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Brown A, Ferrando-Vivas P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson BH, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan K, Pathan N. Use of selective gut decontamination in critically ill children: PICnIC a pilot RCT and mixed-methods study. Health Technol Assess 2024; 28:1-84. [PMID: 38421007 PMCID: PMC11017160 DOI: 10.3310/hdkv1008] [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] [Indexed: 03/02/2024] Open
Abstract
Background Healthcare-associated infections are a major cause of morbidity and mortality in critically ill children. In adults, data suggest the use of selective decontamination of the digestive tract may reduce the incidence of healthcare-associated infections. Selective decontamination of the digestive tract has not been evaluated in the paediatric intensive care unit population. Objectives To determine the feasibility of conducting a multicentre, cluster-randomised controlled trial in critically ill children comparing selective decontamination of the digestive tract with standard infection control. Design Parallel-group pilot cluster-randomised controlled trial with an integrated mixed-methods study. Setting Six paediatric intensive care units in England. Participants Children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 hours were eligible for the PICnIC pilot cluster-randomised controlled trial. During the ecology periods, all children admitted to the paediatric intensive care units were eligible. Parents/legal guardians of recruited patients and healthcare professionals working in paediatric intensive care units were eligible for inclusion in the mixed-methods study. Interventions The interventions in the PICnIC pilot cluster-randomised controlled trial included administration of selective decontamination of the digestive tract as oro-pharyngeal paste and as a suspension given by enteric tube during the period of mechanical ventilation. Main outcome measures The decision as to whether a definitive cluster-randomised controlled trial is feasible is based on multiple outcomes, including (but not limited to): (1) willingness and ability to recruit eligible patients; (2) adherence to the selective decontamination of the digestive tract intervention; (3) acceptability of the definitive cluster-randomised controlled trial; (4) estimation of recruitment rate; and (5) understanding of potential clinical and ecological outcome measures. Results A total of 368 children (85% of all those who were eligible) were enrolled in the PICnIC pilot cluster-randomised controlled trial across six paediatric intensive care units: 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering selective decontamination of the digestive tract, the majority (98%) of children received at least one dose of selective decontamination of the digestive tract, and of these, 68% commenced within the first 6 hours. Consent for the collection of additional swabs was low (44%), though data completeness for potential outcomes, including microbiology data from routine clinical swab testing, was excellent. Recruited children were representative of the wider paediatric intensive care unit population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cluster-randomised controlled trial of 3 children/site/week, based on data from all UK paediatric intensive care units. The proposed trial, including consent and selective decontamination of the digestive tract, was acceptable to parents and staff with adaptations, including training to improve consent and communication, and adaptations to the administration protocol for the paste and ecology monitoring. Clinical outcomes that were considered important included duration of organ failure and hospital stay, healthcare-acquired infections and survival. Limitations The delivery of the pilot cluster-randomised controlled trial was disrupted by the COVID-19 pandemic, which led to slow set-up of sites, and a lack of face-to face training. Conclusions PICnIC's findings indicate that a definitive cluster-randomised controlled trial in selective decontamination of the digestive tract in paediatric intensive care units is feasible with the inclusion modifications, which would need to be included in a definitive cluster-randomised controlled trial to ensure that the efficiency of trial processes is maximised. Future work A definitive trial that incorporates the protocol adaptations and outcomes arising from this study is feasible and should be conducted. Trial registration This trial is registered as ISRCTN40310490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/152/01) and is published in full in Health Technology Assessment; Vol. 28, No. 8. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Mariana Popa
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - John Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University of Southampton, Southampton, UK
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Theodore Gouliouris
- Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- Intensive Care Unit, Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - John Myburgh
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Pathan N, Woolfall K, Popa M, de la Fuente GM, Ferrando-Vivas P, Brown A, Gouliouris T, Tume LN, Shulman R, Cuthbertson BH, Sale I, Feltbower RG, Myburgh J, Pappachan J, Harrison D, Mouncey P, Rowan K. Selective digestive tract decontamination to prevent healthcare associated infections in critically ill children: the PICNIC multicentre randomised pilot clinical trial. Sci Rep 2023; 13:21668. [PMID: 38066012 PMCID: PMC10709430 DOI: 10.1038/s41598-023-46232-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. Data from adult studies suggest Selective Decontamination of the Digestive tract (SDD) may reduce the incidence of HCAIs and improve survival. There are no data from randomised clinical trials in the paediatric setting. An open label, parallel group pilot cRCT and mixed-methods perspectives study was conducted in six paediatric intensive care units (PICUs) in England. Participants were children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 h. Sites undertook standard care for a period of 9 weeks and were randomised into 3 sites which continued standard care and 3 where SDD was incorporated into infection control practice for eligible children. Interviews and focus groups were conducted for parents and staff working in PICU. 434 children fulfilled eligibility criteria, of whom 368 (85%) were enrolled. This included 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering SDD, the majority (98%) of children received at least one dose of SDD and of these, 68% commenced within the first 6 h. Whilst admission swabs were collected in 91% of enrolled children, consent for the collection of additional swabs was low (44%). Recruited children were representative of the wider PICU population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cRCT of 3 children/site/week, based on data from all UK PICUs. Parents (n = 65) and staff (n = 44) were supportive of the aims of the study, suggesting adaptations for a larger definitive trial including formulation and administration of SDD paste, approaches to consent and ecology monitoring. Stakeholders identified preferred clinical outcomes, focusing on complications of critical illness and quality-of-life. A definitive cRCT in SDD to prevent HCAIs in critically ill children is feasible but should include adaptations to ecology monitoring along with the dosing schedule and packaging into a paediatric specific format. A definitive study is supported by the findings with adaptations to ecology monitoring and SDD administration.Trial Registration: ISRCTN40310490 Registered 30/10/2020.
