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Jiang B, Wang Y, He X, Zhang L, Fu S. Meta-analysis of the influence of tracheal intubation with cuff and without cuff on the incidence of total wound complications in ICU intubation patients. Int Wound J 2024; 21:e14741. [PMID: 38414304 PMCID: PMC10899797 DOI: 10.1111/iwj.14741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 02/29/2024] Open
Abstract
At present, it is still controversial whether patients in intensive care unit (ICU) use tracheal intubation with or without cuff. This paper evaluates the effect of tracheal intubation with and without cuff on overall complication rate of patients with intubation in ICU. The database of PubMed, Embase, Conchrane Library and Web of Science was searched by computer, and the clinical research on intubation with and without cuff in ICU was collected. The time range was from the database establishment to November 2023. Literature was independently screened, information was extracted, and quality was assessed by two researchers. Finally, there were nine studies included, with 11 068 patients (7391 in cuff group and 3677 in non-cuff group). The results showed that the overall complication rate of cuff group was significantly lower than that of non-cuff group, and that of cuff group (RR = 0.53, p < 0.01). In addition, compared with the non-cuff group, the cuff group had a lower number of tracheal intubation changes [RR = 0.05, p < 0.01] and a lower incidence of aspiration pneumonia (RR = 0.45, p = 0.01). Compared with the non-cuff group, the cuff group had a higher incidence of oral mucosal ulcers and pharyngitis (RR = 1.99, p = 0.04), while the cuff group had a lower incidence of laryngeal edema (RR = 0.39, p < 0.01). In ICU intubation patients, the use of cuffs reduces overall complication rate in comparison to patients without cuffs. Therefore, patients with intubation in ICU can recommend tracheal intubation with cuff.
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Affiliation(s)
- Bingyu Jiang
- Third People's Hospital of Gansu Province, Lanzhou, China
| | - Yupeng Wang
- Third People's Hospital of Gansu Province, Lanzhou, China
| | - Xiaoyan He
- Third People's Hospital of Gansu Province, Lanzhou, China
| | - Lele Zhang
- Third People's Hospital of Gansu Province, Lanzhou, China
| | - Shangpeng Fu
- Third People's Hospital of Gansu Province, Lanzhou, China
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Fernández-Barat L, López-Aladid R, Vázquez N, Cabrera R, Vila J, Ferrer M, Torres A. Bacterial Adaptive Memory in Methicillin-Resistant Staphylococcus aureus from Endotracheal Tubes. Pathogens 2024; 13:144. [PMID: 38392882 PMCID: PMC10892081 DOI: 10.3390/pathogens13020144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES To evaluate the expression dynamics of biofilm genes in methicillin-resistant Staphylococcus aureus (MRSA) retrieved from endotracheal tubes (ETT) and to determine how gene regulation is attenuated in vitro where host-environmental factors are no longer present. METHODS Biofilm was grown (24 h) in tryptic broth soy plus 0.25% glucose for a clinical MRSA isolate in planktonic state and after sessile growth named ETT-MRSA (S2, S3, S4, S5, S6, S7). Gene expression of five biofilm-related genes (icaC, clfB, ebps, fnbB, and RNA III) was assessed consecutively from day 1 to day 4 after ETT growth through real-time PCR. 16S rRNA was used as a control. RESULTS The MRSA isolates retrieved from ETT were capable of producing biofilms dependent on ica. The gene expression dynamics of ETT-MRSA changed progressively compared to planktonic MRSA gene expression under both ambient air (p < 0.001) and ambient air with 5% CO2 (p < 0.001). Dynamic assessment of icaC expression in both atmospheric conditions showed progressive downregulation in vitro compared to in vivo ETT biofilms. The expression patterns of clfB and ebps genes were similar to icaC. In contrast, the expression of the RNA III gene showed progressive upregulation from day 1 to day 4 (p < 0.001). CONCLUSIONS MRSA loses its biofilm gene expression in vitro, by adaptive features across multiple generations, as evidenced by the progressive downregulation of icaC and upregulation of RNA III. These findings underscore the significance of host-environment dependence in regulating bacterial biofilm genes, highlighting its importance in diagnostics. Bacterial strains lose their host-specific characteristics as they are cultured in vitro.
