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Miller WR, Arias CA. ESKAPE pathogens: antimicrobial resistance, epidemiology, clinical impact and therapeutics. Nat Rev Microbiol 2024; 22:598-616. [PMID: 38831030 DOI: 10.1038/s41579-024-01054-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/05/2024]
Abstract
The rise of antibiotic resistance and a dwindling antimicrobial pipeline have been recognized as emerging threats to public health. The ESKAPE pathogens - Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp. - were initially identified as critical multidrug-resistant bacteria for which effective therapies were rapidly needed. Now, entering the third decade of the twenty-first century, and despite the introduction of several new antibiotics and antibiotic adjuvants, such as novel β-lactamase inhibitors, these organisms continue to represent major therapeutic challenges. These bacteria share several key biological features, including adaptations for survival in the modern health-care setting, diverse methods for acquiring resistance determinants and the dissemination of successful high-risk clones around the world. With the advent of next-generation sequencing, novel tools to track and combat the spread of these organisms have rapidly evolved, as well as renewed interest in non-traditional antibiotic approaches. In this Review, we explore the current epidemiology and clinical impact of this important group of bacterial pathogens and discuss relevant mechanisms of resistance to recently introduced antibiotics that affect their use in clinical settings. Furthermore, we discuss emerging therapeutic strategies needed for effective patient care in the era of widespread antimicrobial resistance.
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Affiliation(s)
- William R Miller
- Department of Internal Medicine, Division of Infectious Diseases, Houston Methodist Hospital, Houston, TX, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Cesar A Arias
- Department of Internal Medicine, Division of Infectious Diseases, Houston Methodist Hospital, Houston, TX, USA.
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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Lee CC, Ho CY, Hong MY, Hung YP, Ko WC. A simple scoring algorithm predicting paravertebral and/or iliopsoas abscess among adults with community-onset bloodstream infections: matters of PVL-producing Staphylococcus aureus. Infection 2024:10.1007/s15010-024-02344-4. [PMID: 39299999 DOI: 10.1007/s15010-024-02344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/02/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE Misdiagnosis or delayed diagnosis of paravertebral and/or iliopsoas abscess (PVIPA) has been frequently reported to be associated with unfavorable prognosis. We aimed to develop a scoring algorithm that can easily and accurately identify patients at greater risk for PVIPA among individuals with community-onset bloodstream infections. METHODS In a multicenter, retrospective cohort study, the score was developed with the first four study years and validated with the remaining two years. Applying logistic regression, the score values of prediction determinants were derived from the adjusted odds ratios (AOR). The performance of the scoring algorithm was assessed with the receiver operating characteristic (ROC) curve. RESULTS In the derivation (3869 patients) and validation (1608) cohorts, patients with PVIPA accounted for 1.7% and 1.4%, respectively. In the derivation cohort, five independent predictors of PVIPA were recognized using multivariable analyses: time-to-defervescence > 5 days (AOR, 7.00; 2 points), Panton-Valentine Leukocidin (PVL)-producing Staphylococcus aureus (AOR, 5.98; 2 points), intravenous drug users (AOR, 2.60; 1 points), and comorbid hemato-oncology (AOR, 0.41; -1 point) or liver cirrhosis (AOR, 2.56; 1 points). In the derivation and validation cohorts, areas under ROC curves (95% confidence intervals) of the prediction algorithm are 0.83 (0.77-0.88) and 0.85 (0.80-0.90), and a cutoff score of + 2 represents sensitivity of 83.3% and 95.7%, specificity of 68.6% and 67.7%, positive predictive values of 4.4% and 4.1%, and negative predictive values of 99.6% and 99.9%, respectively. CONCLUSIONS Of a scoring algorithm with substantial sensitivity and specificity in predicting PVIPA, PVL-producing S. aureus and Time-to-defervescence > 5 days were crucial determinants.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medical Research Center, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Infectious Disease, Departments of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 70403, Taiwan
- Department of Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, Taiwan
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan
- Departments of Emergency Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Pin Hung
- Division of Infectious Disease, Departments of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 70403, Taiwan.
- Department of Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan.
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan City, Taiwan.
| | - Wen-Chien Ko
- Division of Infectious Disease, Departments of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 70403, Taiwan.
- Department of Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan.
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Liu CW, Chen Q, Ding N, Hu LF. Ceftazidime-avibactam: Combination therapy versus monotherapy in the challenge of pneumonia caused by carbapenem-resistant Klebsiella pneumoniae. Heliyon 2024; 10:e35757. [PMID: 39220988 PMCID: PMC11365303 DOI: 10.1016/j.heliyon.2024.e35757] [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: 05/05/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
This research focused on evaluating the clinical results of patients suffering from pneumonia caused by carbapenem-resistant Klebsiella pneumoniae (CRKP), who received treatment with either ceftazidime-avibactam (CZA) alone or in combination with other antibiotics. From January 2020 to December 2023, we retrospectively analyzed CRKP-related pneumonia patients treated in two Chinese tertiary hospitals. Mortality was measured at 14 and 30 days as the primary outcome. Secondary outcomes included the 14-day microbiological cure rate and the 14-day clinical cure rate. Factors contributing to clinical failure were evaluated via both univariate analysis and multivariate logistic regression. To account for confounding factors, propensity score matching (PSM) was utilized. Among the 195 patients with CRKP infections, 103 (52.8 %) received CZA combination therapy, and 92 (47.2 %) patients received CZA monotherapy. The combination therapy group exhibited superior clinical and microbiological cure rates compared to the monotherapy group, with a 14-day clinical cure rate of 60.1 % vs. 45.7 % (P = 0.042) and a 14-day microbiological cure rate of 72.8 % vs. 58.6 % (P = 0.038), respectively. Combination therapy reduced mortality rates at 14 days (7.8 % vs. 17.4 %, P = 0.041), but not at 30 days (14.6 % vs. 25.0 %, P = 0.066). Even after using PSM, the group treated with the CZA combination continued to had a lower mortality rate at 14 days (5.9 % vs. 17.6 %, P = 0.039). The 14-day clinical cure rate for the combination therapy group was 63.2 %, and the 14-day microbial cure rate was 77.9 %. Both of these statistics were notably greater than those observed in the monotherapy group. Furthermore, the multivariate logistic regression model indicated a significant link between combination therapy and a decrease in clinical failure. Carbapenems were noted to be the most effective class of concomitant agents. Our findings indicate that patients with pneumonia due to CRKP benefit from combination treatment of CZA rather than monotherapy; administering carbapenem in combination with CZA in the early stages could provide considerable survival benefits.
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Affiliation(s)
- Chang-wei Liu
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
- The Grade 3 Pharmaceutical Chemistry Laboratory of State Administration of Traditional Chinese Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
| | - Qiang Chen
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
- Anhui Center for Surveillance of Bacterial Resistance, Hefei, PR China
| | - Nan Ding
- Department of Pharmacy, Shanghai Changhai Hospital, The First Affiliated Hospital of Naval Medical University, Shanghai, PR China
| | - Li-fen Hu
- Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, PR China
- Anhui Center for Surveillance of Bacterial Resistance, Hefei, PR China
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Bassetti M, Monti G, Henriksen AS, Longshaw C. Predicting early appropriate therapy for patients infected by carbapenem-resistant Gram-negative pathogens in intensive care units in Italy. Antimicrob Resist Infect Control 2024; 13:91. [PMID: 39183351 PMCID: PMC11345987 DOI: 10.1186/s13756-024-01452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Antibiotic resistance among Gram-negative bacteria in intensive care units (ICUs) is linked with high morbidity and mortality in patients. In this study, we estimated the therapeutic coverage of various antibiotics, focusing on cefiderocol and comparators, administered empirically against an infection of unknown origin in the ICU. METHODS In the ARTEMIS surveillance study, susceptibilities of 624 Italian Gram-negative isolates to amikacin, aztreonam-avibactam, cefiderocol, ceftazidime-avibactam, ceftolozane-tazobactam, colistin, imipenem-relebactam, meropenem, and meropenem-vaborbactam were tested by broth microdilution, and results were interpreted by European Committee on Antimicrobial Susceptibility Testing breakpoints. The susceptibility rates from the ARTEMIS study were extrapolated to Gram-negative isolates obtained from 5,774 patients in Italian ICUs in 2021. The sum of the predicted susceptibilities of individual pathogens represented the overall likelihood of in vitro activity of each antibiotic as early targeted therapy for ICU patients. RESULTS A total of 624 Italian Gram-negative isolates included 206 Pseudomonas aeruginosa, 138 Acinetobacter baumannii, 187 Klebsiella pneumoniae, and 93 Escherichia coli. Against A. baumannii, K. pneumoniae, P. aeruginosa, and E. coli, the overall susceptibility rates for cefiderocol were 87.7%, 96.8%, 99%, and 100%, respectively; and for comparator agents, 8.7-96.4%, 25.7-100%, 73.3-100%, and 89.2-100%, respectively. Among the subset of meropenem-resistant isolates, susceptibility rates of A. baumannii, K. pneumoniae, and P. aeruginosa to cefiderocol were 86.4%, 96.2% and 100%, respectively. Corresponding susceptibility rates to comparator agents were 0-96.8%, 0-100%, and 6.4-100%, respectively. There were no meropenem-resistant isolates of E. coli. The extrapolation of data to isolates from Italian ICUs showed that the highest likelihood of therapeutic coverage, both overall and among meropenem-resistant isolates, was reported for colistin (96.8% and 72.2%, respectively) and cefiderocol (95.7% and 71.4%, respectively). All other antibiotics were associated with a likelihood below 73% overall and between 0% and 41.4% for meropenem-resistant isolates. CONCLUSIONS Based on confirmed susceptibility rates and reported ICU prevalence of multiple Gram-negative species, cefiderocol showed a higher predicted therapeutic coverage and utility in ICUs compared with comparator beta-lactam-beta-lactamase inhibitor antibiotics. Cefiderocol may be a promising early treatment option for patients at high risk of carbapenem-resistant Gram-negative bacterial infections in the ICU.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Cheng Y, Cheng Q, Zhang R, Gao JY, Li W, Wang FK, He ZX, Sun QQ, Meng HB, Yu S. Retrospective analysis of molecular characteristics, risk factors, and outcomes in carbapenem-resistant Klebsiella pneumoniae bloodstream infections. BMC Microbiol 2024; 24:309. [PMID: 39174950 PMCID: PMC11340057 DOI: 10.1186/s12866-024-03465-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Klebsiella pneumoniae (KP) is the second most prevalent Gram-negative bacterium causing bloodstream infections (BSIs). In recent years, the management of BSIs caused by KP has become increasingly complex due to the emergence of carbapenem-resistant Klebsiella pneumoniae (CRKP). Although numerous studies have explored the risk factors for the development of CRKP-BSIs, the mortality of patients with KP-BSIs, and the molecular epidemiological characteristics of CRKP, the variability in data across different populations, countries, and hospitals has led to inconsistent conclusions. In this single-center retrospective observational study, we utilized logistic regression analyses to identify independent risk factors for CRKP-BSIs and factors associated with mortality in KP-BSI patients. Furthermore, a risk factor-based prediction model was developed. CRKP isolates underwent whole-genome sequencing (WGS), followed by an evaluation of microbiological characteristics, including antimicrobial resistance and virulence genes, as well as epidemiological characteristics and phylogenetic analysis. RESULTS Our study included a total of 134 patients with KP-BSIs, comprising 50 individuals infected with CRKP and 84 with carbapenem-susceptible Klebsiella pneumoniae (CSKP). The independent risk factors for CRKP-BSIs were identified as gastric catheterization (OR = 9.143; CI = 1.357-61.618; P = 0.023), prior ICU hospitalization (OR = 4.642; CI = 1.312-16.422; P = 0.017), and detection of CRKP in non-blood sites (OR = 8.112; CI = 2.130-30.894; P = 0.002). Multivariate analysis revealed that microbiologic eradication after 6 days (OR = 3.569; CI = 1.119-11.387; P = 0.032), high Pitt bacteremia score (OR = 1.609; CI = 1.226-2.111; P = 0.001), and inappropriate empirical treatment after BSIs (OR = 6.756; CI = 1.922-23.753; P = 0.003) were independent risk factors for the 28-day mortality in KP-BSIs. The prediction model confirmed that microbiologic eradication after 6.5 days and a Pitt bacteremia score of 4.5 or higher were significant predictors of the 28-day mortality. Bioinformatics analysis identified ST11 as the predominant CRKP sequence type, with blaKPC-2 as the most prevalent gene variant. CRKP stains carried multiple plasmid-mediated resistance genes along with some virulence genes. Phylogenetic analysis indicated the presence of nosocomial transmission of ST11 CRKP within the ICU. CONCLUSIONS The analysis of risk factors for developing CRKP-BSIs and the association between KP-BSIs and 28-day mortality, along with the development of a risk factor-based prediction model and the characterization of CRKP strains, enhances clinicians' understanding of the pathogens responsible for BSIs. This understanding may help in the timely administration of antibiotic therapy for patients with suspected KP-BSIs, potentially improving outcomes.
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Affiliation(s)
- Yan Cheng
- Department of Basic Medical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Qi Cheng
- Department of Outpatient, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Rong Zhang
- Department of Outpatient, General Hospital of Southern Theatre Command of PLA, Guangzhou, 510010, China
| | - Jie-Ying Gao
- Department of Clinical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Wei Li
- Department of Clinical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Fu-Kun Wang
- Department of Clinical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Zheng-Xin He
- Department of Basic Medical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Qing-Qing Sun
- Department of Basic Medical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Han-Bing Meng
- Department of Basic Medical Laboratory, The 980th Hospital of the PLA Joint Logistical Support Force (Bethune International Peace Hospital), Shijiazhuang, 050081, China
| | - Shu Yu
- Department of Laboratory Medicine, Chonggang General Hospital, Chongqing, 400081, China.
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Zhang H, Wang Y, Zhang X, Xu C, Xu D, Shen H, Jin H, Yang J, Zhang X. Carbapenem-resistant Enterobacterales sepsis following endoscopic retrograde cholangiopancreatography: risk factors for 30-day all-cause mortality and the development of a nomogram based on a retrospective cohort. Antimicrob Resist Infect Control 2024; 13:84. [PMID: 39113089 PMCID: PMC11304701 DOI: 10.1186/s13756-024-01441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 07/25/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) has become a routine endoscopic procedure that is essential for diagnosing and managing various conditions, including gallstone extraction and the treatment of bile duct and pancreatic tumors. Despite its efficacy, post-ERCP infections - particularly those caused by carbapenem-resistant Enterobacterales (CRE) - present significant risks. These risks highlight the need for accurate predictive models to enhance postprocedural care, reduce the mortality risk associated with post-ERCP CRE sepsis, and improve patient outcomes in the context of increasing antibiotic resistance. OBJECTIVE This study aimed to examine the risk factors for 30-day mortality in patients with CRE sepsis following ERCP and to develop a nomogram for accurately predicting 30-day mortality risk. METHODS Data from 195 patients who experienced post-ERCP CRE sepsis between January 2010 and December 2022 were analyzed. Variable selection was optimized via the least absolute shrinkage and selection operator (LASSO) regression model. Multivariate logistic regression analysis was then employed to develop a predictive model, which was evaluated in terms of discrimination, calibration, and clinical utility. Internal validation was achieved through bootstrapping. RESULTS The nomogram included the following predictors: age > 80 years (hazard ratio [HR] 2.61), intensive care unit (ICU) admission within 90 days prior to ERCP (HR 2.64), hypoproteinemia (HR 4.55), quick Pitt bacteremia score ≥ 2 (HR 2.61), post-ERCP pancreatitis (HR 2.52), inappropriate empirical therapy (HR 3.48), delayed definitive therapy (HR 2.64), and short treatment duration (< 10 days) (HR 5.03). The model demonstrated strong discrimination and calibration. CONCLUSIONS This study identified significant risk factors associated with 30-day mortality in patients with post-ERCP CRE sepsis and developed a nomogram to accurately predict this risk. This tool enables healthcare practitioners to provide personalized risk assessments and promptly administer appropriate therapies against CRE, thereby reducing mortality rates.
