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Bay P, Fihman V, Woerther PL, Peiffer B, Gendreau S, Arrestier R, Labedade P, Moncomble E, Gaillet A, Carteaux G, de Prost N, Mekontso Dessap A, Razazi K. Performance and impact of rapid multiplex PCR on diagnosis and treatment of ventilated hospital-acquired pneumonia in patients with extended-spectrum β-lactamase-producing Enterobacterales rectal carriage. Ann Intensive Care 2024; 14:118. [PMID: 39073627 PMCID: PMC11286905 DOI: 10.1186/s13613-024-01348-5] [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: 04/16/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship (AMS) for ventilator-associated pneumonia (VAP) or ventilated hospital-acquired pneumonia (vHAP) in extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) carriers is challenging. BioFire® FilmArray® Pneumonia plus Panel (mPCR) can detect bacteria and antibiotic resistance genes, including blaCTX-M, the most common ESBL-encoding gene. METHODS This monocentric, prospective study was conducted on a group of ESBL-E carriers from March 2020 to August 2022. The primary objective was to evaluate the concordance between the results of mPCR and conventional culture performed on respiratory samples of ESBL-E carriers to investigate suspected VAP/vHAP. The secondary objective was to appraise the impact of performing or not mPCR on initial antibiotic therapy adequacy in ESBL-E carriers with confirmed VAP/vHAP. RESULTS Over the study period, 294 patients with ESBL-E carriage were admitted to the ICU, of who 168 (57%) were mechanically ventilated. (i) Diagnostic performance of mPCR was evaluated in suspected 41 episodes of VAP/vHAP: blaCTX-M gene was detected in 15/41 (37%) episodes, where 9/15 (60%) were confirmed ESBL-E-induced pneumonia. The culture and blaCTX-M were concordant in 35/41 (85%) episodes, and in all episodes where blaCTX-M was negative (n = 26), the culture never detected ESBL-E. (ii) The impact of mPCR on initial antibiotic therapy adequacy was assessed in 95 episodes of confirmed VAP/vHAP (22 episodes were tested with mPCR and 73 without); 47 (49%) episodes were ESBL-E-induced, and 24 (25%) were carbapenem-resistant bacteria-induced. The use of mPCR was significantly associated with higher prescription of adequate empirical antibiotic therapy in the multivariable logistic regression (adjusted odds ratio (aOR) (95% CI) of 7.5 (2.1-35.9), p = 0.004), propensity-weighting (aOR of 5.9 (1.6-22.1), p = 0.008), and matching-cohort models (aOR of 5.8 (1.5-22.1), p = 0.01). CONCLUSION mPCR blaCTX-M showed an excellent diagnostic value to rule out the diagnosis of ESBL-E related pneumonia in ESBL-E carriers with suspected VAP/vHAP. In addition, in patients with confirmed VAP/vHAP, a mPCR-based antibiotic therapy was associated with an increased prescription of adequate empirical antibiotic therapy. Performing mPCR on respiratory samples seems to be a promising tool in ESBL-E carriers with suspected vHAP/VAP. However, if mPCR is used in very low pre-test clinical probability of pneumonia, due to the high sensitivity and the rate of overdiagnosed pneumonia, the risk of overconsumption of carbapenem may prevail. Further studies are warranted.
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Affiliation(s)
- Pierre Bay
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France.
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France.
- UPEC (Université Paris Est), INSERM, Unité U955, Équipe 18, 94010, Créteil, France.