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Affiliation(s)
- Laia Fernández-Barat
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
| | - Ruben López-Aladid
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
| | - Nil Vázquez
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
| | - Roberto Cabrera
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
| | - Jordi Vila
- University of Barcelona, 08193 Barcelona, Spain;
- Microbiology Service at Hospital Clinic and Institute of Global Health (ISGlobal), 08036 Barcelona, Spain
| | - Miquel Ferrer
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
- Pulmonary and Critical Care Unit, Respiratory Institute, Hospital Clinic, 08036 Barcelona, Spain
| | - Antoni Torres
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.L.-A.); (N.V.); (R.C.); (M.F.)
- University of Barcelona, 08193 Barcelona, Spain;
- Pulmonary and Critical Care Unit, Respiratory Institute, Hospital Clinic, 08036 Barcelona, Spain
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Kiarostami K, Fernández-Barat L, Battaglini D, Motos A, Bueno-Freire L, Soler-Comas A, Bassi GL, Torres A. The efficacy of telavancin in comparison with linezolid on endotracheal tube biofilm in pigs with methicillin-resistant Staphylococcus aureus pneumonia. Int J Antimicrob Agents 2024; 63:107052. [PMID: 38072170 DOI: 10.1016/j.ijantimicag.2023.107052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 11/23/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The effect of systemic treatment of ventilator-associated pneumonia (VAP) with telavancin, a semisynthetic lipoglycopeptide with good penetration in vitro biofilms, has not been tested in vivo during mechanical ventilation. This study examined the efficacy of telavancin compared with linezolid against endotracheal tube (ETT) biofilms in a porcine model of methicillin-resistant Staphylococcus aureus (MRSA) VAP. METHODS VAP was induced in 18 pigs by instilling 107 colony-forming units (CFU/mL) of an MRSA strain susceptible to telavancin and linezolid into each pulmonary lobe. Randomization into three groups was done at pneumonia diagnosis: control (IV glucose 0.5% solution q24); linezolid (10 mg/kg q12) and telavancin groups (22.5 mg/kg q24). After 72 h of MV, data regarding bronchoalveolar lavage (BAL), tracheal aspirate (TA), ETT MRSA biofilm load and thickness measured by scanning electron microscopy were obtained. RESULTS All 18 pigs completed the study. MRSA was isolated in 100% of ETTs from the control and linezolid groups and in 67% from the telavancin group. Telavancin treatment presented a lower MRSA load compared to the control and linezolid treatments (telavancin median [interquartile range (IQR)] = 1.94 [0.00-5.45], linezolid 3.99 [3.22-4.68] and control 4.93 [4.41-5.15], P = 0.236). Telavancin treatment also resulted in the lowest biofilm thickness according to the SEM (4.04 [2.09-6.00], P < 0.001). We found a positive correlation between ETT and BAL load (rho = 0.511, P = 0.045). CONCLUSIONS In our VAP model, systemic telavancin treatment reduced ETT MRSA occurrence, load, and biofilm thickness. Our findings may have a bearing on ICU patients' clinical outcomes.
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Affiliation(s)
- Kasra Kiarostami
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Laia Fernández-Barat
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain.
| | - Denise Battaglini
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Anna Motos
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain; Institut Clínic Respiratori (ICR), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Leticia Bueno-Freire
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Alba Soler-Comas
- School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Gianluigi Li Bassi
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Queensland University of Technology, Brisbane, Australia; Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 3015, Rotterdam, the Netherlands
| | - Antoni Torres
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine Department of Medicine, University of Barcelona, Spain; Pulmonology Department, Hospital Clínic, Barcelona, Spain; Institut Clínic Respiratori (ICR), Hospital Clínic de Barcelona, Barcelona, Spain.