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Affiliation(s)
- Nazima Pathan
- University of Cambridge, Cambridge, UK.
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | | | | | | | | - Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
- University College London, London, UK
| | | | | | | | | | | | | | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | | | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Paul Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, London, UK
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3
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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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Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers. Eur J Clin Microbiol Infect Dis 2023; 42:229-254. [PMID: 36680641 PMCID: PMC9899200 DOI: 10.1007/s10096-023-04548-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
The clinical impact of infections due to extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacterales (Ent) has reached dramatic levels worldwide. Infections due to these multidrug-resistant (MDR) pathogens-especially Escherichia coli and Klebsiella pneumoniae-may originate from a prior asymptomatic intestinal colonization that could also favor transmission to other subjects. It is therefore desirable that gut carriers are rapidly identified to try preventing both the occurrence of serious endogenous infections and potential transmission. Together with the infection prevention and control countermeasures, any strategy capable of effectively eradicating the MDR-Ent from the intestinal tract would be desirable. In this narrative review, we present a summary of the different aspects linked to the intestinal colonization due to MDR-Ent. In particular, culture- and molecular-based screening techniques to identify carriers, data on prevalence and risk factors in different populations, clinical impact, length of colonization, and contribution to transmission in various settings will be overviewed. We will also discuss the standard strategies (selective digestive decontamination, fecal microbiota transplant) and those still in development (bacteriophages, probiotics, microcins, and CRISPR-Cas-based) that might be used to decolonize MDR-Ent carriers.
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Reynolds D, Burnham JP, Vazquez Guillamet C, McCabe M, Yuenger V, Betthauser K, Micek ST, Kollef MH. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic. Eur Respir Rev 2022; 31:220068. [PMID: 36261159 PMCID: PMC9724833 DOI: 10.1183/16000617.0068-2022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/09/2022] [Indexed: 12/22/2022] Open
Abstract
Antibiotic resistance is recognised as a global threat to human health by national healthcare agencies, governments and medical societies, as well as the World Health Organization. Increasing resistance to available antimicrobial agents is of concern for bacterial, fungal, viral and parasitic pathogens. One of the greatest concerns is the continuing escalation of antimicrobial resistance among Gram-negative bacteria resulting in the endemic presence of multidrug-resistant (MDR) and extremely drug-resistant (XDR) pathogens. This concern is heightened by the identification of such MDR/XDR Gram-negative bacteria in water and food sources, as colonisers of the intestine and other locations in both hospitalised patients and individuals in the community, and as agents of all types of infections. Pneumonia and other types of respiratory infections are among the most common infections caused by MDR/XDR Gram-negative bacteria and are associated with high rates of mortality. Future concerns are already heightened due to emergence of resistance to all existing antimicrobial agents developed in the past decade to treat MDR/XDR Gram-negative bacteria and a scarcity of novel agents in the developmental pipeline. This clinical scenario increases the likelihood of a future pandemic caused by MDR/XDR Gram-negative bacteria.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Mikaela McCabe
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Valerie Yuenger
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Kevin Betthauser
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Scott T Micek
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Brown A, Ferrando P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson B, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan KM, Pathan N. Use of selective gut decontamination in critically ill children: protocol for the Paediatric Intensive Care and Infection Control (PICnIC) pilot study. BMJ Open 2022; 12:e061838. [PMID: 35277414 PMCID: PMC8919465 DOI: 10.1136/bmjopen-2022-061838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. In critically ill adults, there are data that suggest the use of Selective Decontamination of the Digestive tract (SDD), alongside standard infection control measures reduce mortality and the incidence of HCAIs. SDD-enhanced infection control has not been compared directly with standard infection prevention strategies in the Paediatric Intensive Care Unit (PICU) population. The aim of this pilot study is to determine the feasibility of conducting a multicentre cluster randomised controlled trial (cRCT) in critically ill children comparing SDD with standard infection control. METHODS AND ANALYSIS Paediatric Intensive Care and Infection Control is a parallel group pilot cRCT, with integrated mixed-methods study, comparing incorporation of SDD into infection control procedures to standard care. After a 1-week pretrial ecology surveillance period, recruitment to the cRCT will run for a period of 18 weeks, comprising: (1) baseline control period (2) pre, mid and post-trial ecology surveillance periods and (3) intervention period. Six PICUs (in England, UK) will begin with usual care in period 1, then will be randomised 1:1 by the trial statistician using computer-based randomisation, to either continue to deliver usual care or commence delivery of the intervention (SDD) in period 2. Outcomes measures include parent and healthcare professionals' views on trial feasibility, adherence to the SDD intervention, estimation of recruitment rate and understanding of potential patient-centred primary and secondary outcome measures for the definitive trial. The planned recruitment for the cRCT is 324 participants. ETHICS AND DISSEMINATION The trial received favourable ethical opinion from West Midlands-Black Country Research Ethics Committee (reference: 20/WM/0061) and approval from the Health Research Authority (IRAS number: 239324). Informed consent is not required for SDD intervention or anonymised data collection but is sought for investigations as part of the study, any identifiable data collected and monitoring of medical records. Results will be disseminated via publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ISRCTN40310490.