| | - Vincent Fihman
- Département de Virologie, Bactériologie, Parasitologie-Mycologie, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France
- UPEC (Université Paris Est), EA 7380 Dynamic, Ecole Nationale Vétérinaire d'Alfort, USC Anses, Créteil, France
| | - Paul-Louis Woerther
- Département de Virologie, Bactériologie, Parasitologie-Mycologie, AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France
- UPEC (Université Paris Est), EA 7380 Dynamic, Ecole Nationale Vétérinaire d'Alfort, USC Anses, Créteil, France
| | - Bastien Peiffer
- Assistance Publique-Hôpitaux de Paris AP-HP, Hôpital Henri Mondor, DMU Médecine, Créteil, France
| | - Ségolène Gendreau
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Romain Arrestier
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Pascale Labedade
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Elsa Moncomble
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Antoine Gaillet
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
| | - Keyvan Razazi
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, CHU Henri Mondor, 51, Av. de Lattre de Tassigny, 94010, Créteil CEDEX, France
- Faculté de Santé de Créteil, UPEC (Université Paris Est Créteil), IMRB, GRC CARMAS, 94010, Créteil, France
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Razazi K, Luyt CE, Voiriot G, Rouzé A, Garnier M, Ferré A, Camous L, Heming N, Lapidus N, Charles-Nelson A, Mekontso-Dessap A. Ventilator-associated pneumonia related to extended-spectrum beta-lactamase producing Enterobacterales during severe acute respiratory syndrome coronavirus 2 infection: risk factors and prognosis. Crit Care 2024; 28:131. [PMID: 38641851 PMCID: PMC11031867 DOI: 10.1186/s13054-024-04906-2] [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: 10/16/2023] [Accepted: 04/08/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring mechanical ventilation suffer from a high incidence of ventilator associated pneumonia (VAP), mainly related to Enterobacterales. Data regarding extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) VAP are scarce. We aimed to investigate risk factors and outcomes of ESBL-E related VAP among critically ill coronavirus infectious disease-19 (COVID-19) patients who developed Enterobacterales related VAP. PATIENTS AND METHODS We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU) that included 4929 COVID-19 critically ill patients. For the present analysis, only patients with complete data regarding resistance status of the first episode of Enterobacterales related VAP (ESBL-E and/or carbapenem-resistant Enterobacterales, CRE) and outcome were included. RESULTS We included 591 patients with Enterobacterales related VAP. The main causative species were Enterobacter sp (n = 224), E. coli (n = 111) and K. pneumoniae (n = 104). One hundred and fifteen patients (19%), developed a first ESBL-E related VAP, mostly related to Enterobacter sp (n = 40), K. pneumoniae (n = 36), and E. coli (n = 31). Eight patients (1%) developed CRE related VAP. In a multivariable analysis, African origin (North Africa or Sub-Saharan Africa) (OR 1.7 [1.07-2.71], p = 0.02), time between intubation and VAP (OR 1.06 [1.02-1.09], p = 0.002), PaO2/FiO2 ratio on the day of VAP (OR 0.997 [0.994-0.999], p = 0.04) and trimethoprim-sulfamethoxazole exposure (OR 3.77 [1.15-12.4], p = 0.03) were associated with ESBL-E related VAP. Weaning from mechanical ventilation and mortality did not significantly differ between ESBL-E and non ESBL-E VAP. CONCLUSION ESBL-related VAP in COVID-19 critically-ill patients was not infrequent. Several risk factors were identified, among which some are modifiable and deserve further investigation. There was no impact of resistance of the first Enterobacterales related episode of VAP on outcome.
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Affiliation(s)
- Keyvan Razazi
- Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010, Créteil, France.
- IMRB, GRC CARMAS, Faculté de Santé de Créteil, Université Paris Est Créteil (UPEC), 94010, Créteil, France.
- Service de Medicine Intensive Réanimation, CHU Henri Mondor, 51, Av de Lattre de Tassigny, 94000, Créteil Cedex, France.
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Sorbonne-Université, Hôpital Pitié-Salpêtrière, and Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris (APHP), 47-83, Boulevard de L'Hôpital, 75651, Paris, France
| | - Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Anahita Rouzé
- Inserm U1285, CHU Lille, Service de Médecine Intensive - Réanimation, CNRS, UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Univ. Lille, 59000, Lille, France
| | - Marc Garnier
- GRC29, DMU DREAM, Anesthesiology and Critical Care Medicine Department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne University, Paris, France
| | - Alexis Ferré
- Intensive Care Unit, Versailles Hospital, Le Chesnay, France
| | - Laurent Camous
- Medical and Surgical Intensive Care Unit, Guadeloupe Teaching Hospital, Antilles-Guyane University, Les Abymes, France
| | - Nicholas Heming
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin - University Paris Saclay, Paris, France