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Affiliation(s)
- Hongchen Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Yue Wang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Xiaochen Zhang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Chenshan Xu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Dongchao Xu
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Hongzhang Shen
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Hangbin Jin
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Jianfeng Yang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China
- Hangzhou Institute of Digestive Disease, Zhejiang, China
| | - Xiaofeng Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, No. 261 HuanSha Road, Zhejiang, China.
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou First People's Hospital, Hangzhou, 310003, China.
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, China.
- Hangzhou Institute of Digestive Disease, Zhejiang, China.
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Falcone M, Galfo V, Tiseo G. Not all carbapenem-resistant Pseudomonas aeruginosa strains are alike: tailoring antibiotic therapy based on resistance mechanisms. Curr Opin Infect Dis 2024:00001432-990000000-00165. [PMID: 39149832 DOI: 10.1097/qco.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To correlate the resistance mechanisms and the susceptibility to new antibiotics in Pseudomonas aeruginosa . RECENT FINDINGS Definition of antibiotic resistance in Pseudomonas aeruginosa is still debated. Carbapenem-resistant Pseudomonas aeruginosa (CRPA) and difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA) are used but which of them better correlate with the risk of mortality remains debated. Mechanisms underlying resistance in Pseudomonas aeruginosa are complex and may be combined, resulting in unpredictable phenotype and cross-resistance. Thus, not all CRPA are alike and tailoring antibiotic therapy on resistance mechanisms is challenging. SUMMARY Current guidelines recommend the use of new antipseudomonal agents for CRPA or DTR-PA infections but they don't provide specific information on how tailoring antibiotic therapy on underlying resistance mechanisms. This review may be useful to understand which mechanisms are involved in CRPA and may have practical implications helping clinicians to select an appropriate antibiotic regimen. Several antibiotics are now available for Pseudomonas aeruginosa but their rational use is important to avoid development of future resistance. The knowledge of local epidemiology and most common resistance mechanisms may guide empirical therapy, but targeted antibiotic therapy should be re-evaluated as soon as susceptibility testing profile is available and selected according to Pseudomonas aeruginosa phenotype.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Young EL, Roach DJ, Martinsen MA, McGrath G, Holbrook NR, Cho HE, Seyoum EY, Pierce VM, Bhattacharyya RP. Clinical Pilot of Bacterial Transcriptional Profiling as a Combined Genotypic and Phenotypic Antimicrobial Susceptibility Test. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.10.24310021. [PMID: 39040176 PMCID: PMC11261942 DOI: 10.1101/2024.07.10.24310021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Antimicrobial resistance is a growing health threat, but standard methods for determining antibiotic susceptibility are slow and can delay optimal treatment, which is especially consequential in severe infections such as bacteremia. Novel approaches for rapid susceptibility profiling have emerged that characterize either bacterial response to antibiotics (phenotype) or detect specific resistance genes (genotype). GoPhAST-R is a novel assay, performed directly on positive blood cultures, that integrates rapid transcriptional response profiling with detection of key resistance gene transcripts, thereby providing simultaneous data on both phenotype and genotype. Here, we performed the first clinical pilot of GoPhAST-R on 42 positive blood cultures: 26 growing Escherichia coli, 15 growing Klebsiella pneumoniae, and 1 with both. An aliquot of each positive blood culture was exposed to 9 different antibiotics, lysed, then underwent rapid transcriptional profiling on the NanoString® platform; results were analyzed using an in-house susceptibility classification algorithm. GoPhAST-R achieved 95% overall agreement with standard antimicrobial susceptibility testing methods, with the highest agreement for beta-lactams (98%) and the lowest for fluoroquinolones (88%). Epidemic resistance genes including the extended spectrum beta-lactamase bla CTX-M-15 and the carbapenemase bla KPC were also detected within the population. This study demonstrates the clinical feasibility of using transcriptional response profiling for rapid resistance determination, although further validation with larger and more diverse bacterial populations will be essential in future work. GoPhAST-R represents a promising new approach for rapid and comprehensive antibiotic susceptibility testing in clinical settings.
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Affiliation(s)
- E L Young
- The Broad Institute of MIT and Harvard, Boston, MA, USA
| | - D J Roach
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - M A Martinsen
- The Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Geg McGrath
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - N R Holbrook
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - H E Cho
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - E Y Seyoum
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - V M Pierce
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Current address: Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - R P Bhattacharyya
- The Broad Institute of MIT and Harvard, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
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Shields RK, Horcajada JP, Kamat S, Irani PM, Tawadrous M, Welte T. Ceftazidime-Avibactam in the Treatment of Patients with Bacteremia or Nosocomial Pneumonia: A Systematic Review and Meta-analysis. Infect Dis Ther 2024; 13:1639-1664. [PMID: 38822167 PMCID: PMC11219669 DOI: 10.1007/s40121-024-00999-y] [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: 11/15/2023] [Accepted: 05/17/2024] [Indexed: 06/02/2024] Open
Abstract
INTRODUCTION Ceftazidime-avibactam (CAZ-AVI) is a combination of the third-generation cephalosporin ceftazidime and the novel, non-β-lactam β-lactamase inhibitor avibactam that is approved for the treatment of pediatric (≥ 3 months) and adult patients with complicated infections including hospital-acquired and ventilator-associated pneumonia (HAP/VAP), and bacteremia. This systematic literature review and meta-analysis (PROSPERO registration: CRD42022362856) aimed to provide a quantitative and qualitative synthesis to evaluate the effectiveness of CAZ-AVI in treating adult patients with bacteremia or nosocomial pneumonia caused by carbapenem-resistant Enterobacterales (non metallo-β-lactamase-producing strains) and multi-drug resistant (MDR) Pseudomonas aeruginosa infections. METHODS The databases included in the search, until November 7, 2022, were Embase and PubMed. A total of 24 studies (retrospective: 22, prospective: 2) with separate outcomes for patients with bacteremia or pneumonia were included. RESULTS The outcomes assessed were all-cause mortality, clinical cure, and microbiological cure. Qualitative (24 studies) and quantitative (8/24 studies) syntheses were performed. The quality of the studies was assessed using the MINORS checklist and the overall risk of bias was moderate to high. CONCLUSIONS In studies included in the meta-analysis, lower all-cause mortality for patients with bacteremia (OR = 0.30, 95% CI 0.19-0.46) and improved rates of clinical cure for patients with bacteremia (OR = 4.90, 95% CI 2.60-9.23) and nosocomial pneumonia (OR = 3.20, 95% CI 1.55-6.60) was observed in the CAZ-AVI group compared with the comparator group. Data provided here may be considered while using CAZ-AVI for the treatment of patients with difficult-to-treat infections. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022362856.
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Affiliation(s)
- Ryan K Shields
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Juan P Horcajada
- Department of Infectious Diseases, Hospital Del Mar, Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III CIBERINFEC, Madrid, Spain
| | | | | | | | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Member of the German Center of Lung Research, Hannover School of Medicine, Hannover, Germany
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Wu H, Li M, Shou C, Shi F, Song X, Hu Q, Wang Y, Chen Y, Tong X. Pathogenic spectrum and drug resistance of bloodstream infection in patients with acute myeloid leukaemia: a single centre retrospective study. Front Cell Infect Microbiol 2024; 14:1390053. [PMID: 38912203 PMCID: PMC11190328 DOI: 10.3389/fcimb.2024.1390053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/10/2024] [Indexed: 06/25/2024] Open
Abstract
Background Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital. Methods From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI. Results A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with Klebsiella pneumoniae being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after Stenotrophomonas maltophilia infection was up to 71.4%. Conclusions In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, Stenotrophomonas maltophilia infection was found to be associated with a poor prognosis. Early intervention for Stenotrophomonas maltophilia infection in our centre could potentially improve patient outcomes.
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Affiliation(s)
- Han Wu
- Graduate School of Clinical Medicine, Jinzhou Medical University, Jinzhou, Liaoning, China
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Manning Li
- Graduate School of Clinical Medicine, Jinzhou Medical University, Jinzhou, Liaoning, China
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Chunyi Shou
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Fangfang Shi
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaolu Song
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qingfeng Hu
- Department of Clinical Laboratory, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Ying Wang
- Department of Central Laboratory, Affiliated Hangzhou First People’s Hospital, Xihu University, Hangzhou, Zhejiang, China
| | - Yirui Chen
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiangmin Tong
- Cancer Center, Department of Hematology, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Xihu University, Hangzhou, Zhejiang, China
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Costantino V, Principe L, Mehat J, Busetti M, Piccirilli A, Perilli M, Luzzati R, Zerbato V, Meliadò A, La Ragione R, Di Bella S. Synergistic Activity of Temocillin and Fosfomycin Combination against KPC-Producing Klebsiella pneumoniae Clinical Isolates. Antibiotics (Basel) 2024; 13:526. [PMID: 38927192 PMCID: PMC11200827 DOI: 10.3390/antibiotics13060526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/08/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Infections caused by KPC-producing K. pneumoniae continue to pose a significant clinical challenge due to their emerging resistance to new antimicrobials. We investigated the association between two drugs whose roles have been repurposed against multidrug-resistant bacteria: fosfomycin and temocillin. Temocillin exhibits unusual stability against KPC enzymes, while fosfomycin acts as a potent "synergizer". We conducted in vitro antimicrobial activity studies on 100 clinical isolates of KPC-producing K. pneumoniae using a combination of fosfomycin and temocillin. The results demonstrated synergistic activity in 91% of the isolates. Subsequently, we assessed the effect on Galleria mellonella larvae using five genetically different KPC-Kp isolates. The addition of fosfomycin to temocillin increased larvae survival from 73 to 97% (+Δ 32%; isolate 1), from 93 to 100% (+Δ 7%; isolate 2), from 63 to 86% (+Δ 36%; isolate 3), from 63 to 90% (+Δ 42%; isolate 4), and from 93 to 97% (+Δ 4%; isolate 10). Among the temocillin-resistant KPC-producing K. pneumoniae isolates (24 isolates), the addition of fosfomycin reduced temocillin MIC values below the resistance breakpoint in all isolates except one. Temocillin combined with fosfomycin emerges as a promising combination against KPC-producing K. pneumoniae, warranting further clinical evaluation.
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Affiliation(s)
- Venera Costantino
- Microbiology Unit, Trieste University Hospital (ASUGI), 34128 Trieste, Italy; (V.C.); (M.B.)
| | - Luigi Principe
- Clinical Microbiology and Virology Unit, Great Metropolitan Hospital “Bianchi-Melacrino-Morelli”, 89128 Reggio di Calabria, Italy; (L.P.); (A.M.)
| | - Jai Mehat
- Department of Microbial Sciences, School of Biosciences, University of Surrey, Guildford GU2 7XH, UK; (J.M.); (R.L.R.)
| | - Marina Busetti
- Microbiology Unit, Trieste University Hospital (ASUGI), 34128 Trieste, Italy; (V.C.); (M.B.)
| | - Alessandra Piccirilli
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.P.); (M.P.)
| | - Mariagrazia Perilli
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.P.); (M.P.)
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34129 Trieste, Italy;
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), 34125 Trieste, Italy;
| | - Antonietta Meliadò
- Clinical Microbiology and Virology Unit, Great Metropolitan Hospital “Bianchi-Melacrino-Morelli”, 89128 Reggio di Calabria, Italy; (L.P.); (A.M.)
| | - Roberto La Ragione
- Department of Microbial Sciences, School of Biosciences, University of Surrey, Guildford GU2 7XH, UK; (J.M.); (R.L.R.)
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, University of Surrey, Guildford GU2 7XH, UK
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34129 Trieste, Italy;
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Rodríguez-Leal CM, González-Corralejo C, Candel FJ, Salavert M. Candent issues in pneumonia. Reflections from the Fifth Annual Meeting of Spanish Experts 2023. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2024; 37:221-251. [PMID: 38436606 PMCID: PMC11094633 DOI: 10.37201/req/018.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
Pneumonia is a multifaceted illness with a wide range of clinical manifestations, degree of severity and multiple potential causing microorganisms. Despite the intensive research of recent decades, community-acquired pneumonia remains the third-highest cause of mortality in developed countries and the first due to infections; and hospital-acquired pneumonia is the main cause of death from nosocomial infection in critically ill patients. Guidelines for management of this disease are available world wide, but there are questions which generate controversy, and the latest advances make it difficult to stay them up to date. A multidisciplinary approach can overcome these limitations and can also aid to improve clinical results. Spanish medical societies involved in diagnosis and treatment of pneumonia have made a collaborative effort to actualize and integrate last expertise about this infection. The aim of this paper is to reflect this knowledge, communicated in Fifth Pneumonia Day in Spain. It reviews the most important questions about this disorder, such as microbiological diagnosis, advances in antibiotic and sequential therapy, management of beta-lactam allergic patient, preventive measures, management of unusual or multi-resistant microorganisms and adjuvant or advanced therapies in Intensive Care Unit.
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Affiliation(s)
| | | | - F J Candel
- Francisco Javier Candel, Clinical Microbiology Service. Hospital Clínico San Carlos. IdISSC and IML Health Research Institutes. 28040 Madrid. Spain.
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Mauri C, Consonni A, Briozzo E, Giubbi C, Meroni E, Tonolo S, Luzzaro F. The Molecular Mouse System: A New Useful Tool for Guiding Antimicrobial Therapy in Critically Ill Septic Patients. Antibiotics (Basel) 2024; 13:517. [PMID: 38927183 PMCID: PMC11200723 DOI: 10.3390/antibiotics13060517] [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: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Bloodstream infections (BSI) caused by multidrug-resistant (MDR) bacteria, pose a major threat for patients, especially for those who are immunosuppressed. Rapid pathogen detection and characterization from positive blood cultures are crucial in the management of patients with BSI to enable an adequate and timely antimicrobial therapy. This study aimed to investigate the potential role of the Molecular Mouse system, a new CE IVD molecular test designed to rapidly detect the causative agents of bacteremia and their resistance determinants, in the management of the therapy in critically ill patients. Agreement between the results of the Molecular Mouse and the conventional routine method was also considered. Overall, 100 positive blood cultures were collected from septic critically ill patients from May 2023 to January 2024 and analyzed with Molecular Mouse and routine protocols. The new instrument consistently agreed with the routine protocols in the case of monomicrobial blood cultures, while some discrepancies were obtained in the polymicrobial samples. Antimicrobial resistance genes were detected in 35 samples, with vanA and CTX-M-1/9 groups being the most frequently detected targets. Therapy was adjusted in 42 critically ill patients confirming the importance of new rapid molecular tests in the management of positive blood cultures, to adjust empirical therapy and use new antibiotics accurately.