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Endotracheal tube biofilm in critically ill patients during the COVID-19 pandemic : description of an underestimated microbiological compartment. Sci Rep 2022; 12:22389. [PMID: 36575298 PMCID: PMC9794690 DOI: 10.1038/s41598-022-26560-w] [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] [Received: 08/05/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022] Open
Abstract
Biofilm (BF) growth is believed to play a major role in the development of ventilator-associated pneumonia (VAP) in the intensive care unit. Despite concerted efforts to understand the potential implication of endotracheal tube (ETT)-BF dispersal, clinically relevant data are lacking to better characterize the impact of its mesostructure and microbiological singularity on the occurrence of VAP. We conducted a multicenter, retrospective observational study during the third wave of the COVID-19 pandemic, between March and May 2021. In total, 64 ETTs collected from 61 patients were included in the present BIOPAVIR study. Confocal microscopy acquisitions revealed two main morphological aspects of ETT-deposited BF: (1) a thin, continuous ribbon-shaped aspect, less likely monobacterial and predominantly associated with Enterobacter spp., Streptococcus pneumoniae or Viridans streptococci, and (2) a thicker, discontinuous, mushroom-shaped appearance, more likely characterized by the association of bacterial and fungal species in respiratory samples. The microbiological characterization of ETT-deposited BF found higher acquired resistance in more than 80% of analyzed BF phenotypes, compared to other colonization sites from the patient's environment. These findings reveal BF as a singular microbiological compartment, and are of added clinical value, with a view to future ETT-deposited BF-based antimicrobial stewardship in critically ill patients. Trial registration NCT04926493. Retrospectively registered 15 June 2021.
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Huang F, Shen T, Hai X, Xiu H, Zhang K, Huang T, Chen J, Guan Z, Zhou H, Cai J, Cai Z, Cui W, Zhang S, Zhang G. Clinical characteristics of and risk factors for secondary bloodstream infection after pneumonia among patients infected with methicillin-resistant Staphylococcus aureus. Heliyon 2022; 8:e11978. [PMID: 36506352 PMCID: PMC9732304 DOI: 10.1016/j.heliyon.2022.e11978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/29/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To investigate the clinical features and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia (MP) with secondary MRSA bloodstream infections (MRSA-BSI) (termed MP-BSI) compared with MP alone and to study the incidence of MP-BSI among patients with MP. Methods This was a retrospective, single-center study with clinical data derived from previous medical records. The cases were divided into groups: MP alone and MP-BSI. The determination of independent risk factors for MP-BSI relied on logistic regression analysis. Additionally, the crude outcomes were compared. Results A total of 435 patients with MP were recruited, with 18.9% (82/435) having MP-BSI. The median age was 62 (interquartile range, 51,72) years, and 74.5% of the patients were male. Multivariate analysis revealed that immunosuppression, community-acquired MP (CA-MP), time from initial to targeted antibiotic use, high Sequential Organ Failure Assessment (SOFA) score, increased respiratory rate, and elevated γ-GT level (all p < 0.05) were independent risk factors for MP-BSI, while targeted treatment with linezolid was a protective factor. Patients with MP-BSI had a longer duration of hospitalization (median days, 27.5 vs. 19, p = 0.001), a higher 28-day mortality rate (24.4% vs. 11.0%, p = 0.001), and a higher in-hospital mortality rate (26.8% vs. 14.7%, p = 0.009) than those with MP alone. Conclusion Secondary MRSA-BSI among patients with MP is not rare. Immunosuppression, CA-MP, time from initial to targeted antibiotic use, high SOFA score, increased respiratory rate and elevated γ-GT level are all independent risk factors for MP-BSI; however, linezolid, as a targeted antibiotic, is a protective factor. Moreover, patients with MP may have worse clinical outcomes when they develop MRSA-BSI.