- Laboratory of Infection and Inflammation - U1173, School of Medicine Simone Veil, INSERM, University Versailles Saint Quentin - University Paris Saclay, Garches, France
- FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), Garches, France
| | - Nathanaël Lapidus
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Saint-Antoine Hospital, Public Health Department, Sorbonne University, 75012, Paris, France
| | - Anais Charles-Nelson
- Hôpital Européen Georges Pompidou, Unité d'Épidémiologie et de Recherche Clinique, INSERM, Centre d'Investigation Clinique1418, Module Épidémiologie Clinique, AP-HP (Assistance Publique Hôpitaux de Paris), Paris, France
| | - Armand Mekontso-Dessap
- Hôpitaux Universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010, Créteil, France
- IMRB, GRC CARMAS, Faculté de Santé de Créteil, Université Paris Est Créteil (UPEC), 94010, Créteil, France
- INSERM, Unité U955, Université Paris Est, 94010, Créteil, France
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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Abera D, Alemu A, Mihret A, Negash AA, Abegaz WE, Cadwell K. Colonization with extended spectrum beta-lactamase and carbapenemases producing Enterobacteriaceae among hospitalized patients at the global level: A systematic review and meta-analysis. PLoS One 2023; 18:e0293528. [PMID: 38011148 PMCID: PMC10681255 DOI: 10.1371/journal.pone.0293528] [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: 02/04/2023] [Accepted: 10/11/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Gut commensal bacteria can mediate resistance against pathogenic bacteria. However, exposure to antibiotics and hospitalization may facilitate the emergence of multidrug resistant bacteria. We aimed to conduct a systematic review and meta-analysis to provide comprehensive evidence about colonization rate of extended spectrum beta-lactamase and carbapenemases producing Enterobacteriaceae. METHOD We used PubMed, Google Scholar and Web of Science data bases to search studies from January 1, 2016 to August10, 2022 about colonization rate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae. Data were extracted from eligible studies and analyzed using Stata version 16 software. The quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal tools, and publication bias was assessed using funnel plot and eggers test. RESULTS We identified 342 studies from the comprehensive data search and data were extracted from 20 studies. The pooled estimate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae were 45.6%(95%CI: 34.11-57-10) and 16.19% (95% CI: 5.46-26.91) respectively. The predominant extended spectrum beta-lactamase producers were E. coli,32.99% (95% CI: 23.28-42.69) and K. pneumoniae, 11.43% (95% CI:7.98-14.89). Prolonged hospitalization was linked to carbapenemase producing Enterobacteriaceae colonization with the odds of 14.77 (95% CI: -1.35-30.90) at admission and 45.63 (95% CI: 0.86-92.12) after ≥7 days of admission. CONCLUSION The pooled estimate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae were high. This indicates the need for strong mitigation strategies to minimize the spread of multidrug-resistant bacteria at the healthcare facilities.
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Affiliation(s)
- Dessie Abera
- Department of Medical Laboratory Sciences, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ayinalem Alemu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopoia
| | - Adane Mihret
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Abel Abera Negash
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Woldaregay Erku Abegaz
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ken Cadwell
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY, United States of America
- Department of Medicine, Division of Gastroenterology and Hepatology, New York University Langone Health, New York, NY, United States of America
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Leone M, Duclos G, Lakbar I, Martin-Loeches I, Einav S. Antimicrobial resistance and outcome in the critically ill patient: An opinion paper. J Crit Care 2023; 77:154352. [PMID: 37302284 DOI: 10.1016/j.jcrc.2023.154352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
Antimicrobial resistance (AMR) is associated with increased mortality and resources consumption in critically ill patients. However, the causality of AMR in this mortality remains unclear. This opinion paper aims to overview the effects of multidrug resistant (MDR) pathogens on the outcomes of critically ill patients, considering different variables as appropriateness of empirical antimicrobial therapy, severity of sepsis, comorbid conditions and frailty. Large studies based on national database associated MDR and increased mortality in critically ill patients. However, the patients carrying MDR pathogens, as compared with those carrying non-MDR pathogens, are those with co-morbid conditions, high risk of frailty and invasive procedures. In addition, inappropriate empirical antibiotics are more often used in these patients as well as withholding and withdrawing of life-sustained therapy. Future studies on AMR should report the rate of appropriateness of empirical antimicrobial therapy, withholding and withdrawing of life-sustained therapy.