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Hu Q, Lu J, Deng B, Tang X, Hou Z. Clinical characteristics, effectiveness and cost of different treatment methods for invasive Klebsiella pneumoniae liver abscess syndrome. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2024; 49:748-757. [PMID: 39174889 PMCID: PMC11341225 DOI: 10.11817/j.issn.1672-7347.2024.240063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVES Bacterial liver abscess is one of the common infectious diseases of the digestive system. Invasive Klebsiella pneumoniae liver abscess syndrome (IKLAS) refers to cases where, in addition to liver abscess, there are migratory infections foci or other invasive manifestations. The clinical characteristics and risk factors of IKLAS are not fully elucidated, and there is a lack of research on the effectiveness and cost-effectiveness of different treatment methods. This study aims to compare the clinical characteristics of patients with IKLAS and non-IKLAS, and explore effective and economical treatment methods. METHODS This retrospective study collected medical records of patients with Klebsiella pneumoniae liver abscess treated at Xiangya Hospital of Central South University from January 2010 to December 2023. A total of 201 patients were included, dividing into an IKLAS group (n=37) and a non-IKLAS group (n=164). Differences in demographics, symptoms and signs, laboratory indicators, imaging characteristics, comorbidities, treatment methods, treatment outcomes, and direct treatment costs between 2 groups were analyzed. The study also compared the effectiveness and costs of different treatment methods. RESULTS Compared with the non-IKLAS group, the proportion of patients with diabetes, Quick Sequential Organ Failure Assessment (qSOFA)≥2, immune deficiency, anemia, and thrombocytopenia in the IKLAS group was higher, and the level of procalcitonin at the onset in the IKLAS group was also higher (all P<0.05). In terms of symptoms and signs, the IKLAS group had a higher proportion of visual abnormalities and a lower proportion of complaints of abdominal pain (both P<0.05). In terms of complications, the incidence of combined pleural effusion, pulmonary infection, acute renal failure, respiratory failure, and multiple organ failure was higher in the IKLAS group (all P<0.05). The IKLAS group had a higher proportion of patients treated with antibiotics alone (24.32% vs 11.59%), while the non-IKLAS group had a higher proportion of patients treated with antibiotics combined with puncture and drainage (86.59% vs 64.86%, both P<0.05). The overall effective rate of the IKLAS group (83.78%) was lower than that of the non-IKLAS group (95.73%), and the treatment and drug costs were higher (all P<0.05). The treatment method of antibiotics combined with surgical resection of infectious foci showed a 100% improvement rate, antibiotics combined with abscess puncture and drainage had an 84.9% improvement rate, and in antibiotics alone had an 82.1% improvement rate, with statistical differences among the 3 treatment methods (P<0.05). In terms of treatment costs, antibiotics alone were the most expensive (P<0.05). CONCLUSIONS Patients with IKLAS have poorer prognosis and higher direct medical costs. The combination of abscess puncture and drainage or surgery has a higher improvement rate and lower hospitalization costs compared to antibiotics alone, suggesting that surgical intervention may reduce antibiotic costs and save medical expenses.
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Affiliation(s)
- Qin Hu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008.
| | - Jingying Lu
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Binbin Deng
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xuemei Tang
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Zhouhua Hou
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha 410008, China.
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Lee CC, Chen PL, Ho CY, Hong MY, Hung YP, Ko WC. Prompt antimicrobial therapy and source control on survival and defervescence of adults with bacteraemia in the emergency department: the faster, the better. Crit Care 2024; 28:176. [PMID: 38790061 PMCID: PMC11127347 DOI: 10.1186/s13054-024-04963-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence effect on patients with source-control-required (ScR) or unrequired (ScU) bacteraemia. METHODS The multicenter cohort included treatment-naïve adults with bacteraemia in the emergency department. Clinical information was retrospectively obtained and etiologic pathogens were prospectively restored to accurately determine the time-to-appropriate antibiotic (TtAa). The association between TtAa or time-to-source control (TtSc, for ScR bacteraemia) and 30-day crude mortality or delayed defervescence were respectively studied by adjusting independent determinants of mortality or delayed defervescence, recognised by a logistic regression model. RESULTS Of the total 5477 patients, each hour of TtAa delay was associated with an average increase of 0.2% (adjusted odds ratio [AOR], 1.002; P < 0.001) and 0.3% (AOR 1.003; P < 0.001) in mortality rates for patients having ScU (3953 patients) and ScR (1524) bacteraemia, respectively. Notably, these AORs were augmented to 0.4% and 0.5% for critically ill individuals. For patients experiencing ScR bacteraemia, each hour of TtSc delay was significantly associated with an average increase of 0.31% and 0.33% in mortality rates for overall and critically ill individuals, respectively. For febrile patients, each additional hour of TtAa was significantly associated with an average 0.2% and 0.3% increase in the proportion of delayed defervescence for ScU (3085 patients) and ScR (1266) bacteraemia, respectively, and 0.5% and 0.9% for critically ill individuals. For 1266 febrile patients with ScR bacteraemia, each hour of TtSc delay respectively was significantly associated with an average increase of 0.3% and 0.4% in mortality rates for the overall population and those with critical illness. CONCLUSIONS Regardless of the need for source control in cases of bacteraemia, there seems to be a significant association between the prompt administration of appropriate antimicrobials and both a favourable prognosis and rapid defervescence, particularly among critically ill patients. For ScR bacteraemia, delayed source control has been identified as a determinant of unfavourable prognosis and delayed defervescence. Moreover, this association with patient survival and the speed of defervescence appears to be augmented among critically ill patients.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medical Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
| | - Po-Lin Chen
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, No.57, Sec. 1, Dongmen Road, East Dist., Tainan, 70142, Taiwan
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Ming-Yuan Hong
- Departments of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Yuan-Pin Hung
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan City, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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Falcone M, Giordano C, Leonildi A, Galfo V, Lepore A, Suardi LR, Riccardi N, Barnini S, Tiseo G. Clinical Features and Outcomes of Infections Caused by Metallo-β-Lactamase-Producing Enterobacterales: A 3-Year Prospective Study From an Endemic Area. Clin Infect Dis 2024; 78:1111-1119. [PMID: 38036465 DOI: 10.1093/cid/ciad725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Metallo-β-lactamase (MBL)-producing Enterobacterales are increasing worldwide. Our aim was to describe clinical features, treatments, and outcomes of infections by MBL-Enterobacterales. METHODS A prospective observational study conducted in the Pisa University Hospital (January 2019 to October 2022) included patients with MBL-producing Enterobacterales infections. The primary outcome measure was the 30-day mortality rate. Multivariable Cox regression analysis was performed to identify factors associated with that mortality rate, and adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were calculated. RESULTS The study's 343 patients included 15 with Verona integron-encoded MBL (VIM)- and 328 with New Delhi MBL (NDM)-producing Enterobacterales infections; there were 199 patients (58%) with bloodstream infections, 60 (17.5%) with hospital-acquired or ventilator-associated pneumonia, 60 (17.5%) with complicated urinary tract infections, 13 (3.8%) with intra-abdominal infections, and 11 (3.2%) with skin and soft-tissue infections. The 30-day mortality rate was 29.7%. Of 343 patients, 32 did not receive in vitro active antibiotic therapy, 215 (62.7%) received ceftazidime-avibactam plus aztreonam, 33 (9.6%) received cefiderocol-containing regimens, 26 (7.6%) received colistin-containing regimens, and 37 (10.8%) received other active antibiotics. On multivariable analysis, septic shock (aHR, 3.57 [95% CI, 2.05-6.23]; P < .001) and age (1.05 [1.03-1.08]; P < .001) were independently associated with the 30-day mortality rate, while in vitro active antibiotic therapy within 48 hours after infection (0.48 [.26-.8]; P = .007) and source control (0.43 [.26-.72]; P = .001) were protective factors. Sensitivity analysis showed that ceftazidime-avibactam plus aztreonam, compared with colistin, was independently associated with a reduced 30-day mortality rate (aHR, 0.39 [95% CI, .18-.86]; P = .02). Propensity score analyses confirmed these findings. CONCLUSIONS MBL-producing carbapenem-resistant Enterobacterales infections are associated with high 30-day mortality rates. Patients with MBL-producing Enterobacterales infections should receive early active antibiotic therapy.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Cesira Giordano
- Microbiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Aurelio Lepore
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Lorenzo Roberto Suardi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Niccolò Riccardi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Önal U, Tüzemen Ü, Küçükdemirci Kaya P, İşçimen R, Kelebek Girgin N, Özakın C, Kahveci F, Akalın H. A comparative study of ceftazidime/avibactam-based and fosfomycin plus meropenem-based regimens for managing infections caused by carbapenem-resistant Klebsiella pneumoniae in critically ill patients. J Chemother 2024:1-9. [PMID: 38698711 DOI: 10.1080/1120009x.2024.2349439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
The main aim of this study was to compare and analyze the effectiveness of treatment regimens using ceftazidime/avibactam (CAZ/AVI) versus fosfomycin plus meropenem (FOS/MER) for managing bloodstream infections (BSI) or ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) in critically ill patients. Between 4 January 2019, and 16 July 2023, adult patients (≥18 years old) diagnosed with BSI or VAP due to culture confirmed CRKP in ICU of a tertiary care hospital were investigated retrospectively. A total of 71 patients were categorized into two groups: 30 patients in CAZ/AVI-based, and 41 patients in FOS/MER-based group. No substantial disparities were found in the total duration of ICU hospitalization, as well as the 14- and 30-day mortality rates, between patients treated with CAZ/AVI-based and FOS/MER-based therapeutic regimens. We consider that our study provides for the first time a comprehensive understanding of treatment outcomes and associated risk factors among patients with CRKP-related infections.
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Affiliation(s)
- Uğur Önal
- Department of Infectious Diseases and Clinical Microbiology, Uludag University, Bursa, Türkiye
| | - Ülkü Tüzemen
- Department of Medical Microbiology, Uludag University, Bursa, Türkiye
| | | | - Remzi İşçimen
- Department of Anesthesiology and Reanimation, Uludag University, Bursa, Türkiye
| | | | - Cüneyt Özakın
- Department of Medical Microbiology, Uludag University, Bursa, Türkiye
| | - Ferda Kahveci
- Department of Anesthesiology and Reanimation, Uludag University, Bursa, Türkiye
| | - Halis Akalın
- Department of Infectious Diseases and Clinical Microbiology, Uludag University, Bursa, Türkiye
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Li J, Wu W, Wu M, Zhou Z, Wang J, Qiu M, Xu L, Ren J, Wu X. Clinical and Molecular Characteristics of Patients with Bloodstream Infections Caused by KPC and NDM Co-Producing Carbapenem-Resistant Klebsiella pneumoniae. Infect Drug Resist 2024; 17:1685-1697. [PMID: 38711471 PMCID: PMC11073536 DOI: 10.2147/idr.s455146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024] Open
Abstract
Purpose Klebsiella pneumoniae carbapenemase (KPC) and New Delhi metallo-β-lactamase (NDM) co-producing carbapenem-resistant Klebsiella pneumoniae (KPC-NDM-CRKP) isolates have been increasingly reported worldwide but have not yet been systematically studied. Thus, we have conducted a study to compare the risk factors, molecular characteristics, and mortality involved in clinical bloodstream infections (BSIs) caused by KPC-NDM-CRKP and KPC-CRKP strains. Methods A retrospective study was conducted on 231 patients with BSIs caused by CRKP at Jinling Hospital in China from January 2020 to December 2022. Antimicrobial susceptibility testing, carbapenemase genes detection and whole-genome sequencing were performed subsequently. Results Overall, 231 patients were included in this study: 25 patients with KPC-NDM-CRKP BSIs and 206 patients with KPC-CRKP BSIs. Multivariate analysis implicated ICU-acquired BSI, surgery within 30 days, and longer stay of hospitalization prior to CRKP isolation as independent risk factors for KPC-NDM-CRKP BSIs. The 30-day mortality rate of the KPC-NDM-CRKP BSIs group was 56% (14/25) compared with 32.5% (67/206) in the KPC-CRKP BSIs control group (P = 0.02). The ICU-acquired BSIs, APACHE II score at BSI onset, and BSIs caused by KPC-NDM-CRKP were independent predictors for 30-day mortality in patients with CRKP bacteremia. The most prevalent ST in KPC-NDM-CRKP isolates was ST11 (23/25, 92%), followed by ST15 (2/25, 8%). Conclusion In patients with CRKP BSIs, KPC-NDM-CRKP was associated with an excess of mortality. The likelihood that KPC-NDM-CRKP will become the next "superbug" highlights the significance of epidemiologic surveillance and clinical awareness of this pathogen.
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Affiliation(s)
- Jiayang Li
- School of Medicine, Southeast University, Nanjing, People’s Republic of China
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, People’s Republic of China
| | - Wenqi Wu
- School of Medicine, Nanjing University, Nanjing, People’s Republic of China
| | - Meilin Wu
- Nanjing Medical University, Nanjing, People’s Republic of China
| | - Zhitao Zhou
- Nanjing Medical University, Nanjing, People’s Republic of China
| | - Jiajie Wang
- School of Medicine, Southeast University, Nanjing, People’s Republic of China
| | - Mingjie Qiu
- Nanjing Medical University, Nanjing, People’s Republic of China
| | - Li Xu
- Nanjing Medical University, Nanjing, People’s Republic of China
| | - Jianan Ren
- School of Medicine, Southeast University, Nanjing, People’s Republic of China
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, People’s Republic of China
| | - Xiuwen Wu
- School of Medicine, Southeast University, Nanjing, People’s Republic of China
- Research Institute of General Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, People’s Republic of China
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19
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Abdelraouf K, Gill CM, Gethers M, Tiseo G, Barnini S, Falcone M, Menichetti F, Nicolau DP. Deciphering the Efficacy of β-Lactams in the Face of Metallo-β-Lactamase-Derived Resistance in Enterobacterales: Supraphysiologic Zinc in the Broth Is the Culprit. Open Forum Infect Dis 2024; 11:ofae228. [PMID: 38813259 PMCID: PMC11134298 DOI: 10.1093/ofid/ofae228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 05/31/2024] Open
Abstract
Background In vitro-in vivo discordance in β-lactams' activities against metallo-ß-lactamase (MBL)-producing Enterobacterales has been described. We aimed to assess whether this discordance is attributed to the supra-physiologic zinc concentration in in vitro testing media. Methods A clinical and microbiological observational study of patients with bloodstream infections due to New Delhi metallo-ß-lactamase-producing Klebsiella pneumoniae was performed. Outcomes of patients treated empirically with non-MBL-active β-lactam therapy (carbapenems and ceftazidime/avibactam) and MBL-active β-lactam therapy (ceftazidime/avibactam + aztreonam) were documented. The patients' isolates were used to induce septicemia in mice, and survival upon meropenem treatment was recorded. Meropenem minimum inhibitory concentrations (MICs) were determined in standard media and in the presence of physiological zinc concentrations. Results Twenty-nine patients receiving empiric non-MBL-active β-lactams (median duration, 4 days) were compared with 29 receiving MBL-active β-lactams. The 14-day mortality rates were 21% and 14%, respectively. In the murine septicemia model, meropenem treatment resulted in protection from mortality (P < .0001). Meropenem MICs in the physiologic zinc concentration broth were 1- to >16-fold lower vs MICs in zinc-unadjusted broth (≥64 mg/L). Conclusions Our data provide foundational support to establish pharmacokinetic/pharmacodynamic relationships using MICs derived in physiologic zinc concentration, which may better predict β-lactam therapy outcome.