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Affiliation(s)
- Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
| | - Paloma Ferrando
- Intensive Care National Audit and Research Centre, London, UK
| | - Mariana Popa
- Institute of Life and Human Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Brian Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - John Myburgh
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Leone M, Lakbar I, Lopez A, Zunino C, Loeches IM. Selective digestive decontamination and COVID-19: Uncertainty in a moving area. Anaesth Crit Care Pain Med 2021; 41:101009. [PMID: 34920151 PMCID: PMC8670106 DOI: 10.1016/j.accpm.2021.101009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marc Leone
- Aix Marseille Université, APHM, Service d'anesthésie et de réanimation, Hôpital Nord, 13015 Marseille, France.
| | - Ines Lakbar
- Aix Marseille Université, APHM, Service d'anesthésie et de réanimation, Hôpital Nord, 13015 Marseille, France
| | - Alexandre Lopez
- Aix Marseille Université, APHM, Service d'anesthésie et de réanimation, Hôpital Nord, 13015 Marseille, France
| | - Claire Zunino
- Aix Marseille Université, APHM, Service d'anesthésie et de réanimation, Hôpital Nord, 13015 Marseille, France
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
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Drayson MT, Bowcock S, Planche T, Iqbal G, Pratt G, Yong K, Wood J, Raynes K, Higgins H, Dawkins B, Meads D, Hulme CT, Monahan I, Karunanithi K, Dignum H, Belsham E, Neilson J, Harrison B, Lokare A, Campbell G, Hamblin M, Hawkey P, Whittaker AC, Low E, Dunn JA. Levofloxacin prophylaxis in patients with newly diagnosed myeloma (TEAMM): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial. Lancet Oncol 2019; 20:1760-1772. [PMID: 31668592 PMCID: PMC6891230 DOI: 10.1016/s1470-2045(19)30506-6] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/21/2019] [Accepted: 06/26/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Myeloma causes profound immunodeficiency and recurrent, serious infections. Around 5500 new cases of myeloma are diagnosed per year in the UK, and a quarter of patients will have a serious infection within 3 months of diagnosis. We aimed to assess whether patients newly diagnosed with myeloma benefit from antibiotic prophylaxis to prevent infection, and to investigate the effect on antibiotic-resistant organism carriage and health care-associated infections in patients with newly diagnosed myeloma. METHODS TEAMM was a prospective, multicentre, double-blind, placebo-controlled randomised trial in patients aged 21 years and older with newly diagnosed myeloma in 93 UK hospitals. All enrolled patients were within 14 days of starting active myeloma treatment. We randomly assigned patients (1:1) to levofloxacin or placebo with a computerised minimisation algorithm. Allocation was stratified by centre, estimated glomerular filtration rate, and intention to proceed to high-dose chemotherapy with autologous stem cell transplantation. All investigators, patients, laboratory, and trial co-ordination staff were masked to the treatment allocation. Patients were given 500 mg of levofloxacin (two 250 mg tablets), orally once daily for 12 weeks, or placebo tablets (two tablets, orally once daily for 12 weeks), with dose reduction according to estimated glomerular filtration rate every 4 weeks. Follow-up visits occurred every 4 weeks up to week 16, and at 1 year. The primary outcome was time to first febrile episode or death from all causes within the first 12 weeks of trial treatment. All randomised patients were included in an intention-to-treat analysis of the primary endpoint. This study is registered with the ISRCTN registry, number ISRCTN51731976, and the EU Clinical Trials Register, number 2011-000366-35. FINDINGS Between Aug 15, 2012, and April 29, 2016, we enrolled and randomly assigned 977 patients to receive levofloxacin prophylaxis (489 patients) or placebo (488 patients). Median follow-up was 12 months (IQR 8-13). 95 (19%) first febrile episodes or deaths occurred in 489 patients in the levofloxacin group versus 134 (27%) in 488 patients in the placebo group (hazard ratio 0·66, 95% CI 0·51-0·86; p=0·0018. 597 serious adverse events were reported up to 16 weeks from the start of trial treatment (308 [52%] of which were in the levofloxacin group and 289 [48%] of which were in the placebo group). Serious adverse events were similar between the two groups except for five episodes (1%) of mostly reversible tendonitis in the levofloxacin group. INTERPRETATION Addition of prophylactic levofloxacin to active myeloma treatment during the first 12 weeks of therapy significantly reduced febrile episodes and deaths compared with placebo without increasing health care-associated infections. These results suggest that prophylactic levofloxacin could be used for patients with newly diagnosed myeloma undergoing anti-myeloma therapy. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Mark T Drayson
- School of Immunity and Infection, University of Birmingham, Birmingham, UK.