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Affiliation(s)
- Marc Leone
- Department of Anaesthesiology and Intensive Care Unit, North Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France; Centre for Nutrition and Cardiovascular Disease (C2VN), INSERM, INRAE, Aix Marseille University, 13005 Marseille, France.
| | - Gary Duclos
- Department of Anaesthesiology and Intensive Care Unit, North Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | - Ines Lakbar
- Department of Anaesthesiology and Intensive Care Unit, North Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France; CEReSS, Health Service Research and Quality of Life Centre, School of Medicine, La Timone, Aix-Marseille University, Marseille, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland
| | - Sharon Einav
- Hebrew University Faculty of Medicine, Jerusalem 23456, Israel; Intensive Care Unit of the Shaare Zedek Medical Center, Jerusalem Y56L5, Israel
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Russell L, Pène F, Martin-Loeches I. Multidrug-resistant bacteria in the grey shades of immunosuppression. Intensive Care Med 2023; 49:216-218. [PMID: 36688974 DOI: 10.1007/s00134-022-06968-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Lene Russell
- Deptartment of Intensive Care, Copenhagen University Hospital, Gentofte, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris. Centre & University Paris Cité, Paris, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland. .,Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain.
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7
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Pilmis B, Weiss E, Scemla A, Le Monnier A, Grossi PA, Slavin MA, Van Delden C, Lortholary O, Paugam-Burtz C, Zahar JR. Multidrug-resistant Enterobacterales infections in abdominal solid organ transplantation. Clin Microbiol Infect 2023; 29:38-43. [PMID: 35716912 DOI: 10.1016/j.cmi.2022.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Transplant recipients are highly susceptible to multidrug-resistant (MDR) related infections. The lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. OBJECTIVES In this review, we present the current state of knowledge concerning multidrug-resistant Gram negative bacilli's risk management in the care of solid-organ transplant recipients and suggest control strategies. SOURCES We searched for studies treating MDR g-negative bacilli related infections in the renal and hepatic transplant patient population. We included randomized and observational studies. CONTENT Solid-organ transplant is the best therapeutic option for patients diagnosed with end-stage organ disease. While the incidence of opportunistic infections is decreasing due to better prevention, the burden of "classical" infections related to MDR bacteria especially related to Gram-negative bacteria is constantly increasing. Over the last two decades, various MDR pathogens have emerged as a relevant cause of infection in this specific population associated with significant mortality. Several factors related to the management of transplant donor candidates and recipients increase the risk of MDR infections in transplant recipients. The awareness of this high susceptibility of transplant recipients to MDR-related infections challenges the choice of empirical therapy, while its appropriateness can only be validated a posteriori. Indeed, the lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. IMPLICATIONS Multidrug-resistant Gram-negative bacteria are associated with high morbidity and mortality in solid organ transplant recipients. It seems important to identify patients at risk of colonization/MDR bacteria to evaluate strategies to limit the risk of secondary infections and to minimize the inappropriate use of broad-spectrum antibiotics.
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Affiliation(s)
- Benoît Pilmis
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France; Équipe mobile de microbiologie Clinique, Groupe Hospitalier Paris Saint Joseph, Paris, France; Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France.
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Anne Scemla
- Departement of Nephrology-Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - Alban Le Monnier
- Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France; Service de Microbiologie Clinique et Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Paolo Antonio Grossi
- Department of Medicine and Surgery, University of Insubria and ASST Sette Laghi, Ospedale di Circolo of Varese, Varese, Italy
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Olivier Lortholary
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, France; Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, Bobigny, France
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8
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Impact of colonization with multidrug-resistant bacteria on the risk of ventilator-associated pneumonia in septic shock. J Crit Care 2022; 71:154068. [DOI: 10.1016/j.jcrc.2022.154068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/24/2022]
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9
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Garnacho-Montero J, Amaya-Villar R. The problem of multi-resistance in gram-negative bacilli in intensive care units: Treatment and prevention strategies. Med Intensiva 2022; 46:326-335. [PMID: 35545496 DOI: 10.1016/j.medine.2022.04.006] [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: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 06/15/2023]
Abstract
The rise of infections caused by multi-resistant gram-negative bacilli (MR-GNB), which includes carbapenems, represents one of the major current challenges worldwide. These MR-GNB include extended spectrum β-lactamase-producing Enterobacterales, derepressed AmpC-producing or carbapenemase-producing Enterobacterales as well as non-fermenting Gram-negative bacilli such as Pseudomonas aeruginosa or Acinetobacter baumannii. P. aeruginosa predominantly exhibits other resistance mechanisms different to β-lactamases such as expulsion pumps or loss of porins. A. baumannii frequently presents several of these resistance mechanisms. Mortality is high especially if empirical treatment is inadequate. In this review, treatment strategies are revised, describing the tools available to identify patients in whom empirical antibiotic treatment would be justified to cover MR-GNB, the importance of optimizing the administration of these antibiotics, as well as prevention strategies to avoid its spread from patients colonized or infected by a MR-GNB.