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Affiliation(s)
- Kamilia Abdelraouf
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Christian M Gill
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Matthew Gethers
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - David P Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, Connecticut, USA
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20
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Kroneislová G, Závora J, Adámková VG, Rýdlová A, Adámková V. In vitro activity of antibiotics potentially effective against difficult-to-treat strains of Gram-negative rods: retrospective study. Sci Rep 2024; 14:8310. [PMID: 38594467 PMCID: PMC11004177 DOI: 10.1038/s41598-024-59036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 04/05/2024] [Indexed: 04/11/2024] Open
Abstract
Bacterial resistance surveillance is one of the main outputs of microbiological laboratories and its results are important part of antimicrobial stewardship (AMS). In this study, the susceptibility of specific bacteria to selected antimicrobial agents was tested. The susceptibility of 90 unique isolates of pathogens of critical priority obtained from clinically valid samples of ICU patients in 2017-2021 was tested. 50% of these fulfilled difficult-to-treat resistance (DTR) criteria and 50% were susceptible to all antibiotics included in the definition. 10 Enterobacterales strains met DTR criteria, and 2 (20%) were resistant to colistin (COL), 2 (20%) to cefiderocol (FCR), 7 (70%) to imipenem/cilastatin/relebactam (I/R), 3 (30%) to ceftazidime/avibactam (CAT) and 5 (50%) to fosfomycin (FOS). For Enterobacterales we also tested aztreonam/avibactam (AZA) for which there are no breakpoints yet. The highest MIC of AZA observed was 1 mg/l, MIC range in the susceptible cohort was 0.032-0.064 mg/l and in the DTR cohort (incl. class B beta-lactamase producers) it was 0.064-1 mg/l. Two (13.3%) isolates of Pseudomonas aeruginosa (15 DTR strains) were resistant to COL, 1 (6.7%) to FCR, 13 (86.7%) to I/R, 5 (33.3%) to CAT, and 5 (33.3%) to ceftolozane/tazobactam. All isolates of Acinetobacter baumannii with DTR were susceptible to COL and FCR, and at the same time resistant to I/R and ampicillin/sulbactam. New antimicrobial agents are not 100% effective against DTR. Therefore, it is necessary to perform susceptibility testing of these antibiotics, use the data for surveillance (including local surveillance) and conform to AMS standards.
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Affiliation(s)
- Gabriela Kroneislová
- Department of Clinical Microbiology and ATB Centre, Institute of Medical Biochemistry and Laboratory Diagnostic, First Faculty of Medicine, Charles University and General University Hospital, Ke Karlovu 2, Prague, 12808, Czech Republic.
- Department of Biochemistry and Microbiology, Faculty of Food and Biochemical Technology, University of Chemistry and Technology, Prague, Czech Republic.
| | - Jan Závora
- Department of Clinical Microbiology and ATB Centre, Institute of Medical Biochemistry and Laboratory Diagnostic, First Faculty of Medicine, Charles University and General University Hospital, Ke Karlovu 2, Prague, 12808, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacký University-Olomouc, Olomouc, Czech Republic
| | | | - Anna Rýdlová
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Václava Adámková
- Department of Clinical Microbiology and ATB Centre, Institute of Medical Biochemistry and Laboratory Diagnostic, First Faculty of Medicine, Charles University and General University Hospital, Ke Karlovu 2, Prague, 12808, Czech Republic
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21
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Moore LSP, Baltas I, Amos J, Cooray M, Hughes S, Freeman R, Ashfield T. Antimicrobial stewardship markers and healthcare-associated pneumonia threshold criteria in UK hospitals: analysis of the MicroGuide Tm application. JAC Antimicrob Resist 2024; 6:dlae058. [PMID: 38633221 PMCID: PMC11022069 DOI: 10.1093/jacamr/dlae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Background To address antimicrobial resistance, antimicrobial stewardship (AMS) principles must be implemented and adhered to. Clinical decision aids such as the MicroGuideTM app are an important part of these efforts. We sought to evaluate the consistency of core AMS information and the diversity of classification thresholds for healthcare-associated pneumonia (HAP) in the MicroGuide app. Methods Guidelines in the MicroGuide app were extracted and analysed for content related to AMS and HAP. Guidelines were characterized according to HAP naming classification; community-acquired pneumonia (CAP) classifications were analysed to serve as a comparator group. Results In total, 115 trusts (119 hospitals) were included. Nearly all hospitals had developed MicroGuide sections on AMS (n = 112/119, 94%) and sepsis management (n = 117/119, 98%). Other AMS sections were outpatient parenteral antimicrobial therapy (47%), antifungal stewardship (70%), critical care (23%) and IV to oral switch therapy (83%). Only 9% of hospitals included guidance on the maximum six key AMS sections identified. HAP definitions varied widely across hospitals with some classifying by time to onset and some classifying by severity or complexity. The largest proportion of HAP guidelines based classification on severity/complexity (n = 69/119, 58%). By contrast, definitions in CAP guidelines were uniform. Conclusions The high heterogeneity in HAP classification identified suggests inconsistency of practice in identifying thresholds for HAP in the UK. This complicates HAP management and AMS practices. To address HAP in alignment with AMS principles, a comprehensive strategy that prioritizes uniform clinical definitions and thresholds should be developed.
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Affiliation(s)
- Luke S P Moore
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Ioannis Baltas
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, UK
- Department of Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Stephen Hughes
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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22
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Tiseo G, Galfo V, Riccardi N, Suardi LR, Pogliaghi M, Giordano C, Leonildi A, Barnini S, Falcone M. Real-world experience with meropenem/vaborbactam for the treatment of infections caused by ESBL-producing Enterobacterales and carbapenem-resistant Klebsiella pneumoniae. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04758-2. [PMID: 38376634 DOI: 10.1007/s10096-024-04758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE Real-world experience with meropenem/vaborbactam (M/V) is limited. Our aim is to report a clinical experience of M/V in the treatment of resistant Gram-negative bacilli. METHODS This is a prospective observational study including patients hospitalized in the University Hospital of Pisa (March 2021-Jan 2023) with infections by both extended-spectrum β-lactamases (ESBL)-producing Enterobacterales and carbapenem-resistant Klebsiella pneumoniae (Kp) treated with M/V. The primary outcome measure was clinical success, defined as a composite of survival, resolution of signs and symptoms and absence of microbiological failure at day 30 from infection onset. A multivariable regression analysis was performed to identify factors associated with clinical failure. Odds ratio (OR) with 95% confidence intervals (CI) was calculated. RESULTS A total of 104 patients who received M/V were included: 24/104 (23.1%) infections were caused by ESBL non-hypervirulent Enterobacterales, 17/104 (16.3%) by ESBL-producing hypervirulent Klebsiella pneumoniae (hvKp) and 63/104 (60.6%) by CRE. The most common infections were bloodstream infections, followed by urinary tract infections, hospital-acquired pneumonia, intra-abdominal infections and others. Septic shock occurred in 16/104 (15.4%) patients. Clinical success was achieved in 77% of patients, and 30-day mortality rate was 15.4%. In patients with KPC-producing Kp infections, clinical success and 30-day mortality rates were 82% and 11.5%, respectively. On multivariable analysis, SOFA score (OR 1.32, 95% CI 1.02-1.7, p=0.032) was independently associated with clinical failure, while source control (OR 0.16, 95% CI 0.03-0.89, p=0.036) was protective. CONCLUSIONS M/V is a promising therapeutic option against infections caused by difficult-to-treat ESBL-producing Enterobacterales and CR-Kp.
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Affiliation(s)
- Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Niccolò Riccardi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Lorenzo Roberto Suardi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Manuela Pogliaghi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Cesira Giordano
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Simona Barnini
- Microbiology Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Marco Falcone
- University of Pisa, Lungarno Pacinotti, 43, 56126, Pisa, Italy.
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Cao Y, Tian Y, Huang J, Xu L, Fan Z, Pan Z, Chen S, Gao Y, Wei L, Zheng S, Zhang X, Yu Y, Ren F. CRISPR/Cas13-assisted carbapenem-resistant Klebsiella pneumoniae detection. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:118-127. [PMID: 37963801 DOI: 10.1016/j.jmii.2023.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/25/2023] [Accepted: 10/26/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND/PURPOSE Carbapenem-resistant Klebsiella pneumoniae (CRKP) is capable of causing serious community and hospital-acquired infections. However, currently, the identification of CRKP is complex and inefficient. Hence, this study aimed to develop methods for the early and effective identification of CRKP to allow reasonable antimicrobial therapy in a timely manner. METHODS K. pneumoniae (KP)-, K. pneumoniae carbapenemase (KPC)- and New Delhi metallo-β-lactamase (NDM)- specific CRISPR RNAs (crRNAs), polymerase chain reaction (PCR) primers and recombinase-aided amplification (RAA) primers were designed and screened in conserved sequence regions. We established fluorescence and lateral flow strip assays based on CRISPR/Cas13a combined with PCR and RAA, respectively, to assist in the detection of CRKP. Sixty-one clinical strains (including 51 CRKP strains and 10 carbapenem-sensitive strains) were collected for clinical validation. RESULTS Using the PCR-CRISPR assay, the limit of detection (LOD) for KP and the blaKPC and blaNDM genes reached 1 copy/μL with the fluorescence signal readout. Using the RAA-CRISPR assay, the LOD could reach 101 copies/μL with both the fluorescence signal readout and the lateral flow strip readout. Additionally, the positivity rates of CRKP-positive samples detected by the PCR/RAA-CRISPR fluorescence and RAA-CRISPR lateral flow strip methods was 92.16% (47/51). The sensitivity and specificity reached 100% for KP and blaKPC and blaNDM gene detection. For detection in a simulated environmental sample, 1 CFU/cm2 KP could be detected. CONCLUSION We established PCR/RAA-CRISPR assays for the detection of blaKPC and blaNDM carbapenemase genes, as well as KP, to facilitate the detection of CRKP.
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Affiliation(s)
- Yaling Cao
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Yuan Tian
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Jing Huang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Department of Infection Control, Beijing 100730, China.
| | - Ling Xu
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Zihao Fan
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Zhenzhen Pan
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Sisi Chen
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Yao Gao
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Linlin Wei
- Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Sujun Zheng
- Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Xiangying Zhang
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Yanhua Yu
- Center for Clinical Laboratory, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
| | - Feng Ren
- Beijing Institute of Hepatology/Beijing Youan Hospital, Capital Medical University, Beijing 100069, China.
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Mantzarlis K, Manoulakas E, Parisi K, Sdroulia E, Zapaniotis N, Tsolaki V, Zakynthinos E, Makris D. Meropenem plus Ertapenem and Ceftazidime-Avibactam plus Aztreonam for the Treatment of Ventilator Associated Pneumonia Caused by Pan-Drug Resistant Klebsiella pneumonia. Antibiotics (Basel) 2024; 13:141. [PMID: 38391527 PMCID: PMC10886053 DOI: 10.3390/antibiotics13020141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Gram-negative bacteria (GNB) account for about 70% of infections in the intensive care unit (ICU) setting and are associated with significant morbidity and mortality. In recent years, pan-drug resistant (PDR) strains, strains that are not susceptible to any antibiotic, have been emerged and new treatment strategies are required. RESULTS Fifty eligible patients were recruited in the three groups. A statistically significant reduction in the Sequential Organ Failure Assessment (SOFA) score was observed in the control group on day 4 in comparison to day 0 of VAP (p = 0.005). The Clinical Pulmonary Infection Score (CPIS) was also reduced on day 4 (p = 0.0016) and day 7 in comparison to day 0 (p = 0.001). Patients that received combination therapy, CAZ-AVI + ATM and DCT, presented with a lower SOFA score and CPIS on day 7 in comparison to day 0 (p = 0.0288 and p = 0.037, respectively). No differences in the ΔSOFA score and ΔCPIS were found between the groups. The control group presented with a significantly lower ICU stay and duration of mechanical ventilation (p = 0.03 and p = 0.02, respectively). There was no difference in mortality. MATERIALS AND METHODS This is a retrospective analysis. This study was conducted in a mixed ICU in the University Hospital of Larissa, Thessaly, Greece during a three-year period (2020-2022). Patients suffering from ventilator associated pneumonia (VAP) due to carbapenem-resistant K. pneumonia (CR-KP) were divided in three different groups: the first one was treated using ceftazidime-avibactam plus aztreonam (CAZ-AVI + ATM group), the second was treated using double carbapenems (DCT group), and the last one (control group) received appropriate therapy since the strain was susceptible in vitro to at least to one antibiotic. CONCLUSIONS Treatment with CAZ-AVI +ATM or DCT may offer a clinical benefit in patients suffering with infections due to PDR K. pneumoniae. Larger studies are required to confirm our findings.
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Affiliation(s)
- Konstantinos Mantzarlis
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Efstratios Manoulakas
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Kyriaki Parisi
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Evaggelia Sdroulia
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Nikolaos Zapaniotis
- Department of Microbiology, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Vassiliki Tsolaki
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Epaminondas Zakynthinos
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
| | - Demosthenes Makris
- Department of Critical Care, University Hospital of Larissa, School of Medicine, University of Thessaly, 41110 Thessaly, Greece
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Bassetti M, Castaldo N, Fantin A, Giacobbe DR, Vena A. Antibiotic therapy for nonfermenting Gram-negative bacilli infections: future perspectives. Curr Opin Infect Dis 2023; 36:615-622. [PMID: 37846592 DOI: 10.1097/qco.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Serious infections caused by nonfermenting Gram-negative bacteria (NF-GNB) pose a significant challenge for clinicians due to the limited treatment options available, which are frequently associated with issues of toxicity and unfavourable pharmacokinetic profiles. The aim of this review is to provide a brief overview of the existing data concerning the ongoing development of antiinfective agents targeting NF-GNB. RECENT FINDINGS Several agents exhibiting efficacy against NF-GNB are under clinical investigation. Durlobactam-sulbactam and cefepime-taniborbactam emerge as promising therapeutic avenues against carbapenem-resistant Acinetobacter baumanii . Cefepime-zidebactam may serve as a suitable treatment option for urinary tract infections caused by a wide range of NF-GNB. Cefepime-enmetazobactam demonstrates potent in vitro activity against various NF-GNB strains; however, its role as an anti- Pseudomonal agent is inadequately substantiated by available data. Xeruborbactam is a wide β-lactamase inhibitor that can be associated with a range of agents, enhancing in-vitro activity of these against many NF-GNB, including those resistant to newer, broader spectrum options. Lastly, murepavadin appears to be a potential pathogen-specific solution for severe Pseudomonas infections; however, additional investigation is necessary to establish the safety profile of this compound. SUMMARY Each of the novel molecules reviewed possesses an interesting range of in-vitro activity against NF-GNB. In addition, some of them have already been proved effective in vivo, underscoring their potential as future treatment options.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Policlinico San Martino Hospital - IRCCS
- Department of Health Sciences (DISSAL), University of Genoa, Genoa
| | - Nadia Castaldo
- Department of Pulmonology, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Alberto Fantin
- Department of Pulmonology, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Policlinico San Martino Hospital - IRCCS
- Department of Health Sciences (DISSAL), University of Genoa, Genoa
| | - Antonio Vena
- Infectious Diseases Unit, Policlinico San Martino Hospital - IRCCS
- Department of Health Sciences (DISSAL), University of Genoa, Genoa
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Gill CM, Rajkotia P, Roberts AL, Tenover FC, Nicolau DP. Directed carbapenemase testing is no longer just for Enterobacterales: cost, labor, and workflow assessment of expanding carbapenemase testing to carbapenem-resistant P. aeruginosa. Emerg Microbes Infect 2023; 12:2179344. [PMID: 36786132 PMCID: PMC9980414 DOI: 10.1080/22221751.2023.2179344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Molecular carbapenem-resistance testing, such as for the presence of carbapenemases genes, is commonly implemented for the detection of carbapenemase-producing Enterobacterales. Carbapenemase-producing P. aeruginosa is also associated with significant morbidity and mortality, although; prevalence may be underappreciated in the United States due to a lack of carbapenemase testing. The present study sought to compare hands-on time, cost and workflow implementation of carbapenemase gene testing in Enterobacterales and P. aeruginosa isolates versus sending out isolates to a public health laboratory (PHL) for testing to assess if in-house can provide actionable results. The time to carbapenemase gene results were compared. Differences in cost for infection prevention measures were extrapolated from the time of positive carbapenemase gene detection in-house versus PHL. The median time to perform carbapenemase gene testing was 7.5 min (range 5-14) versus 10 min (range 8-22) for preparation to send isolates to the PHL. In-house testing produced same day results compared with a median of 6 days (range 3-14) to receive results from PHL. Cost of in-house testing and send outs were similar ($46.92 versus $40.53, respectively). If contact precautions for patients are implemented until carbapenemase genes are ruled out, in-house testing can save an estimated $76,836.60 annually. Extension of in-house carbapenemase testing to include P. aeruginosa provides actionable results 3-14 days earlier than PHL Standard Pathway testing, facilitating guided therapeutic decisions and infection prevention measures. Supplemental phenotypic algorithms can be implemented to curb the cost of P. aeruginosa carbapenemases testing by identifying isolates most likely to harbour carbapenemases.
