin-Ichi Yokota
- Department of Microbiology, Sapporo Medical University School of Medicine, South-1, West-17, Chuo-ku, Sapporo 060-8556, Japan
| | - Satoshi Ichikawa
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan.,Center for Research and Education on Drug Discovery, Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan.,Global Station for Biosurfaces and Drug Discovery, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
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6
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Tayyar R, Khan O, Chauhan K, Ines A, Carnish E. Pseudomonas MitraClip® endocarditis: A case report and review of literature. IDCases 2020; 19:e00665. [PMID: 31956505 PMCID: PMC6962692 DOI: 10.1016/j.idcr.2019.e00665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/03/2019] [Accepted: 11/03/2019] [Indexed: 12/25/2022] Open
Abstract
Endocarditis from Pseudomonas aeruginosa is a rare cause of endocarditis with most of those cases in patients with intravenous drug abuse. The MitraClip® is a relatively new device with few incidences of endocarditis in the literature. Here we present the first reported case of pseudomonal endocarditis of a MitraClip® in a non-IV drug user.
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Affiliation(s)
- Ralph Tayyar
- Internal Medicine Department, Lankenau Medical Center, Wynnewood, PA, United States
| | - Oneib Khan
- Internal Medicine Department, Lankenau Medical Center, Wynnewood, PA, United States
| | | | - Andrew Ines
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Erin Carnish
- Internal Medicine Department, Lankenau Medical Center, Wynnewood, PA, United States
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7
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Ramireddy S, Gudipati S, Zervos M. Expect the Unexpected: A Rare Case of Pseudomonas aeruginosa Endocarditis. IDCases 2020; 21:e00787. [PMID: 32399394 PMCID: PMC7217105 DOI: 10.1016/j.idcr.2020.e00787] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 11/23/2022] Open
Abstract
Infective endocarditis (IE) caused by Pseudomonas aeruginosa is extremely uncommon. Reported cases have usually been associated with intravenous drug use, prosthetic heart valves, and/or implanted cardiac devices. Traditionally, successful treatment has necessitated a combination of antimicrobial(s) and valve replacement. Yet, P. aeruginosa IE remains difficult to manage, especially in cases where valve replacement may not be an immediate option. We present such a case of P. aeruginosa IE, highlighting that medical management with 2 antipseudomonal synergistic agents may be an alternative to surgery in particularly complicated cases.
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Gürtler N, Osthoff M, Rueter F, Wüthrich D, Zimmerli L, Egli A, Bassetti S. Prosthetic valve endocarditis caused by Pseudomonas aeruginosa with variable antibacterial resistance profiles: a diagnostic challenge. BMC Infect Dis 2019; 19:530. [PMID: 31208366 PMCID: PMC6580457 DOI: 10.1186/s12879-019-4164-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
Background Infective endocarditis (IE) caused by gram-negative bacilli is rare. However, the incidence of this severe infection is rising because of the increasing number of persons at risk, such as patients with immunosuppression or with cardiac implantable devices and prosthetic valves. The diagnosis of IE is often difficult, particularly when microorganisms such as Pseudomonas aeruginosa, which rarely cause this infection, are involved. One of the mainstays for the diagnosis of IE are persistently positive blood cultures with the same bacteria, while polymicrobial bacteremia usually points to another cause, e.g. an abscess. The antimicrobial resistance profile of some P. aeruginosa strains may change, falsely suggesting an infection with several strains, thus further increasing the diagnostic difficulties. Case presentation A 66-year old male patient who had a transcatheter aortic valve implantation (TAVI) one year previously developed fever seven days after an elective inguinal hernia repair. During the following four weeks, P. aeruginosa with different antibiotic resistance profiles was repeatedly isolated from blood cultures. Repeated trans-esophageal echocardiograms (TEE) were negative and an infection by different P. aeruginosa strains was suspected. Extensive diagnostic workup for an infectious focus was performed with no results. Finally, an oscillating mass on the aortic valve was detected by TEE five weeks after the initial positive blood cultures. P. aeruginosa endocarditis was confirmed by culture of the surgically removed valve. Whole genome sequencing of the last two P. aeruginosa isolates (valve and blood culture) revealed identical strains, with genome mutations for AmpR, AmpD and OprD. Conclusions The diagnosis of prosthetic valve endocarditis is particularly difficult for several reasons. The modified Duke criteria have a lower sensitivity for patients with prosthetic valve endocarditis and the infection may be caused by “unusual” pathogens such as P. aeruginosa. Patients with repeatedly positive blood cultures should make clinicians suspicious for endocarditis even if imaging studies are negative and if isolated pathogens are “unusual”. Repeatedly positive blood cultures for P. aeruginosa should be considered as “persistent bacteremia” (suspicious for IE) even in the presence of different antibiotic susceptibility patterns, since P. aeruginosa might rapidly activate or deactivate resistance mechanisms depending on antibiotic exposition.