| | | | - Tim Planche
- Department of Medical Microbiology, St George's, University of London, London, UK
| | - Gulnaz Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Guy Pratt
- University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Kwee Yong
- Department of Haematology, UCL Cancer Institute, London, UK
| | - Jill Wood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Kerry Raynes
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Helen Higgins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Claire T Hulme
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Irene Monahan
- Department of Medical Microbiology, St George's, University of London, London, UK
| | | | | | | | - Jeff Neilson
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Beth Harrison
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Anand Lokare
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Gavin Campbell
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Michael Hamblin
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Peter Hawkey
- West Midlands Public Health Laboratory, Heart of England NHS Trust, Birmingham, UK
| | - Anna C Whittaker
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Eric Low
- Patient Advocacy, Myeloma UK, Edinburgh UK
| | - Janet A Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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van Hout D, Plantinga NL, Bruijning-Verhagen PC, Oostdijk EAN, de Smet AMGA, de Wit GA, Bonten MJM, van Werkhoven CH. Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis. BMJ Open 2019; 9:e028876. [PMID: 31494605 PMCID: PMC6731916 DOI: 10.1136/bmjopen-2018-028876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance. DESIGN Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials. SETTING 24 ICUs in the Netherlands. PARTICIPANTS 12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232). INTERVENTIONS SDD versus SOD. PRIMARY AND SECONDARY OUTCOME MEASURES The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death. RESULTS The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI -€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD. CONCLUSION In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
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Affiliation(s)
- Denise van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
| | - Nienke L Plantinga
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Patricia C Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Center for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Evelien A N Oostdijk
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Marie G A de Smet
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marc J M Bonten
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
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Amornphimoltham P, Yuen PST, Star RA, Leelahavanichkul A. Gut Leakage of Fungal-Derived Inflammatory Mediators: Part of a Gut-Liver-Kidney Axis in Bacterial Sepsis. Dig Dis Sci 2019; 64:2416-2428. [PMID: 30863955 DOI: 10.1007/s10620-019-05581-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening response to systemic infection. In addition to frank gastrointestinal (GI) rupture/puncture, sepsis can also be exacerbated by translocation of pathogen-associated molecular patterns (PAMPs) from the GI tract to the systemic circulation (gut origin of sepsis). In the human gut, Gram-negative bacteria and Candida albicans are abundant, along with their major PAMP components, endotoxin (LPS) and (1 → 3)-β-D-glucan (BG). Whereas the influence of LPS in bacterial sepsis has been studied extensively, exploration of the role of BG in bacterial sepsis is limited. Post-translocation, PAMPs enter the circulation through lymphatics and the portal vein, and are detoxified and then excreted via the liver and the kidney. Sepsis-induced liver and kidney injury might therefore affect the kinetics and increase circulating PAMPs. In this article, we discuss the current knowledge of the impact of PAMPs from both gut mycobiota and microbiota, including epithelial barrier function and the "gut-liver-kidney axis," on bacterial sepsis severity.
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Affiliation(s)
| | - Peter S T Yuen
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert A Star
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Asada Leelahavanichkul
- Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, 10330, Thailand. .,Center of Excellence in Immunology and Immune-mediated Diseases, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
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11
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Catho G, Huttner BD. Strategies for the eradication of extended-spectrum beta-lactamase or carbapenemase-producing Enterobacteriaceae intestinal carriage. Expert Rev Anti Infect Ther 2019; 17:557-569. [PMID: 31313610 DOI: 10.1080/14787210.2019.1645007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Among the multidrug resistant pathogens, extended-spectrum beta-lactamase (ESBL-E) or carbapenemase-producing Enterobacteriaceae (CPE) are currently considered the main threat due to the scarcity of therapeutic options and their rapid spread around the globe. In addition to developing new antibiotics and stopping transmission, recent research has focused on 'decolonization' strategies to eradicate the carriage of ESBL-E/CPE before infection occurs. Areas covered: In this narrative review, we aim to describe the current evidence of decolonization strategies for ESBL-E or CPE intestinal carriage. We first define decolonization and highlight the issues related to the lack of standardized definitions, then we summarize the available data on the natural history of colonization. Finally, we review the strategies assessed over the past 10 years for ESBL and CPE decolonization: oral antibiotics, probiotics and more recently fecal microbiota transplantation. We conclude by presenting the risks and uncertainties associated with these strategies. Expert opinion: The evidence available today is too low to recommend decolonization strategies for ESBL-E or CPE in routine clinical practice. The potential increase of resistance and the impact of microbiome manipulation should not be underestimated. Some of these decolonization strategies may nevertheless be effective, at least in temporarily suppressing colonization, which could be useful for specific populations such as high-risk patients. Effectiveness and long-term effects must be properly assessed through well-designed randomized controlled trials.