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Affiliation(s)
- Christian M. Gill
- Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA, Christian M. Gill Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA
| | - Poonam Rajkotia
- Microbiology Laboratory Services, Hartford Healthcare Ancillary Microbiology Laboratory, Newington, CT, USA
| | - Amity L. Roberts
- Microbiology Laboratory Services, Hartford Healthcare Ancillary Microbiology Laboratory, Newington, CT, USA
| | | | - David P. Nicolau
- Center for Anti-Infective Research & Development Hartford Hospital, Hartford, CT, USA,Department of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Witt LS, Page A, Burd EM, Ozturk T, Weiss DS, Ray SM, Satola S, Gottlieb LB. Discordant antimicrobial susceptibility and polymerase chain reaction (PCR) testing in a Klebsiella pneumoniae isolate with a carbapenemase gene. Infect Control Hosp Epidemiol 2023; 44:2100-2102. [PMID: 37652898 DOI: 10.1017/ice.2023.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Lucy S Witt
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta Veterans' Affairs Medical Center, Decatur, Georgia
| | - Alex Page
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta Veterans' Affairs Medical Center, Decatur, Georgia
| | - Eileen M Burd
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| | - Tugba Ozturk
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| | - David S Weiss
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| | - Susan M Ray
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta Veterans' Affairs Medical Center, Decatur, Georgia
| | - Sarah Satola
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta Veterans' Affairs Medical Center, Decatur, Georgia
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
- Emory Antibiotic Resistance Center, Atlanta, Georgia
| | - Lindsey B Gottlieb
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Dettori S, Portunato F, Vena A, Giacobbe DR, Bassetti M. Severe infections caused by difficult-to-treat Gram-negative bacteria. Curr Opin Crit Care 2023; 29:438-445. [PMID: 37641512 PMCID: PMC10919274 DOI: 10.1097/mcc.0000000000001074] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Antimicrobial resistance (AMR) in Gram-negative bacteria (GNB) poses a significant global health concern, contributing to increased infections, mortality rates, and healthcare costs. This review discusses the main clinical manifestations, therapeutic options, and recent findings in managing antibiotic-resistant GNB, with a focus on difficult-to-treat infections. RECENT FINDINGS Difficult-to-treat resistance (DTR) is a novel classification that identifies GNB exhibiting intermediate or resistant phenotypes to first-line agents in the carbapenem, beta-lactam, and fluoroquinolone categories. The main pathogens implicated in severe infections include DTR Enterobacterales, DTR Pseudomonas aeruginosa , and DTR Acinetobacter baumannii. Although the clinical implications of DTR strains are still under investigation, certain studies have linked them to prolonged hospital stays and poor patient outcomes. SUMMARY Severe infections caused by DTR-GNB pose a formidable challenge for healthcare providers and represent a growing global health issue. The proper administration and optimization of novel antibiotics at our disposal are of paramount importance for combating bacterial resistance and improving patient prognosis.
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Affiliation(s)
- Silvia Dettori
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience
| | - Federica Portunato
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Meng H, Yang J, Niu M, Zhu H, Zhou Y, Lu J. Risk factors and clinical outcomes of carbapenem-resistant Klebsiella pneumoniae bacteraemia in children: a retrospective study. Int J Antimicrob Agents 2023; 62:106933. [PMID: 37500022 DOI: 10.1016/j.ijantimicag.2023.106933] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES Carbapenem-resistant Klebsiella pneumoniae (CRKP) is increasingly being identified in children, but data on the clinical outcomes in this population are limited. This study aimed to characterise the risk factors for 30-day mortality with CRKP bloodstream infection (BSI) in children. METHODS A retrospective study was performed from January 2018 to December 2021 at the First Affiliated Hospital of Zhengzhou University. Patients aged < 18 years and with CRKP BSI were included. Multivariable Cox and logistic regression were performed to determine risk factors for death and the development of septic shock following CRKP infection, respectively. RESULTS This study identified 33 neonates aged 0-4 weeks and 37 older children. The 30-day mortality rate was 39.4% in neonates and 43.2% in older children. In the neonatal population, a higher Pitt bacteremia score (HR 1.694; 95% CI 1.313-2.186; P < 0.001) was an independent risk factor for 30-day mortality. In the non-neonatal population, higher platelet count (HR 0.990; 95% CI 0.982-0.998; P = 0.010), the use of carbapenems (HR 0.212; 95% CI 0.064-0.702; P = 0.011) and appropriately targeted antimicrobial treatment (HR 0.327; 95% CI 0.111-0.969; P = 0.044) were associated with decreased 30-day mortality. Monocyte count < 0.1 × 109 cells/L (OR 3.615; 95% CI 1.165-11.444; P = 0.026) and a higher Pitt bacteremia score (OR 1.330; 95% CI 1.048-1.688; P = 0.019) were identified as risk factors for the development of septic shock. CONCLUSIONS Carbapenem-resistant Klebsiella pneumoniae BSI was associated with high mortality in children. Appropriate antimicrobial treatment is important to improve survival, but more work is needed to assess the efficacy of specific treatment regimens in children.
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Affiliation(s)
- Haiyang Meng
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jie Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Mengxia Niu
- Department of Pharmacy, The Third People's Hospital of Zhengzhou, Zhengzhou, China
| | - Han Zhu
- Department of Pharmacy, Anyang Maternal and Child Health Care Hospital, Anyang Children's Hospital, Anyang, China
| | - Yuke Zhou
- Department of Pharmacy, The First People's Hospital of Yiyang, Luoyang, China
| | - Jingli Lu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China.
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Önal U, Tüzemen Ü, Kaya PK, İşçimen R, Girgin NK, Özakın C, Kahveci F, Akalın H. OXA-48 Dominance Meets Ceftazidime-Avibactam: A Battle Against Life-Threatening Carbapenem-Resistant Klebsiella pneumoniae Infections in the Intensive Care Unit. Cureus 2023; 15:e46780. [PMID: 37822692 PMCID: PMC10563373 DOI: 10.7759/cureus.46780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 10/13/2023] Open
Abstract
Objective In this study, we aimed to describe the outcomes in ICU patients with bloodstream infection (BSI) or ventilatory-associated pneumonia (VAP) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) who received ceftazidime-avibactam treatment at a tertiary care university hospital. Methods Patients aged 18 years or older who were admitted to the Anesthesiology and Reanimation ICU at Bursa Uludag University Faculty of Medicine Hospital between June 13, 2021, and July 16, 2023, and diagnosed with BSI or VAP due to CRKP were included in this study. Results A total of 42 patients treated with ceftazidime-avibactam were included. Total crude mortality rates were 33.3% on day 14 and 54.8% on day 30. Mortality rates on the 14th and 30th days were 37.5% and 62.5% in patients with BSI and 27.8% and 44.4% in patients with VAP, respectively. There was no statistically significant difference between monotherapy and combination therapy in terms of mortality rates on days 14 and 30, respectively (3/11 vs. 11/31, p=0.620; 5/11 vs. 18/31, p=0.470). Immunosuppression (10/11 vs. 13/31, p=0.005), the Sequential Organ Failure Assessment (SOFA) score ≥8 (at the initiation of treatment; 19/25 vs. 4/17, p<0.001), INCREMENT-CPE score ≥10 (12/16 vs. 3/10, p=0.024) and longer duration (in days) from culture collection to treatment initiation (5.0 ± 0.61 vs. 3.11 ± 0.48, p=0.024) were found to have a statistically significant effect on 30-day mortality. In multivariate analysis, a SOFA score ≥8 at the initiation of treatment (p=0.037, OR: 17.442, 95% CI: 1.187-256.280) was found to be a significant risk factor affecting mortality (30-day). Conclusion The mortality rates of patients with CRKP infection who were followed up in the ICU were found to be high, and it was observed that whether ceftazidime-avibactam treatment was given as a combination or monotherapy did not affect mortality. Further multicentre studies with a larger number of patients are needed to gain a comprehensive understanding of the topic, given that this treatment is typically reserved for documented infections.
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Affiliation(s)
- Uğur Önal
- Infectious Diseases, Uludag University Faculty of Medicine, Bursa, TUR
| | - Ülkü Tüzemen
- Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
| | - Pınar K Kaya
- Anesthesiology and Critical Care, Uludag University, Bursa, TUR
| | - Remzi İşçimen
- Intensive Care Unit, Uludag University Faculty of Medicine, Bursa, TUR
- Anesthesiology and Critical Care, Uludag University Faculty of Medicine, Bursa, TUR
- Anesthesiology and Reanimation, Uludag University Faculty of Medicine, Bursa, TUR
| | - Nermin K Girgin
- Anesthesiology and Reanimation, Uludag University, Bursa, TUR
| | - Cüneyt Özakın
- Medical Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
| | - Ferda Kahveci
- Anesthesiology and Reanimation, Uludag University, Bursa, TUR
| | - Halis Akalın
- Infectious Diseases and Clinical Microbiology, Uludag University Faculty of Medicine, Bursa, TUR
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Bavaro DF, Belati A, Diella L, Frallonardo L, Guido G, Papagni R, Pellegrino C, Brindicci G, De Gennaro N, Di Gennaro F, Denicolò S, Ronga L, Mosca A, Pomarico F, Dell'Aera M, Stufano M, Dalfino L, Grasso S, Saracino A. Loading dose plus continuous/extended infusion versus intermittent bolus of β-lactams for the treatment of Gram-negative bacteria bloodstream infections: a propensity score-adjusted retrospective cohort study. J Antimicrob Chemother 2023; 78:2175-2184. [PMID: 37428015 DOI: 10.1093/jac/dkad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Optimal β-lactam dosing for the treatment of Gram-negative bacteria bloodstream infections (GNB-BSIs) remains a debated issue. Herein, the efficacy and safety of a loading dose (LD) followed by extended/continuous infusion (EI/CI) versus intermittent bolus (IB) of these drugs for the treatment of GNB-BSIs was evaluated. METHODS This is a retrospective observational study enrolling patients with GNB-BSIs treated with β-lactams from 1 October 2020 to 31 March 2022. The 30 day infection-related mortality rate was assessed with Cox regression, while mortality risk reduction was evaluated by an inverse probability of treatment weighting regression adjustment (IPTW-RA) model. RESULTS Overall, 224 patients were enrolled: 140 and 84 in the IB and EI/CI groups, respectively. β-Lactam regimens were chosen according to pathogen antibiogram, clinical judgement and current guidelines. Interestingly, the LD + EI/CI regimen was associated with a significant lower mortality rate (17% versus 32%, P = 0.011). Similarly, β-lactam LD + EI/CI was significantly associated with a reduced risk of mortality at multivariable Cox regression [adjusted HR (aHR) = 0.46; 95%CI = 0.22-0.98; P = 0.046]. Finally, the IPTW-RA (adjusted for multiple covariates) was performed, showing a significant risk reduction in the overall population [-14% (95% CI = -23% to -5%)]; at the subgroup restricted analysis, a significant risk reduction (>15%) was observed in the case of GNB-BSI in severely immunocompromised patients (P = 0.003), for SOFA score > 6 (P = 0.014) and in septic shock (P = 0.011). CONCLUSIONS The use of LD + EI/CI of β-lactams in patients with a GNB-BSI may be associated with reduced mortality; also in patients with severe presentation of infection or with additional risk factors, such as immunodepression.
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Affiliation(s)
- Davide Fiore Bavaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Alessandra Belati
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Lucia Diella
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Luisa Frallonardo
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Giacomo Guido
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Roberta Papagni
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Carmen Pellegrino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Gaetano Brindicci
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Nicolò De Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Sofia Denicolò
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Luigi Ronga
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Adriana Mosca
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Francesco Pomarico
- Hospital Pharmacy Department, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Maria Dell'Aera
- Hospital Pharmacy Department, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Monica Stufano
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Salvatore Grasso
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
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Anton-Vazquez V, Evans TJ, Fernando S, Somasunderam D, David K, Melzer M, Hawkins L, Morris-Jones S, Arias M, Drazho B, Dall’Antonia M, Planche T. Clinical, microbiological characteristics and predictors of mortality in patients with carbapenemase-producing Enterobacterales bloodstream infections: a multicentre study. Infect Prev Pract 2023; 5:100298. [PMID: 37534297 PMCID: PMC10393540 DOI: 10.1016/j.infpip.2023.100298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/04/2023] [Indexed: 08/04/2023] Open
Abstract
Objectives To investigate the clinical, microbiological characteristics and outcomes of patients with bloodstream infections (BSI) due to carbapenemase-producing Enterobacterales (CPE). Methods A multicentre retrospective observational study of patients with BSIs due to CPE admitted to six UK hospitals was conducted between 2011 and 2021. Multivariate analysis was used to identify factors predicting 30-day case fatality rate (CFR). Results There were 84 episodes of CPE-BSIs, 37 (44%) due to OXA-48, 35 (42%) to metallo-betalactamases (MBL) and 12 (14%) to KPC. 63% of patients were male with a median age of 64 years. Common organisms included Klebsiella spp. (61%), Escherichia coli (20%) and Enterobacter spp. (13%). Urinary devices were more often involved in OXA-48 BSIs (12/37; 32%) compared to infections caused by MBL and KPC (4/35; 11% and 1/12; 8%; P = 0.046). In contrast, central venous catheters were more frequently present in KPC-BSIs (10/12; 92%) compared with OXA-48 and MBL (11/37; 30% and 20/35; 57%; P = 0.002). Effective definitive antimicrobials were received by 72/84 (86%) patients, comprising monotherapy (32/72; 44%) or combination therapy (40/72; 56%). 30-day case fatality rate (CFR) was 38%. Sepsis or septic shock was associated with death [OR 3.81 (CI 1.19-12.14), P = 0.024]. Conclusion Strategies targeting high-risk patients and adherence to infection prevention bundles for urinary devices and central venous catheters can reduce OXA-48 and KPC-BSIs. Early recognition and management of severe sepsis, prompt initiation of appropriate antimicrobial therapy and development of novel antimicrobials are crucial to mitigate the high CFR associated with CPE-BSIs.