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Affiliation(s)
- Fangfang Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Department of Critical Care Medicine, Yuyao People's Hospital, Yuyao 315400, China
| | - Ting Shen
- Department of Critical Care Medicine, Yuyao People's Hospital, Yuyao 315400, China
| | - Xin Hai
- Department of Pharmacy, First Affiliated Hospital, Harbin Medical University, Harbin, 150001, China
| | - Huiqing Xiu
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Tiancha Huang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Juan Chen
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Department of Intensive Care Unit, Ningbo Fourth Hospital Ningbo, Zhejiang 315700, China
| | - Zhihui Guan
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Department of Critical Care Medicine, Taizhou First People's Hospital, Taizhou 318020, China
| | - Hongwei Zhou
- Clinical Microbiology Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jiachang Cai
- Clinical Microbiology Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Zhijian Cai
- Institute of Immunology, and Department of Orthopaedics of the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Corresponding author.
| | - Shufang Zhang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Corresponding author.
| | - Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China,Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, China,Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, China,Corresponding author.
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Zoller M, Paal M, Greimel A, Kallee S, Vogeser M, Irlbeck M, Schroeder I, Liebchen U, Scharf C. Serum linezolid concentrations are reduced in critically ill patients with pulmonary infections: A prospective observational study. J Crit Care 2022; 71:154100. [PMID: 35780622 DOI: 10.1016/j.jcrc.2022.154100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
RATIONALE The concentration-time profile of linezolid varies considerably in critically ill patients. Question of interest is, if the site of infection influences linezolid serum concentrations. METHODS 68 critically ill patients, treated with linezolid, were included. The concentration-time-profile for linezolid was determined using maximum a-posteriori predictions. A trough concentration (Cmin) between 2 and 10 mg/L was defined as the target. A generalized linear model (GLM) was established to evaluate potential covariates. RESULTS The indications for linezolid therapy were in descending order: peritonitis (38.2%), pneumonia (25.0%), infectious acute respiratory distress syndrome (ARDS) (19.1%), and other non-pulmonary infection (17.7%). 27.2 and 7.9% of Cmin were subtherapeutic and toxic, respectively. In the GLM, ARDS (mean: -2.1 mg/L, CI: -3.0 to -1.2 mg/L) and pneumonia (mean: -2.2 mg/L, CI: -2.8 to -1.6 mg/L) were significant (p < 0.001) determinants of Cmin. Patients with ARDS (mean: 2.3 mg/L, 51.2% subtherapeutic, 0.0% toxic) and pneumonia (mean: 3.5 mg/L, 41.5% subtherapeutic, 7.7% toxic) had significantly (p < 0.001) lower Cmin than those with peritonitis (mean: 5.5 mg/L, 14.4% subtherapeutic, 9.3% toxic) and other non-pulmonary infection (mean: 5.2 mg/L, 3.3% subtherapeutic, 16.5% toxic). CONCLUSION Linezolid serum concentrations are reduced in patients with pulmonary infections. Future studies should investigate if other linezolid thresholds are needed in those patients due to linezolid pooling in patients´ lung.
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Affiliation(s)
- Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Antonia Greimel
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany.