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Affiliation(s)
- Gaud Catho
- a Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva , Geneva , Switzerland
| | - Benedikt D Huttner
- a Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva , Geneva , Switzerland
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12
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Shekar K, Abrams D, Schmidt M. Awake extracorporeal membrane oxygenation in immunosuppressed patients with severe respiratory failure-a stretch too far? J Thorac Dis 2019; 11:2656-2659. [PMID: 31463086 DOI: 10.21037/jtd.2019.05.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.,University of Queensland and Bond University, Queensland, Australia
| | - Darryl Abrams
- Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA.,Center for Acute Respiratory Failure, Columbia University Medical Center, New York, NY, USA
| | - Matthieu Schmidt
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
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13
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Buitinck S, Jansen R, Rijkenberg S, Wester JPJ, Bosman RJ, van der Meer NJM, van der Voort PHJ. The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:208. [PMID: 31174575 PMCID: PMC6555978 DOI: 10.1186/s13054-019-2480-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/19/2019] [Indexed: 02/03/2023]
Abstract
Background The long-term ecological effects on the emergence of antimicrobial resistance at the ICU level during selective decontamination of the digestive tract (SDD) are unknown. We determined the incidence of newly acquired antimicrobial resistance of aerobic gram-negative potentially pathogenic bacteria (AGNB) during SDD. Methods In a single-centre observational cohort study over a 21-year period, all consecutive patients, treated with or without SDD, admitted to the ICU were included. The antibiotic regime was unchanged over the study period. Incidence rates for ICU-acquired AGNB’s resistance for third-generation cephalosporins, colistin/polymyxin B, tobramycin/gentamicin or ciprofloxacin were calculated per year. Changes over time were tested by negative binomial regression in a generalized linear model. Results Eighty-six percent of 14,015 patients were treated with SDD. Most cultures were taken from the digestive tract (41.9%) and sputum (21.1%). A total of 20,593 isolates of AGNB were identified. The two most often found bacteria were Escherichia coli (N = 6409) and Pseudomonas (N = 5269). The incidence rate per 1000 patient-day for ICU-acquired resistance to cephalosporins was 2.03, for polymyxin B/colistin 0.51, for tobramycin 2.59 and for ciprofloxacin 2.2. The incidence rates for ICU-acquired resistant microbes per year ranged from 0 to 4.94 per 1000 patient-days, and no significant time-trend in incidence rates were found for any of the antimicrobials. The background prevalence rates of resistant strains measured on admission for cephalosporins, polymyxin B/colistin and ciprofloxacin rose over time with 7.9%, 3.5% and 8.0% respectively. Conclusions During more than 21-year SDD, the incidence rates of resistant microbes at the ICU level did not significantly increase over time but the background resistance rates increased. An overall ecological effect of prolonged application of SDD by counting resistant microorganisms in the ICU was not shown in a country with relatively low rates of resistant microorganisms. Electronic supplementary material The online version of this article (10.1186/s13054-019-2480-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Buitinck
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands
| | - Rogier Jansen
- Department of Medical Microbiology, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Saskia Rijkenberg
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Jos P J Wester
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Rob J Bosman
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Nardo J M van der Meer
- TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.,Department of Intensive Care, Amphia Hospital, Molengracht 21, 4814 CK, Breda, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands. .,TIAS School for Business and Society, Warandelaan 2, 5037 AB, Tilburg, The Netherlands.
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14
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Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S279-S288. [PMID: 30348572 DOI: 10.1016/j.arth.2018.09.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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15
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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16
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Westendorp WF, Zock E, Vermeij JD, Kerkhoff H, Nederkoorn PJ, Dijkgraaf MG, van de Beek D. Preventive Antibiotics in Stroke Study (PASS). Neurology 2018; 90:e1553-e1560. [DOI: 10.1212/wnl.0000000000005412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/02/2018] [Indexed: 12/22/2022] Open
Abstract
ObjectiveTo evaluate the cost-effectiveness of preventive ceftriaxone vs standard stroke unit care without preventive antimicrobial therapy in acute stroke patients.MethodsIn this multicenter, randomized, open-label trial with masked endpoint assessment, 2,550 patients with acute stroke were included between 2010 and 2014. Economic evaluation was performed from a societal perspective with a time horizon of 3 months. Volumes and costs of direct, indirect, medical, and nonmedical care were assessed. Primary outcome was cost per unit of the modified Rankin Scale (mRS) and per quality-adjusted life year (QALY) for cost-effectiveness and cost-utility analysis. Incremental cost-effectiveness analyses were performed.ResultsA total of 2,538 patients were available for the intention-to-treat analysis. For the cost-effectiveness analysis, 2,538 patients were available for in-hospital resource use and 1,453 for other resource use. Use of institutional care resources, out-of-pocket expenses, and productivity losses was comparable between treatment groups. The mean score on mRS was 2.38 (95% confidence interval [CI] 2.31–2.44) vs 2.44 (95% CI 2.37–2.51) in the ceftriaxone vs control group, the decrease by 0.06 (95% CI −0.04 to 0.16) in favor of ceftriaxone treatment being nonsignificant. However, the number of QALYs was 0.163 (95% CI 0.159–0.166) vs 0.155 (95% CI 0.152–0.158) in the ceftriaxone vs control group, with the difference of 0.008 (95% CI 0.003–0.012) in favor of ceftriaxone (p = 0.006) at 3 months. The probability of ceftriaxone being cost-effective ranged between 0.67 and 0.89. Probability of 0.75 was attained at a willing-to-pay level of €2,290 per unit decrease in the mRS score and of €12,200 per QALY.ConclusionsPreventive ceftriaxone has a probability of 0.7 of being less costly than standard treatment per unit decrease in mRS and per QALY gained.
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17
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Impact of selective digestive decontamination without systemic antibiotics in a major heart surgery intensive care unit. J Thorac Cardiovasc Surg 2018; 156:685-693. [PMID: 29628347 DOI: 10.1016/j.jtcvs.2018.02.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE The incidence density of ventilator-associated pneumonia (VAP) is higher in patients undergoing major heart surgery than in other populations, despite the introduction of bundles of preventive measures, because many risk factors are not amenable to intervention. Selective digestive decontamination (SDD) has been shown to be efficacious for decreasing the frequency of VAP, although it has not been incorporated into the routine of most intensive care units. The objective of our study was to evaluate the efficacy of SDD without parenteral antibiotics for preventing VAP in a major heart surgery intensive care unit. METHODS We compared the incidence of VAP before the introduction of SDD (17 months) and during the 17 months after the introduction of SDD and examined its ecologic influence. RESULTS The rates of VAP in the overall population before and during the intervention were 16.26/1000 days and 6.80 episodes/1000 days of mechanical ventilation, respectively (P = .01). The rates of VAP in the 173 patients remaining under mechanical ventilation > 48 hours after surgery were, respectively, 25.85/1000 days of mechanical ventilation versus 12.06 episodes/1000 days of mechanical ventilation (P = .04). We found a significant reduction in the number of patients with multidrug-resistant microorganisms (P = .01) in the second period of the study. CONCLUSIONS Our study shows that SDD without parenteral antibiotics can reduce the incidence of VAP in high-risk patients after major heart surgery, with no significant ecologic influence.