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Affiliation(s)
- Nicolas Gürtler
- Division of Internal Medicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Michael Osthoff
- Division of Internal Medicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Florian Rueter
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Wüthrich
- Clinical Microbiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lukas Zimmerli
- Department of Internal Medicine, Kantonsspital Olten, Olten, Switzerland
| | - Adrian Egli
- Clinical Microbiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefano Bassetti
- Division of Internal Medicine and Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
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9
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Edgeworth JD, Merante D, Patel S, Young C, Jones P, Vithlani S, Wyncoll D, Roberts P, Jones A, Den Nagata T, Ariyasu M, Livermore DM, Beale R. Compassionate Use of Cefiderocol as Adjunctive Treatment of Native Aortic Valve Endocarditis Due to Extremely Drug-resistant Pseudomonas aeruginosa. Clin Infect Dis 2019; 68:1932-1934. [PMID: 30418554 PMCID: PMC6522681 DOI: 10.1093/cid/ciy963] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022] Open
Abstract
Serious infections such as endocarditis due to extremely drug-resistance gram-negative bacteria are an increasing challenge. Here, we present successful adjunctive use of cefiderocol for a patient with persistently bacteremic healthcare-associated native aortic valve endocarditis due to an extended-spectrum beta-lactamase-positive Pseudomonas aeruginosa susceptible in vitro only to colistin, following failure of conventional therapeutic options.
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Affiliation(s)
- Jonathan D Edgeworth
- Department of Infectious Diseases, Guy’s Hospital, Kings College London, London, United Kingdom
| | - Domenico Merante
- Shionogi Limited, Global Clinical Development Unit, London, United Kingdom
| | - Sanjay Patel
- Shionogi Limited, Global Clinical Development Unit, London, United Kingdom
| | - Christopher Young
- Intensive Care Unit, London Bridge Hospital, HCA International, London, United Kingdom
| | - Paul Jones
- Microbiology Department, HCA International, London, United Kingdom
| | - Seema Vithlani
- Pharmacy Department, London Bridge Hospital, HCA International, London, United Kingdom
| | - Duncan Wyncoll
- Intensive Care Unit, London Bridge Hospital, HCA International, London, United Kingdom
| | - Peter Roberts
- Intensive Care Unit, London Bridge Hospital, HCA International, London, United Kingdom
| | - Andrew Jones
- Intensive Care Unit, London Bridge Hospital, HCA International, London, United Kingdom
| | | | | | - David M Livermore
- Norwich Medical School, University of East Anglia, United Kingdom
- Antimicrobial Resistance & Healthcare Associated Infections Reference Unit, Public Health England, Colindale, London
| | - Richard Beale
- School of Medicine, Guy’s Hospital, Kings College London, United Kingdom
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10
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Microbial Epidemiology of Infectious Endocarditis in the Intravenous Drug Abuse Population: A Retrospective Study. Infect Dis Ther 2019; 8:113-118. [PMID: 30673991 PMCID: PMC6374230 DOI: 10.1007/s40121-019-0232-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction The microbial epidemiology differs between infective endocarditis (IE) patients with and without a history of injection drug use. We set out to determine the prevalence and microbial epidemiology of infective endocarditis in our region, the Southeastern USA, to determine if any changes need to be made in empiric antimicrobial treatment. Methods The electronic medical record was reviewed for patients with IE between January 2013 and July 2017, which revealed 299 cases. The cases were then sorted between patients with and without a history of injection drug use. The growth of their initial set of blood cultures and side of cardiac involvement were then recorded. Statistical analyses were run on the data sets. Results There were statistically significant effects associated with both methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas species infections occurring more often in individuals with active injection drug use, while streptococcus and enterococcus infections were more likely to occur in the population of individuals who do not inject drugs. Conclusion In IE patients who use or are suspected of injection drug use, first-line broad-spectrum antibiotics with excellent MRSA and Pseudomonas coverage are essential.
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Soukarieh F, Williams P, Stocks MJ, Cámara M. Pseudomonas aeruginosa Quorum Sensing Systems as Drug Discovery Targets: Current Position and Future Perspectives. J Med Chem 2018; 61:10385-10402. [PMID: 29999316 DOI: 10.1021/acs.jmedchem.8b00540] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antimicrobial resistance (AMR) is a serious threat to public health globally, manifested by the frequent emergence of multidrug resistant pathogens that render current chemotherapy inadequate. Health organizations worldwide have recognized the severity of this crisis and implemented action plans to contain its adverse consequences and prolong the utility of conventional antibiotics. Hence, there is a pressing need for new classes of antibacterial agents with novel modes of action. Quorum sensing (QS), a communication system employed by bacterial populations to coordinate virulence gene expression, is a potential target that has been intensively investigated over the past decade. This Perspective will focus on recent advances in targeting the three main quorum sensing systems ( las, rhl, and pqs) of a major opportunistic human pathogen, Pseudomonas aeruginosa, and will specifically evaluate the medicinal chemistry strategies devised to develop QS inhibitors from a drug discovery perspective.
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Affiliation(s)
- Fadi Soukarieh
- School of Life Sciences, Centre for Biomolecular Sciences , University of Nottingham , Nottingham , NG7 2RD , U.K
| | - Paul Williams
- School of Life Sciences, Centre for Biomolecular Sciences , University of Nottingham , Nottingham , NG7 2RD , U.K
| | - Michael J Stocks
- School of Pharmacy, Centre for Biomolecular Sciences , University of Nottingham , Nottingham , NG7 2RD , U.K
| | - Miguel Cámara
- School of Life Sciences, Centre for Biomolecular Sciences , University of Nottingham , Nottingham , NG7 2RD , U.K
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