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Affiliation(s)
- Vanesa Anton-Vazquez
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Terry John Evans
- Medical Microbiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Samitha Fernando
- Infectious Diseases and Medical Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Donald Somasunderam
- Department of Infection, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Kate David
- Department of Infection, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Mark Melzer
- Department of Infection, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Lois Hawkins
- Medical Microbiology, Epsom and St. Helier University Hospitals NHS Trust, London, UK
| | - Stephen Morris-Jones
- Medical Microbiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mauricio Arias
- Infectious Diseases and Medical Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Borana Drazho
- Infectious Diseases and Medical Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Martino Dall’Antonia
- Medical Microbiology, Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust, London, UK
| | - Timothy Planche
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK
- Medical Microbiology, Southwest London Pathology, St. George's Hospital, London, UK
- Institute of Infection and Immunity, St. George's University of London, London, UK
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Xiao S, Fu Q, Miao Y, Zhao M, Lu S, Xu J, Zhao W. Clinical efficacy and drug resistance of ceftazidime-avibactam in the treatment of Carbapenem-resistant gram-negative bacilli infection. Front Microbiol 2023; 14:1198926. [PMID: 37664109 PMCID: PMC10469675 DOI: 10.3389/fmicb.2023.1198926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To examine the clinical efficacy, safety, and resistance of Ceftazidime-Avibactam (CAZ-AVI) in patients with Carbapenem-resistant Gram-negative bacilli (CR-GNB) infections. Methods We retrospectively analyzed relevant data of CR-GNB infected patients receiving CAZ-AVI treatment, analyzed relevant factors affecting drug efficacy, and compared the efficacy and safety with patients receiving Polymyxin B treatment. Results A total of 139 patients were included. Agranulocytosis, septic shock, SOFA score, and CAZ-AVI treatment course were independent risk factors affecting the prognosis of patients with CR-GNB infection treated with CAZ-AVI while prolonging the treatment course of CAZ-AVI was the only protective factor for bacterial clearance. The fundamental indicators showed no statistically significant differences between CAZ-AVI and Polymyxin B treatment groups. At the same time, the proportion of patients treated with monotherapy was significantly higher in the CAZ-AVI group than in the Polymyxin B group (37.2% vs. 8.9%, p < 0.05), the 30-day mortality rate of the CAZ-AVI treatment group (27.7% vs. 46.7%, p = 0.027) was lower than that of the Polymyxin B treatment group. The 30-day clinical cure rate (59.6% vs. 40% p = 0.030) and 14-day microbiological clearance rate (42.6% vs. 24.4%, p = 0.038) were significantly higher in the CAZ-AVI than in the Polymyxin B treatment group. Eighty nine patients were monitored for CAZ-AVI resistance, and the total resistance rate was 14.6% (13/89). The resistance rates of Carbapenem-resistant Klebsiella pneumoniae (CRKP) and Carbapenem-resistant Pseudomonas aeruginosa (CRPA) to CAZ-AVI were 13.5 and 15.4%, respectively. Conclusion CAZ-AVI has shown high clinical efficacy and bacterial clearance in treating CR-GNB infections. Compared with Polymyxin B, CAZ-AVI significantly improved the outcome of mechanical ventilation in patients with septic shock, agranulocytosis, Intensive Care Unit (ICU) patients, bloodstream infection, and patients with SOFA score > 6, and had a lower incidence of adverse events. We monitored the emergence of CAZ-AVI resistance and should strengthen the monitoring of drug susceptibility in clinical practice and the rational selection of antibiotic regimens to delay the onset of resistance.
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Affiliation(s)
- Shuang Xiao
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qianwen Fu
- Department of Critical Care Medicine, The First People's Hospital of Tonglu, Hangzhou, China
| | - Youhan Miao
- Department of Infectious Diseases, The Third Affiliated Hospital of Nantong University, Nantong, China
| | - Manna Zhao
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shengwei Lu
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Xu
- Center of Clinical Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weifeng Zhao
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
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Taddei R, Riccardi N, Tiseo G, Galfo V, Biancofiore G. Early Intra-Abdominal Bacterial Infections after Orthotopic Liver Transplantation: A Narrative Review for Clinicians. Antibiotics (Basel) 2023; 12:1316. [PMID: 37627736 PMCID: PMC10451386 DOI: 10.3390/antibiotics12081316] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
Despite recent advances in the transplant field, infectious complications after orthotopic liver transplantation (OLT) are major causes of morbidity and mortality. Bacterial intra-abdominal infections (IAIs) are predominant during the first month post-transplantation and affect patient and graft survival. Recently, the emergence of multidrug resistant bacteria has generated great concern in OLT patients. We performed this narrative review of the literature in order to propose a "ready-to-use" flowchart for reasoned empirical antibiotic therapy in the case of suspected post-OLT IAIs. The review was ultimately organized into four sections: "Epidemiology and predisposing factors for IAI"; "Surgical-site infections and perioperative prophylaxis"; "MDRO colonization and infections"; and "Reasoned-empirical antibiotic therapy in early intra-abdominal infections post OLT and source control". Multidisciplinary teamwork is warranted to individualize strategies for the prevention and treatment of IAIs in OLT recipients, taking into account each patient's risk factors, the surgical characteristics, and the local bacterial epidemiology.
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Affiliation(s)
- Riccardo Taddei
- Division of Transplant Anesthesia and Critical Care, Department of Anesthesia, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy;
| | - Niccolò Riccardi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (N.R.); (G.T.); (V.G.)
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (N.R.); (G.T.); (V.G.)
| | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy; (N.R.); (G.T.); (V.G.)
| | - Giandomenico Biancofiore
- Division of Transplant Anesthesia and Critical Care, Department of Anesthesia, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy;
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Cogliati Dezza F, Covino S, Petrucci F, Sacco F, Viscido A, Gavaruzzi F, Ceccarelli G, Raponi G, Borrazzo C, Alessandri F, Mastroianni CM, Venditti M, Oliva A. Risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections and related mortality in critically ill patients with CRAB colonization. JAC Antimicrob Resist 2023; 5:dlad096. [PMID: 37577156 PMCID: PMC10412853 DOI: 10.1093/jacamr/dlad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/21/2023] [Indexed: 08/15/2023] Open
Abstract
Background Among MDR bacteria, carbapenem-resistant Acinetobacter baumannii (CRAB) is a major concern due to the limited therapeutic options. During the COVID-19 pandemic, a worrying increase in the spread of CRAB infections was reported. Objectives The study assessed the risk factors for CRAB bloodstream infection (BSI) in patients admitted to the ICU with CRAB colonization, and the related mortality risk factors. Methods We conducted a single-centre, observational, prospective study; all consecutive patients with CRAB colonization admitted to the ICU of a tertiary hospital in Rome from January 2021 to September 2022 were included in the study. Univariate and multivariate analyses were performed to investigate BSI and mortality risk factors. Results Overall, 129 patients were included in the study; 57 (44%) out of these developed BSI. In our study population, at the multivariable analysis the Charlson comorbidity index (CCI) (P = 0.026), COVID-19 (P < 0.001), multisite colonization (P = 0.016) and the need for mechanical ventilation (P = 0.024) were risk factors independently associated with BSI development. Furthermore, age (P = 0.026), CCI (P < 0.001), septic shock (P = 0.001) and Pitt score (P < 0.001) were independently associated with mortality in the BSI patients. Instead, early appropriate therapy (P = 0.002) and clinical improvement within 72 h (P = 0.011) were shown to be protective factors. Conclusions In critically ill patients colonized by CRAB, higher CCI, multisite colonization and the need for mechanical ventilation were identified as risk factors for BSI onset. These predictors could be useful to identify patients at highest risk of BSI.
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Affiliation(s)
| | - Sara Covino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Flavia Petrucci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Federica Sacco
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Agnese Viscido
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Gavaruzzi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Gianmarco Raponi
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristian Borrazzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | | | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Oliva A, Campogiani L, Savelloni G, Vitale P, Lodi A, Sacco F, Imeneo A, Volpicelli L, Polani R, Raponi G, Sarmati L, Venditti M. Clinical Characteristics and Outcome of Ceftazidime/Avibactam-Resistant Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae Infections: A Retrospective, Observational, 2-Center Clinical Study. Open Forum Infect Dis 2023; 10:ofad327. [PMID: 37476077 PMCID: PMC10354859 DOI: 10.1093/ofid/ofad327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/26/2023] [Indexed: 07/22/2023] Open
Abstract
Background Recently, Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) with resistance to ceftazidime/avibactam (CZA-R) has been described, including KPC variants that restore carbapenem susceptibility. The aim of the study was to analyze the clinical characteristics and outcomes of infections caused by CZA-R KPC-Kp. Methods From 2019 to 2021, a retrospective 2-center study including patients with infections due to CZA-R KPC-Kp hospitalized at 2 academic hospitals in Rome was conducted. Demographic and clinical characteristics were collected. Principal outcome was 30-day all-cause mortality. Statistical analyses were performed with Stata-IC17 software. Results Overall, 59 patients were included (mean age, 64.4 ± 14.6 years; mean Charlson comorbidity index score, 4.5 ± 2.7). Thirty-four patients (57.6%) had infections caused by CZA-R and meropenem (MEM)-susceptible strains. A previous CZA therapy was observed in 40 patients (67.8%), mostly in patients with MEM-susceptible KPC variant (79.4% vs 52%, P = .026). Primary bacteremia was observed in 28.8%, followed by urinary tract infections and pneumonia. At infection onset, septic shock was present in 15 subjects (25.4%). After adjustment for confounders, only the presence of septic shock was independently associated with mortality (P = .006). Conclusions Infections due to CZA-R KPC-Kp often occur in patients who had previously received CZA, especially in the presence of strains susceptible to MEM. Nevertheless, one-third of patients had never received CZA before KPC-Kp CZA-R. Since the major driver for mortality was infection severity, understanding the optimal therapy in patients with KPC-Kp CZA-R infections is of crucial importance.
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Affiliation(s)
- Alessandra Oliva
- Correspondence: Assistant Professor Oliva Alessandra, MD, PhD, Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy. ()
| | - Laura Campogiani
- Infectious Disease Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of System Medicine, Tor Vergata University, Rome, Italy
| | - Giulia Savelloni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Pietro Vitale
- Infectious Disease Clinic, Policlinico Tor Vergata, Rome, Italy
| | - Alessandra Lodi
- Infectious Disease Clinic, Policlinico Tor Vergata, Rome, Italy
| | - Frederica Sacco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Lorenzo Volpicelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Riccardo Polani
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giammarco Raponi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Loredana Sarmati
- Infectious Disease Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of System Medicine, Tor Vergata University, Rome, Italy
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Falcone M, Tiseo G, Carbonara S, Marino A, Di Caprio G, Carretta A, Mularoni A, Mariani MF, Maraolo AE, Scotto R, Dalfino L, Corbo L, Macera M, Medaglia AA, d'Errico ML, Gioè C, Sgroi C, Del Vecchio RF, Ceccarelli G, Albanese A, Buscemi C, Talamanca S, Raponi G, Foti G, De Stefano G, Franco A, Iacobello C, Corrao S, Morana U, Pieralli F, Gentile I, Santantonio T, Cascio A, Coppola N, Cacopardo B, Farcomeni A, Venditti M, Menichetti F. Mortality Attributable to Bloodstream Infections Caused by Different Carbapenem-Resistant Gram-Negative Bacilli: Results From a Nationwide Study in Italy (ALARICO Network). Clin Infect Dis 2023; 76:2059-2069. [PMID: 36801828 DOI: 10.1093/cid/ciad100] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Our aim was to analyze mortality attributable to carbapenem-resistant (CR) gram-negative bacilli (GNB) in patients with bloodstream infections (BSIs). METHODS Prospective multicentric study including patients with GNB-BSI from 19 Italian hospitals (June 2018-January 2020). Patients were followed-up to 30 days. Primary outcomes were 30-day mortality and attributable mortality. Attributable mortality was calculated in the following groups: Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales, metallo-β-lactamases (MBL)-producing Enterobacterales, CR-Pseudomonas aeruginosa (CRPA), CR-Acinetobacter baumannii (CRAB). A multivariable analysis with hospital fixed-effect was built to identify factors associated with 30-day mortality. Adjusted OR (aORs) were reported. Attributable mortality was calculated according to the DRIVE-AB Consortium. RESULTS Overall, 1276 patients with monomicrobial GNB BSI were included: 723/1276 (56.7%) carbapenem-susceptible (CS)-GNB, 304/1276 (23.8%) KPC-, 77/1276 (6%) MBL-producing CRE, 61/1276 (4.8%) CRPA, and 111/1276 (8.7%) CRAB BSI. Thirty-day mortality in patients with CS-GNB BSI was 13.7% compared to 26.6%, 36.4%, 32.8% and 43.2% in patients with BSI by KPC-CRE, MBL-CRE, CRPA and CRAB, respectively (P < .001). On multivariable analysis, age, ward of hospitalization, SOFA score, and Charlson Index were factors associated with 30-day mortality, while urinary source of infection and early appropriate therapy resulted protective factors. Compared to CS-GNB, MBL-producing CRE (aOR 5.86, 95% CI 2.72-12.76), CRPA (aOR 1.99, 95% CI 1.48-5.95) and CRAB (aOR 2.65, 95% CI 1.52-4.61) were significantly associated with 30-day mortality. Attributable mortality rates were 5% for KPC-, 35% for MBL, 19% for CRPA, and 16% for CRAB. CONCLUSIONS In patients with BSIs, carbapenem-resistance is associated with an excess of mortality, with MBL-producing CRE carrying the highest risk of death.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sergio Carbonara
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro," Bari, Italy
| | - Andrea Marino
- Unit of Infectious Diseases, ARNAS Garibaldi, Nesima Hospital, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giovanni Di Caprio
- Infectious Diseases Unit, AORN Sant' Anna e San Sebastiano, Caserta, Italy
| | - Anna Carretta
- Department of Infectious Diseases, University Hospital "Ospedali Riuniti" of Foggia, Foggia, Italy
| | - Alessandra Mularoni
- Department of Infectious Diseases, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS ISMETT), Palermo, Italy
| | - Michele Fabiano Mariani
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro," Bari, Italy
| | - Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, AORN Ospedali dei Colli, Naples, Italy
| | - Riccardo Scotto
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Lorenzo Corbo
- Medicina per la complessità assistenziale 1 AOU Careggi, Florence, Italy
| | - Margherita Macera
- Department of Mental Health and Public Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Maria Luca d'Errico
- Department of Infectious Diseases, University Hospital "Ospedali Riuniti" of Foggia, Foggia, Italy
| | - Claudia Gioè
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone," Palermo, Italy
| | | | | | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Calogero Buscemi
- Infectious Diseases Unit, ARNAS Ospedale Civico of Palermo, Palermo, Italy
| | - Simona Talamanca
- Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche, Università di Palermo, Palermo, Italy
| | - Giammarco Raponi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
- Microbiology and Virology Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Giuseppe Foti
- Infetious Diseases Unit, "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Giulio De Stefano
- Department of Infectious Diseases, Hospital of Potenza and Matera, Matera, Italy
| | - Antonina Franco
- Department of Infectious Diseases, Umberto I Public Hospital, Siracusa, Italy
| | - Carmelo Iacobello
- UOC Malattie Infettive, Azienda Ospedaliera per l'Emergenza, Cannizzaro, Catania, Italy
| | - Salvatore Corrao
- Department of Clinical Medicine, Internal Medicine Division, ARNAS Civico Di Cristina Benfratelli Hospital Trust, Palermo, Italy
| | | | - Filippo Pieralli
- Intermediate Care Unit, Careggi University Hospital, Florence, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | - Teresa Santantonio
- Department of Infectious Diseases, University Hospital "Ospedali Riuniti" of Foggia, Foggia, Italy
| | - Antonio Cascio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties G D'Alessandro, University of Palermo, Palermo, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Bruno Cacopardo
- Unit of Infectious Diseases, ARNAS Garibaldi, Nesima Hospital, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alessio Farcomeni
- Department of Economics & Finance, University of Rome "Tor Vergata," Rome, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
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Russo A, Pallone R, Trecarichi EM, Torti C. Lights and Shadows of Sepsis Management: Challenges and Future Perspectives. Int J Mol Sci 2023; 24:ijms24119426. [PMID: 37298376 DOI: 10.3390/ijms24119426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
The complex interaction between microorganisms, the host's immune response, and [...].