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Affiliation(s)
- J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain.
| | - R Amaya-Villar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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10
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Russo A, Olivadese V, Trecarichi EM, Torti C. Bacterial Ventilator-Associated Pneumonia in COVID-19 Patients: Data from the Second and Third Waves of the Pandemic. J Clin Med 2022; 11:jcm11092279. [PMID: 35566405 PMCID: PMC9100863 DOI: 10.3390/jcm11092279] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/30/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, many patients requiring invasive mechanical ventilation were admitted to intensive care units (ICU) for COVID-19-related severe respiratory failure. As a matter of fact, ICU admission and invasive ventilation increased the risk of ventilator-associated pneumonia (VAP), which is associated with high mortality rate and a considerable burden on length of ICU stay and healthcare costs. The objective of this review was to evaluate data about VAP in COVID-19 patients admitted to ICU that developed VAP, including their etiology (limiting to bacteria), clinical characteristics, and outcomes. The analysis was limited to the most recent waves of the epidemic. The main conclusions of this review are the following: (i) P. aeruginosa, Enterobacterales, and S. aureus are more frequently involved as etiology of VAP; (ii) obesity is an important risk factor for the development of VAP; and (iii) data are still scarce and increasing efforts should be put in place to optimize the clinical management and preventative strategies for this complex and life-threatening disease.
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11
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Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”. Antibiotics (Basel) 2022; 11:antibiotics11030359. [PMID: 35326822 PMCID: PMC8944836 DOI: 10.3390/antibiotics11030359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/26/2022] Open
Abstract
Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.
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12
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Garnacho-Montero J, Amaya-Villar R. El problema de la multi-resistencia en bacilos gram-negativos en las unidades de cuidados intensivos: estrategias de tratamiento y prevención. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Arzilli G, Scardina G, Casigliani V, Petri D, Porretta A, Moi M, Lucenteforte E, Rello J, Lopalco P, Baggiani A, Privitera GP, Tavoschi L. Screening for Antimicrobial-Resistant Gram-negative bacteria in hospitalised patients, and risk of progression from colonisation to infection: Systematic review. J Infect 2021; 84:119-130. [PMID: 34793762 DOI: 10.1016/j.jinf.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Transmission of antimicrobial-resistant Gram-negative bacteria (AMR-GNB) among hospitalised patients can lead to new cases of carriage, infection and outbreaks, hence the need for early carrier identification. We aim to explore two key elements that may guide control policies for colonisation/infection in hospital settings: screening practices on admission to hospital wards and risk of developing infection from colonisation. METHODS We searched on PubMed, Scopus and Cochrane databases for studies published from 2010 up to 2021 reporting on adult patients hospitalised in high-income countries. RESULTS The search retrieved 11853 articles. After screening, 100 studies were included. Combining target patient groups and setting type, we identified six screening approaches. The most reported approach was all admitted patients to high-risk (HR) wards (49.4%). The overall prevalence of AMR-GNB was 13.8% (95%CI 9.3-19.0) with significant differences across regions and time. Risk of progression to infection among colonised patients was 11.0% (95%CI 8.0-14.3) and varied according to setting and pathogens' group (p value<0.0001), with higher values reported for Klebsiella species (18.1%; 95%CI 8.9-29.3). CONCLUSIONS While providing a comprehensive overview of the screening approaches, our study underlines the considerable burden of AMR-GNB colonisation and risk of progression to infection in hospitals by pathogen, setting and time.
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Affiliation(s)
- Guglielmo Arzilli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Giuditta Scardina
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Virginia Casigliani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Davide Petri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56123, Italy
| | - Andrea Porretta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy.