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Ma A, Dong M, Cheng J, Liao X, Dong W, Liu C, Hu C, Yang J, Kang Y. Clinical efficacy and safety of linezolid in intensive care unit patients. JOURNAL OF INTENSIVE MEDICINE 2022; 3:65-72. [PMID: 36789359 PMCID: PMC9923966 DOI: 10.1016/j.jointm.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/24/2022] [Accepted: 05/14/2022] [Indexed: 10/17/2022]
Abstract
Background To characterize the population of critically ill patients and infections treated with linezolid in the intensive care unit (ICU), and to evaluate the clinical efficacy and safety of linezolid therapy. Methods This multi-center, observational, real-world study was conducted across 52 hospitals between June 9, 2018, and December 28, 2019. Patients who met the following inclusion criteria were included: (1) admitted to the ICU, (2) of any age group, and (3) having a clinical or laboratory diagnosis of a Gram-positive bacterial infection. Clinical efficacy was categorized as success (cured or improved), failed, or non-evaluable. Adverse events and serious adverse events were recorded during treatment. Results A total of 366 ICU patients who met the inclusion criteria were evaluated. Linezolid was used as second- and first-line treatment in 232 (63.4%) and 134 (36.6%) patients, respectively. The most common isolated strain was Staphylococcus aureus (methicillin-resistant Staphylococcus aureus: n=37/119, 31.1%; methicillin-susceptible Staphylococcus aureus: n=15/119, 12.6%); this was followed by Enterococci (vancomycin-resistant Enterococci: n=8/119, 6.7%; vancomycin-susceptible Enterococci: n=11/119, 9.2%) and Streptococcus pneumoniae (multidrug-resistant: n=4/119, 3.4%; non-multidrug resistant: n=2/119, 1.7%). The main infection sites where pathogens were detected included the lung (n=216/366, 59.6%), skin and soft tissue (n=104/366, 28.4%), and blood (n=50/366, 13.7%). Clinical success was achieved in 301 (82.2%) patients; 34 (9.3%) were cured and 267 (73.0%) improved; treatment failure and non-evaluable outcomes were observed in 29 (7.9%) in 36 (9.8%) patients, respectively. Linezolid-related adverse events were reported in 8 (2.2%) patients. No treatment-related serious adverse events were reported. Conclusions Based on real-world results, linezolid was found to be effective and safe in the treatment of Gram-positive bacterial infections in critically ill patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Jing Yang
- Corresponding authors: Jing Yang and Yan Kang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
| | - Yan Kang
- Corresponding authors: Jing Yang and Yan Kang, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China.
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Wei Y, Zhang H, Fu M, Ma R, Li R, Kong L. Plasma and Intrapulmonary Pharmacokinetics, and Dosage Regimen Optimization of Linezolid for Treatment of Gram-Positive Cocci Infections in Patients with Pulmonary Infection After Cerebral Hemorrhage. Infect Drug Resist 2022; 15:1733-1742. [PMID: 35422643 PMCID: PMC9004730 DOI: 10.2147/idr.s357300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yongli Wei
- Grade Three Laboratory of Traditional Chinese Medicine Preparation of the National Administration of Traditional Chinese Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China
| | - He Zhang
- Grade Three Laboratory of Traditional Chinese Medicine Preparation of the National Administration of Traditional Chinese Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China
| | - Maowu Fu
- Department of Neurosurgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China
| | - Rui Ma
- Grade Three Laboratory of Traditional Chinese Medicine Preparation of the National Administration of Traditional Chinese Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China
| | - Ronghui Li
- Department of Neurosurgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China
- Correspondence: Ronghui Li, Neurosurgery Department, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, 250014, People’s Republic of China, Email
| | - Lingti Kong
- Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China
- Lingti Kong, Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, 233004, People’s Republic of China, Email
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Huang Y, He L, Deng Y, Zhang R, Meng M, Liu J, Chen D. Target serum concentration of vancomycin may be reached earlier with a loading dose. Chin Med J (Engl) 2022; 135:317-323. [PMID: 34985019 PMCID: PMC8812668 DOI: 10.1097/cm9.0000000000001905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Vancomycin treatment failure against vancomycin-susceptible gram-positive cocci is not rare in the intensive care unit (ICU). One of the reasons for this is the substandard drug trough concentration. We aimed to examine the hypothesis that the target serum concentration could be reached earlier with a loading dose of vancomycin. METHODS This retrospective cohort study was conducted at our ICU between June 2018 and June 2020 and involved patients who were suspected of having, or confirmed to have, gram-positive cocci infection and treated with vancomycin. One group of the patients was administered a loading dose of vancomycin (loading group) and compared with the group that did not receive a loading dose (control group). The baseline characteristics, vancomycin serum concentrations, and clinical outcomes were collected and analyzed. RESULTS Fifty-five patients were finally included, of which 29 received a loading dose of vancomycin. The serum concentration of vancomycin before the second dose was significantly higher for the loading group than for the control group (10.3 ± 6.1 mg/L vs. 5.7 ± 4.4 mg/L, P = 0.002). The results for both groups were similar before the fifth dose (12.4 ± 7.3 mg/L vs. 10.3 ± 6.3 mg/L in the loading and the control groups, respectively; P = 0.251). The 28-day mortality was lower for the loading group than for the control group (6.7% vs. 34.6% in the loading and control groups, respectively; P = 0.026). No significant differences were observed in serum creatinine (Cr) concentrations of the two groups. CONCLUSION With the loading dose of vancomycin, the target serum concentration of vancomycin may be reached earlier without increasing the risk of acute kidney injury. TRIAL REGISTRATION https://www.chictr.org.cn; ChiCTR2000035369.