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18
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Cevasco M, Hastie J, Takayama H. Expanding our arsenal against an old foe. J Thorac Cardiovasc Surg 2018; 156:694-695. [PMID: 29548589 DOI: 10.1016/j.jtcvs.2018.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Marisa Cevasco
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Jonathan Hastie
- Division of Critical Care Medicine, Columbia University Medical Center, New York, NY; Division of Adult Cardiothoracic Anesthesiology, Columbia University Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY.
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19
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Local antibiotic decontamination to prevent anastomotic leakage short-term outcome in rectal cancer surgery. Int J Colorectal Dis 2018; 33:53-60. [PMID: 29119289 DOI: 10.1007/s00384-017-2933-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Anastomotic leakage still presents an issue in rectal cancer surgery with rates of about 11%. As bacteria play a critical role, there is the concept of perioperative local decontamination to prevent anastomotic leakage. METHODS To ascertain the effectiveness of this treatment, we performed a retrospective analysis on 206 rectal resections with primary anastomosis and routine use of a selective decontamination of the digestive tract (SDD) regimen for local decontamination. SDD medication was administered every 8 h from the day before surgery to the seventh postoperative day. All patients were treated according to the fast-track protocol without mechanical bowel preparation; instead, a laxative was used. RESULTS Overall morbidity was 30%, overall mortality 0.5%. In our data, overall rate of anastomotic leakage (AL) was 5.8%, with 3.9% in anterior rectal resection and 6.5% in low anterior rectal resection group. In 75% of cases, anastomotic leakage was grade "C" and needed re-laparotomy. Surgical site infection rate was 19.9%. No serious adverse events were related to decontamination. CONCLUSION Local antibiotic decontamination appears to be safe and effective to decrease the rate of anastomotic leakage in rectal cancer surgery. Further focus should be on perioperative management including bowel preparation and choice of antimicrobial agents for local decontamination.
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20
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Pérez-Granda MJ, Latorre MC, Alonso B, Hortal J, Samaniego R, Bouza E, Guembe M. Eradication of P. aeruginosa biofilm in endotracheal tubes based on lock therapy: results from an in vitro study. BMC Infect Dis 2017; 17:746. [PMID: 29202722 PMCID: PMC5715999 DOI: 10.1186/s12879-017-2856-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/26/2017] [Indexed: 02/08/2023] Open
Abstract
Background Despite the several strategies available for the management of biofilm-associated ventilator-associated pneumonia, data regarding the efficacy of applying antibiotics to the subglottic space (SS) are scarce. We created an in vitro model to assess the efficacy of antibiotic lock therapy (ALT) applied in the SS for eradication of Pseudomonas aeruginosa biofilm in endotracheal tubes (ETTs). Methods We applied 2 h of ALT to a P. aeruginosa biofilm in ETTs using a single dose (SD) and a 5-day therapy model (5D). We used sterile saline lock therapy (SLT) as the positive control. We compared colony count and the percentage of live cells between both models. Results The median (IQR) cfu counts/ml and percentage of live cells in the SD-ALT and SD-SLT groups were, respectively, 3.12 × 105 (9.7 × 104-0) vs. 8.16 × 107 (7.0 × 107-0) (p = 0.05) and 53.2% (50.9%-57.2%) vs. 91.5% (87.3%-93.9%) (p < 0.001). The median (IQR) cfu counts/ml and percentage of live cells in the 5D-ALT and 5D-SLT groups were, respectively, 0 (0-0) vs. 3.2 × 107 (2.32 × 107-0) (p = 0.03) and 40.6% (36.6%-60.0%) vs. 90.3% (84.8%-93.9%) (p < 0.001). Conclusion We demonstrated a statistically significant decrease in the viability of P. aeruginosa biofilm after application of 5D-ALT in the SS. Future clinical studies to assess ALT in patients under mechanical ventilation are needed.
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Affiliation(s)
- María Jesús Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | | | - Beatriz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Hortal
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - María Guembe
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, 28007, Madrid, Spain.