| | - Marco Moi
- Department of Surgical Sciences, University of Cagliari, Cagliari 09124, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56123, Italy
| | - Jordi Rello
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Clinical Research/epidemiology In Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Clinical Research, CHU Nîmes, Nîmes, France
| | - Pierluigi Lopalco
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
| | - Angelo Baggiani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy
| | - Gaetano Pierpaolo Privitera
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy; University Hospital of Pisa, Pisa 56123, Italy
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56123, Italy
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14
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Lakbar I, Medam S, Ronflé R, Cassir N, Delamarre L, Hammad E, Lopez A, Lepape A, Machut A, Boucekine M, Zieleskiewicz L, Baumstarck K, Savey A, Leone M. Association between mortality and highly antimicrobial-resistant bacteria in intensive care unit-acquired pneumonia. Sci Rep 2021; 11:16497. [PMID: 34389761 PMCID: PMC8363636 DOI: 10.1038/s41598-021-95852-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/26/2021] [Indexed: 12/21/2022] Open
Abstract
Data on the relationship between antimicrobial resistance and mortality remain scarce, and this relationship needs to be investigated in intensive care units (ICUs). The aim of this study was to compare the ICU mortality rates between patients with ICU-acquired pneumonia due to highly antimicrobial-resistant (HAMR) bacteria and those with ICU-acquired pneumonia due to non-HAMR bacteria. We conducted a multicenter, retrospective cohort study using the French National Surveillance Network for Healthcare Associated Infection in ICUs ("REA-Raisin") database, gathering data from 200 ICUs from January 2007 to December 2016. We assessed all adult patients who were hospitalized for at least 48 h and presented with ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii. The association between pneumonia caused by HAMR bacteria and ICU mortality was analyzed using the whole sample and using a 1:2 matched sample. Among the 18,497 patients with at least one documented case of ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii, 3081 (16.4%) had HAMR bacteria. The HAMR group was associated with increased ICU mortality (40.3% vs. 30%, odds ratio (OR) 95%, CI 1.57 [1.45-1.70], P < 0.001). This association was confirmed in the matched sample (3006 HAMR and 5640 non-HAMR, OR 95%, CI 1.39 [1.27-1.52], P < 0.001) and after adjusting for confounding factors (OR ranged from 1.34 to 1.39, all P < 0.001). Our findings suggest that ICU-acquired pneumonia due to HAMR bacteria is associated with an increased ICU mortality rate, ICU length of stay, and mechanical ventilation duration.
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Affiliation(s)
- Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,Department of Anesthesiology and Intensive Care Unit, University hospital of Toulouse, Toulouse, France
| | - Sophie Medam
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Romain Ronflé
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Nadim Cassir
- MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Louis Delamarre
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,Department of Anesthesiology and Intensive Care Unit, University hospital of Toulouse, Toulouse, France
| | - Emmanuelle Hammad
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Alexandre Lopez
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France.,MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France
| | - Alain Lepape
- Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, Hospices Civils de Lyon, France.,Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,PHE3ID, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS Unité Mixte de Recherche 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Saint Genis Laval, France
| | - Anaïs Machut
- Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,Infection Control & Prevention, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, France
| | - Mohamed Boucekine
- APHM, EA 3279 CEReSS, School of Medicine, La Timone Medical Campus, Health Service Research and Quality of Life Center, Aix Marseille Université, Marseille, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Karine Baumstarck
- APHM, EA 3279 CEReSS, School of Medicine, La Timone Medical Campus, Health Service Research and Quality of Life Center, Aix Marseille Université, Marseille, France
| | - Anne Savey
- Rea-Raisin study group (National network for Healthcare-Associated Infection surveillance in ICU, Marseille, France.,Infection Control & Prevention, Hôpital Henry Gabrielle, Hospices Civils de Lyon, Saint Genis Laval, France.,PHE3ID, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS Unité Mixte de Recherche 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Saint Genis Laval, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France. .,MEPHI, IHU Méditerranée Infection, Aix Marseille Université, Marseille, France. .,Service d'anesthésie et de réanimation, Chemin des Bourrely, Hôpital Nord, 13015, Marseille, France.