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Affiliation(s)
- Yanxia Huang
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Le He
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Yunxin Deng
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Renjing Zhang
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Mei Meng
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 201801, China
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10
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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11
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Rowe SE, Beam JE, Conlon BP. Recalcitrant Staphylococcus aureus Infections: Obstacles and Solutions. Infect Immun 2021; 89:e00694-20. [PMID: 33526569 PMCID: PMC8090968 DOI: 10.1128/iai.00694-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Antibiotic treatment failure of Staphylococcus aureus infections is very common. In addition to genetically encoded mechanisms of antibiotic resistance, numerous additional factors limit the efficacy of antibiotics in vivo Identifying and removing the barriers to antibiotic efficacy are of major importance, as even if new antibiotics become available, they will likely face the same barriers to efficacy as their predecessors. One major obstacle to antibiotic efficacy is the proficiency of S. aureus to enter a physiological state that is incompatible with antibiotic killing. Multiple pathways leading to antibiotic tolerance and the formation of tolerant subpopulations called persister cells have been described for S. aureus Additionally, S. aureus is a versatile pathogen that can infect numerous tissues and invade a variety of cell types, of which some are poorly penetrable to antibiotics. It is therefore unlikely that there will be a single solution to the problem of recalcitrant S. aureus infection. Instead, specific approaches may be required for targeting tolerant cells within different niches, be it through direct targeting of persister cells, sensitization of persisters to conventional antibiotics, improved penetration of antibiotics to particular niches, or any combination thereof. Here, we examine two well-described reservoirs of antibiotic-tolerant S. aureus, the biofilm and the macrophage, the barriers these environments present to antibiotic efficacy, and potential solutions to the problem.
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Affiliation(s)
- Sarah E Rowe
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jenna E Beam
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian P Conlon
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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12
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Michalik M, Kosecka-Strojek M, Wolska M, Samet A, Podbielska-Kubera A, Międzobrodzki J. First Case of Staphylococci Carrying Linezolid Resistance Genes from Laryngological Infections in Poland. Pathogens 2021; 10:pathogens10030335. [PMID: 33805734 PMCID: PMC8000362 DOI: 10.3390/pathogens10030335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Linezolid is currently used to treat infections caused by multidrug-resistant Gram-positive cocci. Both linezolid-resistant S. aureus (LRSA) and coagulase-negative staphylococci (CoNS) strains have been collected worldwide. Two isolates carrying linezolid resistance genes were recovered from laryngological patients and characterized by determining their antimicrobial resistance patterns and using molecular methods such as spa typing, MLST, SCCmec typing, detection of virulence genes and ica operon expression, and analysis of antimicrobial resistance determinants. Both isolates were multidrug resistant, including resistance to methicillin. The S. aureus strain was identified as ST-398/t4474/SCCmec IVe, harboring adhesin, hemolysin genes, and the ica operon. The S. haemolyticus strain was identified as ST-42/mecA-positive and harbored hemolysin genes. Linezolid resistance in S. aureus strain was associated with the mutations in the ribosomal proteins L3 and L4, and in S. haemolyticus, resistance was associated with the presence of cfr gene. Moreover, S. aureus strain harbored optrA and poxtA genes. We identified the first case of staphylococci carrying linezolid resistance genes from patients with chronic sinusitis in Poland. Since both S. aureus and CoNS are the most common etiological factors in laryngological infections, monitoring of such infections combined with surveillance and infection prevention programs is important to decrease the number of linezolid-resistant staphylococcal strains.