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Plantinga NL, Bonten MJM. Selective digestive and oropharyngeal decontamination in medical and surgical ICU patients: authors' reply. Clin Microbiol Infect 2017; 24:552-553. [PMID: 28993168 DOI: 10.1016/j.cmi.2017.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/15/2022]
Affiliation(s)
- N L Plantinga
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - M J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Karacaer F, Hamed I, Özogul F, Glew RH, Özcengiz D. The function of probiotics on the treatment of ventilator-associated pneumonia (VAP): facts and gaps. J Med Microbiol 2017; 66:1275-1285. [PMID: 28855004 DOI: 10.1099/jmm.0.000579] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Probiotics have been used for centuries in making fermented dairy products. The health benefits related to probiotics consumption are well recognized and they are generally regarded as safe (GRAS). Their therapeutic effects are due to the production of a variety of antimicrobial compounds, such as short-chain fatty acids, organic acids (such as lactic, acetic, formic, propionic and butyric acids), ethanol, hydrogen peroxide and bacteriocins. Ventilator-associated pneumonia (VAP) is a nosocomial infection associated with high mortality in intensive care units. VAP can result from endotracheal intubation and mechanical ventilation. These interventions increase the risk of infection as patients lose the natural barrier between the oropharynx and the trachea, which in turn facilitates the entry of pathogens through the aspiration of oropharyngeal secretions containing bacteria into the lung. In order to prevent this, probiotics have been used extensively against VAP. This review is an update containing information extracted from recent studies on the use of probiotics to treat VAP. In addition, probiotic safety, the therapeutic properties of probiotics, the probiotic strains used and the action of the probiotics mechanism are reviewed. Furthermore, the therapeutic effects of probiotic treatment procedures for VAP are compared to those of antibiotics. Finally, the influences of bacteriocin on the growth of human pathogens, and the side-effects and limitations of using probiotics for the treatment of VAP are addressed.
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Affiliation(s)
- Feride Karacaer
- Department of Anaesthesiology and Reanimation, School of Medicine, Cukurova University, Adana, Turkey
| | - Imen Hamed
- Biotechnology Research and Application Centre, Cukurova University, Adana, Turkey
| | - Fatih Özogul
- Department of Seafood Processing Technology, Faculty of Fisheries, Cukurova University, 01330, Adana, Turkey
| | - Robert H Glew
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Dilek Özcengiz
- Department of Anaesthesiology and Reanimation, School of Medicine, Cukurova University, Adana, Turkey
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Buelow E, Bello González TDJ, Fuentes S, de Steenhuijsen Piters WAA, Lahti L, Bayjanov JR, Majoor EAM, Braat JC, van Mourik MSM, Oostdijk EAN, Willems RJL, Bonten MJM, van Passel MWJ, Smidt H, van Schaik W. Comparative gut microbiota and resistome profiling of intensive care patients receiving selective digestive tract decontamination and healthy subjects. MICROBIOME 2017; 5:88. [PMID: 28803549 PMCID: PMC5554972 DOI: 10.1186/s40168-017-0309-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 07/13/2017] [Indexed: 05/13/2023]
Abstract
BACKGROUND The gut microbiota is a reservoir of opportunistic pathogens that can cause life-threatening infections in critically ill patients during their stay in an intensive care unit (ICU). To suppress gut colonization with opportunistic pathogens, a prophylactic antibiotic regimen, termed "selective decontamination of the digestive tract" (SDD), is used in some countries where it improves clinical outcome in ICU patients. Yet, the impact of ICU hospitalization and SDD on the gut microbiota remains largely unknown. Here, we characterize the composition of the gut microbiota and its antimicrobial resistance genes ("the resistome") of ICU patients during SDD and of healthy subjects. RESULTS From ten patients that were acutely admitted to the ICU, 30 fecal samples were collected during ICU stay. Additionally, feces were collected from five of these patients after transfer to a medium-care ward and cessation of SDD. Feces from ten healthy subjects were collected twice, with a 1-year interval. Gut microbiota and resistome composition were determined using 16S rRNA gene phylogenetic profiling and nanolitre-scale quantitative PCRs. The microbiota of the ICU patients differed from the microbiota of healthy subjects and was characterized by lower microbial diversity, decreased levels of Escherichia coli and of anaerobic Gram-positive, butyrate-producing bacteria of the Clostridium clusters IV and XIVa, and an increased abundance of Bacteroidetes and enterococci. Four resistance genes (aac(6')-Ii, ermC, qacA, tetQ), providing resistance to aminoglycosides, macrolides, disinfectants, and tetracyclines, respectively, were significantly more abundant among ICU patients than in healthy subjects, while a chloramphenicol resistance gene (catA) and a tetracycline resistance gene (tetW) were more abundant in healthy subjects. CONCLUSIONS The gut microbiota of SDD-treated ICU patients deviated strongly from the gut microbiota of healthy subjects. The negative effects on the resistome were limited to selection for four resistance genes. While it was not possible to disentangle the effects of SDD from confounding variables in the patient cohort, our data suggest that the risks associated with ICU hospitalization and SDD on selection for antibiotic resistance are limited. However, we found evidence indicating that recolonization of the gut by antibiotic-resistant bacteria may occur upon ICU discharge and cessation of SDD.