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Affiliation(s)
- Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, 'Magna Graecia' University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Rita Pallone
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, 'Magna Graecia' University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Enrico Maria Trecarichi
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, 'Magna Graecia' University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, 'Magna Graecia' University of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
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Xu S, Song Z, Han F, Zhang C. Effect of appropriate empirical antimicrobial therapy on mortality of patients with Gram-negative bloodstream infections: a retrospective cohort study. BMC Infect Dis 2023; 23:344. [PMID: 37221465 DOI: 10.1186/s12879-023-08329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Little evidence exists regarding the prevalence of pathogens in bloodstream infections (BSIs), the mortality risk, and the benefit of combination therapy over monotherapy. This study aims to describe patterns of empiric antimicrobial therapy, and the epidemiology of Gram-negative pathogens, and to investigate the effect of appropriate therapy and appropriate combination therapy on the mortality of patients with BSIs. METHODS This was a retrospective cohort study including all patients with BSIs of Gram-negative pathogens from January 2017 to December 2022 in a Chinese general hospital. The in-hospital mortality was compared between appropriate and inappropriate therapy, and between monotherapy and combination therapy for patients receiving appropriate therapy. We used Cox regression analysis to identify factors independently associated with in-hospital mortality. RESULTS We included 205 patients in the study, of whom 147 (71.71%) patients received appropriate therapy compared with 58 (28.29%) who received inappropriate therapy. The most common Gram-negative pathogen was Escherichia coli (37.56%). 131 (63.90%) patients received monotherapy and 74 (36.10%) patients received combination therapy. The in-hospital mortality was significantly lower in patients administered appropriate therapy than inappropriate therapy (16.33% vs. 48.28%, p = 0.004); adjusted hazard ratio [HR] 0.55 [95% CI 0.35-0.84], p = 0.006). In-hospital mortality was also not different in combination therapy and monotherapy in the multivariate Cox regression analyses (adjusted HR 0.42 [95% CI 0.15-1.17], p = 0.096). However, combination therapy was associated with lower mortality than monotherapy in patients with sepsis or septic shock (adjusted HR 0.94 [95% CI 0.86-1.02], p = 0.047). CONCLUSIONS Appropriate therapy was associated with a protective effect on mortality among patients with BSIs due to Gram-negative pathogens. Combination therapy was associated with improved survival in patients with sepsis or septic shock. Clinicians need to choose optical empirical antimicrobials to improve survival outcomes in patients with BSIs.
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Affiliation(s)
- Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
- , No.1 Dongjiaomin Lane, Beijing, Dongcheng District, China.
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Zhang L, Zhen S, Shen Y, Zhang T, Wang J, Li J, Lin Q, Xiao Z, Zheng Y, Jiang E, Han M, Wang J, Feng S. Bloodstream infections due to Carbapenem-Resistant Enterobacteriaceae in hematological patients: assessment of risk factors for mortality and treatment options. Ann Clin Microbiol Antimicrob 2023; 22:41. [PMID: 37202758 DOI: 10.1186/s12941-023-00586-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
PURPOSE Bloodstream infection (BSI) caused by Carbapenem-Resistant Enterobacteriaceae (CRE) are associated with poor outcomes in hematological patients. The aim of this study was to identify risk factors for mortality and evaluate the value of epidemiological feature of carbapenemases in guiding antimicrobial treatment options. METHODS Hematological patients with monomicrobial CRE BSI between January 2012 and April 2021 were included. The primary outcome was all-cause mortality 30 days after BSI onset. RESULTS A total of 94 patients were documented in the study period. Escherichia coli was the most common Enterobacteriaceae, followed by Klebsiella pneumoniae. 66 CRE strains were tested for carbapenemase genes, and 81.8% (54/66) were positive, including NDM (36/54), KPC (16/54), IMP (1/54). Besides, one E. coli isolate was found to express both NDM and OXA-48-like genes. Overall, 28 patients received an antimicrobial treatment containing ceftazidime-avibactam (CAZ-AVI), of which 21 cases were combined with aztreonam. The remaining 66 patients were treated with other active antibiotics (OAAs). The 30-day mortality rate was 28.7% (27/94) for all patients, and was only 7.1% ((2/28) for patients treated with CAZ-AVI. In multivariate analysis, the presence of septic shock at BSI onset (OR 10.526, 95% CI 1.376-76.923) and pulmonary infection (OR 6.289, 95% CI 1.351-29.412) were independently risk factors for 30-day mortality. Comparing different antimicrobial regimens, CAZ-AVI showed a significant survive benefit than OAAs (OR 0.068, 95% CI 0.007-0.651). CONCLUSION CAZ-AVI-containing regimen is superior to OAAs for CRE BSI. As the predominance of blaNDM in our center, we recommend the combination with aztreonam when choose CAZ-AVI.
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Affiliation(s)
- Lining Zhang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Sisi Zhen
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Yuyan Shen
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Tingting Zhang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jieru Wang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jia Li
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Qingsong Lin
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
| | - Zhijian Xiao
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Yizhou Zheng
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Erlie Jiang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Mingzhe Han
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Jianxiang Wang
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China
| | - Sizhou Feng
- Hematopoietic Stem Cell Transplantation Center, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300020, China.
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Yang P, Li Y, Wang X, Chen N, Lu X. Efficacy and safety of ceftazidime-avibactam versus polymyxins in the treatment of carbapenem-resistant Enterobacteriaceae infection: a systematic review and meta-analysis. BMJ Open 2023; 13:e070491. [PMID: 37137556 PMCID: PMC10163451 DOI: 10.1136/bmjopen-2022-070491] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVES Carbapenem-resistant Enterobacteriaceae is increasingly recognised as a significant public health concern. Ceftazidime-avibactam (CAZ-AVI) and polymyxins are considered as the last therapeutic options worldwide. This is the first meta-analysis of recently published data to compare the clinical efficacy and safety of CAZ-AVI with polymyxins in the treatment of carbapenem-resistant Enterobacteriaceae infections. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Embase and the Cochrane Library were systematically searched, for publications in any language, from database inception to February 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies comparing the clinical efficacy and safety of CAZ-AVI with polymyxins were included. Mortality, clinical success, microbiological eradication and nephrotoxicity were assessed as the main outcomes. DATA EXTRACTION AND SYNTHESIS Literature screening, data extraction and the quality evaluation of studies were conducted by two researchers independently, with disagreements resolved by another researcher. The Newcastle-Ottawa Scale was used to assess the bias risk for the included studies. Review Manager V.5.3 was employed for the meta-analysis. RESULTS The meta-analysis included seven retrospective and four prospective cohort studies with 1111 patients enrolled. The CAZ-AVI groups demonstrated a lower 30-day mortality (risk ratio (RR)=0.48, 95% CI of 0.37 to 0.63, I2=10%, p<0.0001) in nine studies with 766 patients; higher clinical success (RR=1.71, 95% CI 1.33 to 2.20, I2=35%, p<0.0001) in four studies with 463 patients; and lower nephrotoxicity in seven studies with 696 patients (RR=0.42, 95% CI 0.23 to 0.77, I2=35%, p<0.05). However, no significant difference in microbiological eradication rates was observed in 249 patients from two studies (RR=1.16, 95% CI 0.97 to 1.39, I2=0, p>0.05). CONCLUSION Available evidence suggested that CAZ-AVI treatment held a dominant position with respect to efficacy and safety compared with polymyxins in carbapenem-resistant Enterobacteriaceae infections. However, the analysis included only observational studies, and high-quality, large-scale, multicentre, double-blind randomised controlled trials are needed to confirm the advantage of CAZ-AVI.
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Affiliation(s)
- Ping Yang
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Hangzhou, People's Republic of China
| | - Yinyan Li
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaojuan Wang
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Na Chen
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoyang Lu
- Department of Clinical Pharmacy, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Cortegiani A, Antonelli M, Falcone M, Giarratano A, Girardis M, Leone M, Pea F, Stefani S, Viaggi B, Viale P. Rationale and clinical application of antimicrobial stewardship principles in the intensive care unit: a multidisciplinary statement. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:11. [PMID: 37386615 PMCID: PMC10245548 DOI: 10.1186/s44158-023-00095-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/21/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Antimicrobial resistance represents a major critical issue for the management of the critically ill patients hospitalized in the intensive care unit (ICU), since infections by multidrug-resistant bacteria are characterized by high morbidity and mortality, high rates of treatment failure, and increased healthcare costs worldwide. It is also well known that antimicrobial resistance can emerge as a result of inadequate antimicrobial therapy, in terms of drug selection and/or treatment duration. The application of antimicrobial stewardship principles in ICUs improves the quality of antimicrobial therapy management. However, it needs specific considerations related to the critical setting. METHODS The aim of this consensus document gathering a multidisciplinary panel of experts was to discuss principles of antimicrobial stewardship in ICU and to produce statements that facilitate their clinical application and optimize their effectiveness. The methodology used was a modified nominal group discussion. CONCLUSION The final set of statements underlined the importance of the specific interpretation of antimicrobial stewardship's principles in critically ill patient management, quasi-targeted therapy, the use of rapid diagnostic methods, the personalization of antimicrobial therapies' duration, obtaining microbiological surveillance data, the use of PK/PD targets, and the use of specific indicators in antimicrobial stewardship programs.
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy.
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy.
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, Aix-Marseille University, AP-HM, North Hospital, Marseille, France
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138, Bologna, Italy
| | - Stefania Stefani
- Microbiology Section, Dept of Biomedical and Biotechnological Science, University of Catania, Catania, Italy
- Unità Operativa Complessa (UOC) Laboratory Analysis, University Hospital Policlinico-San Marco, Catania, Italy
| | - Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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Boattini M, Bianco G, Charrier L, Comini S, Iannaccone M, Almeida A, Cavallo R, De Rosa FG, Costa C. Rapid diagnostics and ceftazidime/avibactam for KPC-producing Klebsiella pneumoniae bloodstream infections: impact on mortality and role of combination therapy. Eur J Clin Microbiol Infect Dis 2023; 42:431-439. [PMID: 36806056 DOI: 10.1007/s10096-023-04577-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Abstract
This study was aimed at investigating risk factors for mortality in patients suffering from KPC-producing Klebsiella pneumoniae (KPC-Kp) bloodstream infections (BSIs), evaluating the impact of rapid diagnostics and ceftazidime/avibactam use. This observational retrospective study (January 2017-May 2021) included all patients with a KPC-Kp BSI. Uni-multivariable analyses were carried out to evaluate the effect of clinical variables on both in-hospital death (IHD) and 30-day all-cause mortality, and the role of the combination of ceftazidime/avibactam plus polymyxin. One hundred and ninety-six patients met the study's inclusion criteria. Older age, having undergone renal replacement therapy during the 30 days preceding the KPC-Kp BSI onset, having an INCREMENT-CPE score ≥ 8, and having suffered from a superimposed and/or following KPC-Kp BSI treatment candidemia were found to be the main factors associated with both mortality rates. Among protective factors, the centrality of ceftazidime/avibactam in monotherapy (IHD: OR: 0.34; CI 95%: 0.11-1.00-30-day all-cause mortality: OR: 0.18; CI 95%: 0.04-0.77) or combination (IHD: OR: 0.51; CI 95%: 0.22-1.19-30-day all-cause mortality: OR: 0.62; CI 95%: 0.21-1.84) emerged and became even more evident once the effect of ceftazidime/avibactam plus polymyxin was removed. Rapid diagnostics may be useful to adopt more effective strategies for the treatment of KPC-Kp BSI patients and implement infection control measures, even if not associated with higher patient survival. Ceftazidime/avibactam, even when used alone, represents an important option against KPC-Kp, while combined use with polymyxin might not have altered its efficacy. Patient comorbidities, severity of BSI, and complications such as candidemia were confirmed to have a significant burden on survival.
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Affiliation(s)
- Matteo Boattini
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy. .,Department of Public Health and Paediatrics, University of Torino, Turin, Italy.
| | - Gabriele Bianco
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy
| | - Lorena Charrier
- Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Sara Comini
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Marco Iannaccone
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy
| | - André Almeida
- Department of Internal Medicine 4, Hospital de Santa Marta, Central Lisbon Hospital Centre, Lisbon, Portugal.,NOVA Medical School, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056, Lisbon, Portugal
| | - Rossana Cavallo
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, 10126, Turin, Italy.,Unit of Infectious Diseases, Cardinal Massaia, 14100, Asti, Italy
| | - Cristina Costa
- Microbiology and Virology Unit, University Hospital Città della Salute e della Scienza di Torino, Corso Bramante 88/90, 10126, Turin, Italy.,Department of Public Health and Paediatrics, University of Torino, Turin, Italy
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Karampatakis T, Tsergouli K, Lowrie K. Efficacy and safety of ceftazidime-avibactam compared to other antimicrobials for the treatment of infections caused by carbapenem-resistant Klebsiella pneumoniae strains, a systematic review and meta-analysis. Microb Pathog 2023; 179:106090. [PMID: 37004964 DOI: 10.1016/j.micpath.2023.106090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/24/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a significant public health issue. CRKP infections can increase the mortality of severely ill hospitalised patients and elevate the financial burden of their hospitalisation globally. Colistin and tigecycline are the main antimicrobials which have been widely used for the treatment of CRKP infections. However, novel antimicrobials have been recently launched. Ceftazidime-avibactam (CAZ-AVI) seems one of the most efficient ones. AIM The aim of the current systematic literature review and meta-analysis is to assess the efficacy and safety of CAZ-AVI compared to other antimicrobials in adult patients (aged >18) with CRKP infection. METHODS All data were retrieved using PubMed/Medline, the Web of Science and Cochrane library. The main outcome was the effective treatment of CRKP infection or the microbiological eradication of CRKP in the culture of biological samples. Secondary outcomes included the impact on 28- or 30-day mortality and adverse effects, if available. Pooled analysis was conducted using Review Manager v. 5.4.1 software (RevMan). The level of statistical significance was set at p < 0.05. RESULTS CAZ-AVI was proved more effective than other antimicrobials against CRKP infections and CRKP bloodstream infections (p < 0.00001 and p < 0.0001, respectively). Patients in the CAZ-AVI arm displayed statistically lower 28- and 30-day mortality rates (p = 0.002 and p < 0.00001, respectively). Concerning the microbiological eradication, no meta-analysis was feasible due to high heterogeneity. CONCLUSION The promotion of CAZ-AVI for treating CRKP infections over other antimicrobials seems favourable. However, there is a long way ahead to reveal additional scientific findings to further strengthen this statement.