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Affiliation(s)
- Michał Michalik
- MML Medical Centre, Bagno 2, 00-112 Warsaw, Poland; (M.M.); (A.S.); (A.P.-K.)
| | - Maja Kosecka-Strojek
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Gronostajowa 7, 30-387 Kraków, Poland; (M.W.); (J.M.)
- Correspondence:
| | - Mariola Wolska
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Gronostajowa 7, 30-387 Kraków, Poland; (M.W.); (J.M.)
| | - Alfred Samet
- MML Medical Centre, Bagno 2, 00-112 Warsaw, Poland; (M.M.); (A.S.); (A.P.-K.)
| | | | - Jacek Międzobrodzki
- Department of Microbiology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Gronostajowa 7, 30-387 Kraków, Poland; (M.W.); (J.M.)
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13
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Fernández-Barat L, López-Aladid R, Torres A. Reconsidering ventilator-associated pneumonia from a new dimension of the lung microbiome. EBioMedicine 2020; 60:102995. [PMID: 32950001 PMCID: PMC7492164 DOI: 10.1016/j.ebiom.2020.102995] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 12/12/2022] Open
Abstract
Complex microbial communities that reside in the lungs, skin and gut are now appreciated for their role in maintaining organ, tissue and immune homoeostasis. As lungs are currently seen as an ecosystem, the shift in paradigm calls for the consideration of new algorithms related to lung ecology in pulmonology. Evidence of lung microbiota does not solely challenge the traditional physiopathology of ventilator-associated pneumonia (VAP); indeed, it also reinforces the need to include molecular techniques in VAP diagnosis and accelerate the use of immunomodulatory drugs, including corticosteroids, and other supplements such as probiotics for VAP prevention and/or treatment. With that stated, both microbiome and virome, including phageome, can lead to new opportunities in further understanding the relationship between health and dysbiosis in VAP. Previous knowledge may be, however, reconsidered at a microbiome scale.
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Affiliation(s)
- Laia Fernández-Barat
- Cellex Laboratory, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; School of Medicine, University of Barcelona, Barcelona, Spain.
| | - Ruben López-Aladid
- Cellex Laboratory, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - Antoni Torres
- Cellex Laboratory, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain; School of Medicine, University of Barcelona, Barcelona, Spain; Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona, Spain.
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14
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Antimicrobial Photoinactivation Approach Based on Natural Agents for Control of Bacteria Biofilms in Spacecraft. Int J Mol Sci 2020; 21:ijms21186932. [PMID: 32967302 PMCID: PMC7554952 DOI: 10.3390/ijms21186932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 01/08/2023] Open
Abstract
A spacecraft is a confined system that is inhabited by a changing microbial consortium, mostly originating from life-supporting devices, equipment collected in pre-flight conditions, and crewmembers. Continuous monitoring of the spacecraft’s bioburden employing culture-based and molecular methods has shown the prevalence of various taxa, with human skin-associated microorganisms making a substantial contribution to the spacecraft microbiome. Microorganisms in spacecraft can prosper not only in planktonic growth mode but can also form more resilient biofilms that pose a higher risk to crewmembers’ health and the material integrity of the spacecraft’s equipment. Moreover, bacterial biofilms in space conditions are characterized by faster formation and acquisition of resistance to chemical and physical effects than under the same conditions on Earth, making most decontamination methods unsafe. There is currently no reported method available to combat biofilm formation in space effectively and safely. However, antibacterial photodynamic inactivation based on natural photosensitizers, which is reviewed in this work, seems to be a promising method.