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Affiliation(s)
- Elena Buelow
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Université Limoges, INSERM, CHU Limoges, UMR 1092, Limoges, France
| | | | - Susana Fuentes
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Center for Immunology of Infectious Diseases and Vaccines, Bilthoven, The Netherlands
| | - Wouter A A de Steenhuijsen Piters
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatric Immunology and Infectious Diseases, The Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Lahti
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Department of Mathematics and Statistics, University of Turku, Turku, Finland
| | - Jumamurat R Bayjanov
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eline A M Majoor
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna C Braat
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maaike S M van Mourik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob J L Willems
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark W J van Passel
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
- Center of Infectious Disease Control, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Willem van Schaik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
- Institute of Microbiology and Infection, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
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Selective decontamination of the digestive tract and oropharynx: after 30 years of debate is the definitive answer in sight? Curr Opin Crit Care 2016; 22:161-6. [PMID: 26766392 DOI: 10.1097/mcc.0000000000000281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Selective digestive or oropharyngeal decontamination has been being used as a means to prevent infections and death in intensive care patients for the past 30 years. It remains controversial and its use is limited. In this review, we summarize the recently published data on efficacy of selective decontamination and effects on antibiotic resistances. RECENT FINDINGS The most recent meta-analysis shows a reduced mortality when selective digestive or oropharyngeal decontamination are compared with either standard care or oropharyngeal chlorhexidine. Selective decontamination is associated with reduced bacteraemia, and although this effect is greater with selective digestive decontamination compared with selective oropharyngeal decontamination, there is not a mortality difference between these two interventions. Reanalysis of infection data suggests, however, that selective decontamination may also have effects on concurrent control groups. Current evidence generally shows that antibiotic resistance is decreased although much of these data come from the Netherlands (an area with low endemic antibiotic resistance rates). There are currently two huge cluster randomized clinical trials, one in early recruitment, one in development, which will hopefully provide definitive answers in the years to come. SUMMARY Current evidence suggests that selective decontamination reduces mortality without increasing antibiotic resistances; this will be tested again in two huge international trials.
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25
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Tarr PI, Warner BB. Gut bacteria and late-onset neonatal bloodstream infections in preterm infants. Semin Fetal Neonatal Med 2016; 21:388-393. [PMID: 27345372 DOI: 10.1016/j.siny.2016.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Late-onset neonatal bloodstream infections remain challenges in neonatology. Hand hygiene, line care, and judicious use of indwelling lines are welcome interventions, but might not reduce the incidence of late-onset neonatal bloodstream infections from bacteria originating in the gut. Accumulating data suggest that many pathogens causing late-onset neonatal bloodstream infections are of gut origin, including Gram-positive cocci. In addition to the host-canonical paradigm (i.e., all bacteria have equal risk of invasion and bloodstream infections are functions of variable infant susceptibility), we should now consider bacteria-canonical paradigms, whereby late-onset neonatal bloodstream infection is a function of colonization with a specific subset of bacteria with exceptional invasive potential. In either event, we can no longer be content to reactively approach late-onset neonatal bloodstream infections; instead we need to reduce the occurrences of these infections by broadening our scope of effort beyond line care, and determine the pre-invasive habitat of these pathogens.
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Affiliation(s)
- Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Pathobiology Research Unit, Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA.
| | - Barbara B Warner
- Fetal Center, Division of Newborn Medicine, Washington University School of Medicine, St Louis, MO, USA
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26
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Krause KM, Serio AW, Kane TR, Connolly LE. Aminoglycosides: An Overview. Cold Spring Harb Perspect Med 2016; 6:6/6/a027029. [PMID: 27252397 DOI: 10.1101/cshperspect.a027029] [Citation(s) in RCA: 511] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aminoglycosides are natural or semisynthetic antibiotics derived from actinomycetes. They were among the first antibiotics to be introduced for routine clinical use and several examples have been approved for use in humans. They found widespread use as first-line agents in the early days of antimicrobial chemotherapy, but were eventually replaced in the 1980s with cephalosporins, carbapenems, and fluoroquinolones. Aminoglycosides synergize with a variety of other antibacterial classes, which, in combination with the continued increase in the rise of multidrug-resistant bacteria and the potential to improve the safety and efficacy of the class through optimized dosing regimens, has led to a renewed interest in these broad-spectrum and rapidly bactericidal antibacterials.
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Affiliation(s)
| | | | | | - Lynn E Connolly
- Achaogen, South San Francisco, California 94080 Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, San Francisco, California 94143
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27
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Dik JWH, Hendrix R, Poelman R, Niesters HG, Postma MJ, Sinha B, Friedrich AW. Measuring the impact of antimicrobial stewardship programs. Expert Rev Anti Infect Ther 2016; 14:569-75. [PMID: 27077229 DOI: 10.1080/14787210.2016.1178064] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antimicrobial Stewardship Programs (ASPs) are being implemented worldwide to optimize antimicrobial therapy, and thereby improve patient safety and quality of care. Additionally, this should counteract resistance development. It is, however, vital that correct and timely diagnostics are performed in parallel, and that an institution runs a well-organized infection prevention program. Currently, there is no clear consensus on which interventions an ASP should comprise. Indeed this depends on the institution, the region, and the patient population that is served. Different interventions will lead to different effects. Therefore, adequate evaluations, both clinically and financially, are crucial. Here, we provide a general overview of, and perspective on different intervention strategies and methods to evaluate these ASP programs, covering before mentioned topics. This should lead to a more consistent approach in evaluating these programs, making it easier to compare different interventions and studies with each other and ultimately improve infection and patient management.
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Affiliation(s)
- Jan-Willem H Dik
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
| | - Ron Hendrix
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands.,b Medical Microbiology , Certe Laboratory for Infectious Diseases , Groningen , The Netherlands
| | - Randy Poelman
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
| | - Hubert G Niesters
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
| | - Maarten J Postma
- c Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy , University of Groningen , Groningen , The Netherlands.,d Institute of Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen , University of Groningen , Groningen , The Netherlands.,e Department of Epidemiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
| | - Bhanu Sinha
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
| | - Alexander W Friedrich
- a Department of Medical Microbiology, University Medical Center Groningen , University of Groningen , Groningen , The Netherlands
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