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Sader HS, Mendes RE, Duncan L, Kimbrough JH, Carvalhaes CG, Castanheira M. Ceftazidime-avibactam, Meropenem-vaborbactam, and Imipenem-relebactam Activities against Multidrug-Resistant Enterobacterales from United States Medical Centers (2018–2022). Diagn Microbiol Infect Dis 2023; 106:115945. [PMID: 37060707 DOI: 10.1016/j.diagmicrobio.2023.115945] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/01/2023] [Accepted: 03/14/2023] [Indexed: 04/07/2023]
Abstract
A total of 35,360 Enterobacterales isolates were consecutively collected from 75 US medical centers in 2018-2022. Among these isolates, 2612 (7.4%) were categorized as multidrug-resistant (MDR). Isolates were susceptibility tested by reference broth microdilution methods. Carbapenem-resistant Enterobacterales (CRE) were screened for carbapenemase (CPE) genes by whole genome sequencing. The highest MDR rates was observed among Klebsiella pneumoniae (12.2%), followed by Raoultella spp. (10.9%) and Providencia stuartii (9.8%). Ceftazidime-avibactam and meropenem-vaborbactam were very active and showed identical susceptibility rates against MDR isolates (97.9%). Imipenem-relebactam (93.5% susceptible [S]) exhibited slightly lower susceptibility rates due to its limited activity against Morganellaceae family. The most active β-lactamase inhibitor combination (BLI) against CRE isolates (n = 310) was ceftazidime-avibactam (84.2%S), followed by meropenem-vaborbactam (81.9%S) and imipenem-relebactam (74.8%S). All 3 BLIs were very active against KPC producers and none were active against MBL producers. Ceftazidime-avibactam exhibited greater activity against OXA-48-type producers than meropenem-vaborbactam and imipenem-vaborbactam.
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Clinical Outcomes and Risk Factors for Death following Carbapenem-Resistant Klebsiella pneumoniae Infection in Solid Organ Transplant Recipients. Microbiol Spectr 2023; 11:e0475522. [PMID: 36515527 PMCID: PMC9927413 DOI: 10.1128/spectrum.04755-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) are associated with significant morbidity and mortality. Among solid organ transplant recipients (SOTRs), clinical outcomes and risk factors for death following such infections remain not well documented. A single-center retrospective study was performed. All SOTRs with a CRKP infection at the First Affiliated Hospital of Zhengzhou University between 1 January 2018 and 31 December 2021 were included. Multivariable Cox regression was performed to determine risk factors for death following CRKP infection. We identified 94 SOTRs with CRKP infection, with a median age of 50 years old. CRKP infections resulted in 38.3% of overall 30-day mortality. On multivariable analysis, independent risk factors for death following CRKP infection included older age (hazard ratio [HR], 1.044; 95% confidence interval [CI], 1.007 to 1.083; P = 0.02), allograft failure (HR, 3.962; 95% CI, 1.628 to 9.644; P = 0.002), and septic shock (HR, 8.512; 95% CI, 3.294 to 21.998; P < 0.001). Receiving appropriate targeted therapy was associated with a reduced hazard of death (HR, 0.245; 95% CI, 0.111 to 0.543; P = 0.001). Our study characterized the clinical features and mortality in SOTRs with CRKP infection. The protective effects of appropriate targeted therapy highlight the importance of assessing how antibiotic choices affect the clinical outcomes among SOTRs. IMPORTANCE Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are increasingly identified in solid organ transplant recipients (SOTRs), but data on the clinical outcomes and risk factors for death following such infections remain limited. Here, we reported CRKP infection was associated with 38.3% of overall 30-day mortality in SOTRs. Independent risk factors for death after CRKP infection included older age, allograft failure, and septic shock. Appropriate targeted therapy was important for alleviating the impact of CRKP infections on these SOTRs.
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Herrera F, Torres D, Laborde A, Berruezo L, Jordán R, Rossi IR, Valledor A, Costantini P, Dictar M, Nenna A, Pereyra ML, Lambert S, Benso J, Poletta F, Gonzalez Ibañez ML, Baldoni N, Eusebio MJ, Lovano F, Barcán L, Luck M, Racioppi A, Tula L, Pasterán F, Corso A, Rapoport M, Nicola F, García Damiano MC, Carbone R, Monge R, Reynaldi M, Greco G, Bronzi M, Valle S, Chaves ML, Vilches V, Blanco M, Carena AÁ. Development of a Clinical Score to Stratify the Risk for Carbapenem-Resistant Enterobacterales Bacteremia in Patients with Cancer and Hematopoietic Stem Cell Transplantation. Antibiotics (Basel) 2023; 12:antibiotics12020226. [PMID: 36830136 PMCID: PMC9952392 DOI: 10.3390/antibiotics12020226] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/06/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
Identifying the risk factors for carbapenem-resistant Enterobacterales (CRE) bacteremia in cancer and hematopoietic stem cell transplantation (HSCT) patients would allow earlier initiation of an appropriate empirical antibiotic treatment. This is a prospective multicenter observational study in patients from 12 centers in Argentina, who presented with cancer or hematopoietic stem-cell transplant and developed Enterobacterales bacteremia. A multiple logistic regression model identified risk factors for CRE bacteremia, and a score was developed according to the regression coefficient. This was validated by the bootstrap resampling technique. Four hundred and forty-three patients with Enterobacterales bacteremia were included: 59 with CRE and 384 with carbapenem-susceptible Enterobacterales (CSE). The risk factors that were identified and the points assigned to each of them were: ≥10 days of hospitalization until bacteremia: OR 4.03, 95% CI 1.88-8.66 (2 points); previous antibiotics > 7 days: OR 4.65, 95% CI 2.29-9.46 (2 points); current colonization with KPC-carbapenemase-producing Enterobacterales: 33.08, 95% CI 11.74-93.25 (5 points). With a cut-off of 7 points, a sensitivity of 35.59%, specificity of 98.43%, PPV of 77.7%, and NPV of 90.9% were obtained. The overall performance of the score was satisfactory (AUROC of 0.85, 95% CI 0.80-0.91). Finally, the post-test probability of CRE occurrence in patients with none of the risk factors was 1.9%, which would virtually rule out the presence of CRE bacteremia.
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Affiliation(s)
- Fabián Herrera
- Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1431, Argentina
- Correspondence: ; Tel.: +54-911-58628323
| | - Diego Torres
- Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1431, Argentina
| | | | | | - Rosana Jordán
- Hospital Británico de Buenos Aires, Buenos Aires C1280, Argentina
| | | | | | | | - Miguel Dictar
- Instituto Alexander Fleming, Buenos Aires C1426, Argentina
| | - Andrea Nenna
- Hospital Municipal de Oncología Marie Curie, Buenos Aires C1405, Argentina
| | | | | | - José Benso
- Hospital Italiano de San Justo, Buenos Aires C1198, Argentina
| | - Fernando Poletta
- Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1431, Argentina
| | | | - Nadia Baldoni
- Hospital HIGA Rodolfo Rossi, La Plata B1902, Argentina
| | | | | | - Laura Barcán
- Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Martín Luck
- Instituto de Oncología Angel H. Roffo, Buenos Aires C1417, Argentina
| | | | - Lucas Tula
- Hospital El Cruce, Buenos Aires B1888, Argentina
| | - Fernando Pasterán
- Servicio de Antimicrobianos, ANLIS Malbrán, Buenos Aires C1282, Argentina
| | - Alejandra Corso
- Servicio de Antimicrobianos, ANLIS Malbrán, Buenos Aires C1282, Argentina
| | - Melina Rapoport
- Servicio de Antimicrobianos, ANLIS Malbrán, Buenos Aires C1282, Argentina
| | - Federico Nicola
- Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1431, Argentina
| | | | - Ruth Carbone
- Hospital HIGA Rodolfo Rossi, La Plata B1902, Argentina
| | - Renata Monge
- Hospital Británico de Buenos Aires, Buenos Aires C1280, Argentina
| | | | - Graciela Greco
- Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
- Hospital Italiano de San Justo, Buenos Aires C1198, Argentina
| | - Marcelo Bronzi
- Instituto de Oncología Angel H. Roffo, Buenos Aires C1417, Argentina
| | - Sandra Valle
- Instituto Alexander Fleming, Buenos Aires C1426, Argentina
| | - María Laura Chaves
- Hospital Municipal de Oncología Marie Curie, Buenos Aires C1405, Argentina
| | - Viviana Vilches
- Hospital Universitario Austral, Buenos Aires B1629, Argentina
| | | | - Alberto Ángel Carena
- Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires C1431, Argentina
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Zhang H, Hu S, Li L, Jin H, Yang J, Shen H, Zhang X. Development and Assessment of a Novel Predictive Nomogram to Predict the Risk of Secondary CR-GNB Bloodstream Infections among CR-GNB Carriers in the Gastroenterology Department: A Retrospective Case-Control Study. J Clin Med 2023; 12:jcm12030804. [PMID: 36769451 PMCID: PMC9918196 DOI: 10.3390/jcm12030804] [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: 11/29/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND With the number of critically ill patients increasing in gastroenterology departments (GEDs), infections associated with Carbapenem-resistant Gram-negative bacteria (CR-GNB) are of great concern in GED. However, no CR-GNB bloodstream infection (BSI) risk prediction model has been established for GED patients. Almost universally, CR-GNB colonization precedes or occurs concurrently with CR-GNB BSI. The objective of this study was to develop a nomogram that could predict the risk of acquiring secondary CR-GNB BSI in GED patients who are carriers of CR-GNB. METHODS We conducted a single-center retrospective case-control study from January 2020 to March 2022. Univariate and multivariable logistic regression analysis was used to identify independent risk factors of secondary CR-GNB bloodstream infections among CR-GNB carriers in the gastroenterology department. A nomogram was constructed according to a multivariable regression model. Various aspects of the established predicting nomogram were evaluated, including discrimination, calibration, and clinical utility. We assessed internal validation using bootstrapping. RESULTS The prediction nomogram includes the following predictors: high ECOG PS, severe acute pancreatitis, diabetes mellitus, neutropenia, a long stay in hospital, and parenteral nutrition. The model demonstrated good discrimination and good calibration. CONCLUSIONS With an estimate of individual risk using the nomogram developed in this study, clinicians and nurses can identify patients with a high risk of secondary CR-GNB BSI early.
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Affiliation(s)
- Hongchen Zhang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Shanshan Hu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Lingyun Li
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Hangbin Jin
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Jianfeng Yang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Hongzhang Shen
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
| | - Xiaofeng Zhang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310003, China
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou 310000, China
- Hangzhou Institute of Digestive Disease, Hangzhou 310000, China
- Correspondence: ; Tel.: +86-135-8829-6257; Fax: +86-571-5600-5600
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Fast Track Diagnostic Tools for Clinical Management of Sepsis: Paradigm Shift from Conventional to Advanced Methods. Diagnostics (Basel) 2023; 13:diagnostics13020277. [PMID: 36673087 PMCID: PMC9857847 DOI: 10.3390/diagnostics13020277] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/24/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Sepsis is one of the deadliest disorders in the new century due to specific limitations in early and differential diagnosis. Moreover, antimicrobial resistance (AMR) is becoming the dominant threat to human health globally. The only way to encounter the spread and emergence of AMR is through the active detection and identification of the pathogen along with the quantification of resistance. For better management of such disease, there is an essential requirement to approach many suitable diagnostic techniques for the proper administration of antibiotics and elimination of these infectious diseases. The current method employed for the diagnosis of sepsis relies on the conventional culture of blood suspected infection. However, this method is more time consuming and generates results that are false negative in the case of antibiotic pretreated samples as well as slow-growing microbes. In comparison to the conventional method, modern methods are capable of analyzing blood samples, obtaining accurate results from the suspicious patient of sepsis, and giving all the necessary information to identify the pathogens as well as AMR in a short period. The present review is intended to highlight the culture shift from conventional to modern and advanced technologies including their limitations for the proper and prompt diagnosing of bloodstream infections and AMR detection.
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Qian C, Wu Q, Ruan Z, Liu F, Li W, Shi W, Ma L, Peng D, Yin H, Yao L, Li Z, Hong M, Xia L. A Visualized Mortality Prediction Score Model in Hematological Malignancies Patients with Carbapenem-Resistant Organisms Bloodstream Infection. Infect Drug Resist 2023; 16:201-215. [PMID: 36644657 PMCID: PMC9833326 DOI: 10.2147/idr.s393932] [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: 10/18/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
Background Bloodstream infection (BSI) due to carbapenem-resistant organisms (CROs) has emerged as a worldwide problem associated with high mortality. This study aimed to evaluate the risk factors associated with mortality in HM patients with CROs BSI and to establish a scoring model for early mortality prediction. Methods We conducted a retrospective cohort study at our hematological department from January 2018 to December 2021, including all HM patients with CROs BSI. The outcome measured was death within 30-day of BSI onset. Survivor and non-survivor subgroups were compared to identify predictors of mortality. Univariate and multivariate Cox regression analyses were used to identify prognostic risk factors and develop a nomogram. Results In total, 150 HM patients were included in the study showing an overall 30-day mortality rate of 56%. Klebsiella pneumonia was the dominant episode. Cox regression analysis showed that pre-infection length of stay was >14 days (score 41), Pitt score >4 (score 100), mucositis (score 41), CAR (The ratio of C-reactive protein to albumin) >8.8 (score 57), early definitive therapy (score 44), and long-duration (score 78) were positive independent risk predictors associated with 30-day mortality, all of which were selected into the nomogram. Furthermore, all patients were divided into the high-risk group (≥160 points) or the low-risk group based on the prediction score model. The mortality of the high-risk group was 8 times more than the low-risk group. Kaplan-Meier analysis showed that empirical polymyxin B therapy was associated with a lower 30-day mortality rate, which was identified as a good prognostic factor in the high-risk group. In comparison, empirical carbapenems and tigecycline were poor prognostic factors in a low-risk group. Conclusion Our score model can accurately predict 30-day mortality in HM patients with CROs BSI. Early administration of CROs-targeted therapy in the high-risk group is strongly recommended to decrease mortality.
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Affiliation(s)
- Chenjing Qian
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Qiuling Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Zhixuan Ruan
- Faculty of Natural, Mathematical and Engineering Sciences, King’s College, London, UK
| | - Fang Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Weiming Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Ling Ma
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Danyue Peng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Hua Yin
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Lan Yao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Zixuan Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
| | - Mei Hong
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, People’s Republic of China,Correspondence: Mei Hong; Linghui Xia, Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road No. 1277, Wuhan, Hubei Province, People’s Republic of China, Tel +8613037137937; +8618627733999, Email ;
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, People’s Republic of China
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