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15
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Cabrera R, Fernández-Barat L, Motos A, López-Aladid R, Vázquez N, Panigada M, Álvarez-Lerma F, López Y, Muñoz L, Castro P, Vila J, Torres A. Molecular characterization of methicillin-resistant Staphylococcus aureus clinical strains from the endotracheal tubes of patients with nosocomial pneumonia. Antimicrob Resist Infect Control 2020; 9:43. [PMID: 32111258 PMCID: PMC7049205 DOI: 10.1186/s13756-020-0679-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Background Among all cases of nosocomial pneumonia, Staphylococcus aureus is the second most prevalent pathogen (17.8%). In Europe, 29.9% of the isolates are oxacillin-resistant. The changing epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections and the decreasing susceptibility to first-line antibiotics leave clinicians with few therapeutic options. The objective of our study was to determine the antimicrobial susceptibility, the associated molecular mechanisms of resistance and the epidemiological relatedness of MRSA strains isolated from the endotracheal tubes (ETT) of intubated critically ill patients in the intensive care unit (ICU) with nosocomial pneumonia caused by Staphylococcus aureus. Methods The antimicrobial susceptibility to vancomycin, linezolid, ciprofloxacin, clindamycin, erythromycin, chloramphenicol, fusidic acid, gentamicin, quinupristin-dalfopristin, rifampicin, sulfamethoxazole/trimethoprim, and tetracycline were measured. Resistance mechanisms were then analyzed by polymerase chain reaction and sequencing. Molecular epidemiology was carried out by multi-locus sequence typing. Results S. aureus isolates were resistant to ciprofloxacin, erythromycin, gentamicin, tetracycline, clindamycin, and fusidic acid. The most frequent mutations in quinolone-resistant S. aureus strains were S84L in the gyrA gene, V511A in the gyrB gene, S144P in the grlA gene, and K401R/E in the grlB gene. Strains resistant to erythromycin carried the ermC, ermA, and msrA genes; the same ermC and ermA genes were detected in strains resistant to clindamycin. The aac(6′)-aph(2″) gene was related to gentamicin resistance, while resistance to tetracycline was related to tetK (efflux pump). The fusB gene was detected in the strain resistant to fusidic acid. The most frequent sequence types were ST22, ST8, and ST217, which were distributed in four clonal complexes (CC5, CC22, CC45, and CC59). Conclusions High levels of resistance to second-line antimicrobials threatens the treatment of nosocomial respiratory infections due to methicillin-resistant S. aureus with decreased susceptibility to linezolid and vancomycin. The wide genotypic diversity found reinforces the central role of ICU infection control in preventing nosocomial transmission.
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Affiliation(s)
- Roberto Cabrera
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain.,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Laia Fernández-Barat
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain. .,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain.
| | - Anna Motos
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain.,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Rubén López-Aladid
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain.,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Nil Vázquez
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain.,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain
| | - Mauro Panigada
- Department of Anesthesiology, Intensive Care and Emergency, U.O.C. Rianimazione e Terapia Intensiva, Fondazione IRCCS Ca' Granda, Policlinic Milan, Milan, Italy
| | - Francisco Álvarez-Lerma
- Critical Care Department, Hospital del Mar, Critical Illness Research Group (GREPAC), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Yuly López
- Barcelona Global Health Institute, Department of Clinical Microbiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Laura Muñoz
- Barcelona Global Health Institute, Department of Clinical Microbiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Internal Medicine Intensive Care Unit, Hospital Clínic, Barcelona, Spain
| | - Jordi Vila
- Barcelona Global Health Institute, Department of Clinical Microbiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Antoni Torres
- Cellex Laboratory, CibeRes (Center for net Biomedical Research Respiratory diseases, 06/06/0028)- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Spain. .,Respiratory Intensive Care Unit, Pulmonology Department, Hospital Clínic, Barcelona, Spain.
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