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15
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Wyres KL, Hawkey J, Mirčeta M, Judd LM, Wick RR, Gorrie CL, Pratt NF, Garlick JS, Watson KM, Pilcher DV, McGloughlin SA, Abbott IJ, Macesic N, Spelman DW, Jenney AWJ, Holt KE. Genomic surveillance of antimicrobial resistant bacterial colonisation and infection in intensive care patients. BMC Infect Dis 2021; 21:683. [PMID: 34261450 PMCID: PMC8278603 DOI: 10.1186/s12879-021-06386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Third-generation cephalosporin-resistant Gram-negatives (3GCR-GN) and vancomycin-resistant enterococci (VRE) are common causes of multi-drug resistant healthcare-associated infections, for which gut colonisation is considered a prerequisite. However, there remains a key knowledge gap about colonisation and infection dynamics in high-risk settings such as the intensive care unit (ICU), thus hampering infection prevention efforts. METHODS We performed a three-month prospective genomic survey of infecting and gut-colonising 3GCR-GN and VRE among patients admitted to an Australian ICU. Bacteria were isolated from rectal swabs (n = 287 and n = 103 patients ≤2 and > 2 days from admission, respectively) and diagnostic clinical specimens between Dec 2013 and March 2014. Isolates were subjected to Illumina whole-genome sequencing (n = 127 3GCR-GN, n = 41 VRE). Multi-locus sequence types (STs) and antimicrobial resistance determinants were identified from de novo assemblies. Twenty-three isolates were selected for sequencing on the Oxford Nanopore MinION device to generate completed reference genomes (one for each ST isolated from ≥2 patients). Single nucleotide variants (SNVs) were identified by read mapping and variant calling against these references. RESULTS Among 287 patients screened on admission, 17.4 and 8.4% were colonised by 3GCR-GN and VRE, respectively. Escherichia coli was the most common species (n = 36 episodes, 58.1%) and the most common cause of 3GCR-GN infection. Only two VRE infections were identified. The rate of infection among patients colonised with E. coli was low, but higher than those who were not colonised on admission (n = 2/33, 6% vs n = 4/254, 2%, respectively, p = 0.3). While few patients were colonised with 3GCR- Klebsiella pneumoniae or Pseudomonas aeruginosa on admission (n = 4), all such patients developed infections with the colonising strain. Genomic analyses revealed 10 putative nosocomial transmission clusters (≤20 SNVs for 3GCR-GN, ≤3 SNVs for VRE): four VRE, six 3GCR-GN, with epidemiologically linked clusters accounting for 21 and 6% of episodes, respectively (OR 4.3, p = 0.02). CONCLUSIONS 3GCR-E. coli and VRE were the most common gut colonisers. E. coli was the most common cause of 3GCR-GN infection, but other 3GCR-GN species showed greater risk for infection in colonised patients. Larger studies are warranted to elucidate the relative risks of different colonisers and guide the use of screening in ICU infection control.
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Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Jane Hawkey
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mirianne Mirčeta
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ryan R Wick
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claire L Gorrie
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel F Pratt
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jill S Garlick
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Kerrie M Watson
- Infectious Diseases Clinical Research Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David V Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Steve A McGloughlin
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Iain J Abbott
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nenad Macesic
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Denis W Spelman
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam W J Jenney
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- London School of Hygiene and Tropical Medicine, London, UK
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16
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Lin M, Zhu S, Weng H, Zhu Y. Effect of cefoperazone sulbactam sodium combined with meropenem on the immune function in the treatment of neonatal pneumonia caused by multidrug-resistant bacteria. Am J Transl Res 2021; 13:6342-6351. [PMID: 34306373 PMCID: PMC8290662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/21/2020] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To explore the effect of cefoperazone sulbactam sodium combined with meropenem on the immune function in the treatment of neonatal multi-drug resistant pneumonia. METHODS Altogether 130 children with pneumonia caused by multi-drug resistant bacteria admitted to our hospital from January 2016 to January 2019 were recruited as the study cohort. The children were randomly divided into a combined group (n=80, combined therapy) and a control group (n=50, cefoperazone sulbactam sodium therapy). Their clinical indexes and their pulmonary function indexes, their serum heparin-binding protein (HBP) 1,25-dihydroxy vitamin D3 [1,25-(OH)2D3] levels, and their inflammatory factors and immune indexes were observed. The bacterial eradication rates, total effective rates, and adverse reaction rates of the two groups were investigated. RESULTS Compared with the control group, the cough disappearance times, the antipyretic times, the pulmonary rales disappearance times, and the hospital stay lengths in the combination group were shorter, the FEV1% Pred (the percentage of forced expiratory volume in one second compared to the predicted value) and the FEV1/Fvc% (the percentage of forced expiratory volume in one second compared to the forced vital capacity) were higher, the HBP levels and the inflammatory factor CRP and IL-6 levels were lower, the 1,25-(OH)2D3, and the immune index gA, IgG, and C4 levels were higher, and the bacterial eradication rates and the total effective rates were higher, and the incidence of adverse reactions was lower. CONCLUSION Cefoperazone sulbactam sodium combined with meropenem can improve the immune function of newborn children with multi-drug resistant pneumonia.
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Affiliation(s)
- Mingjing Lin
- Department of Neonatal, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan Province, China
| | - Shuxia Zhu
- Department of Paediatrics, Binzhou Medical University HospitalBinzhou 256600, Shandong Province, China
| | - Haimei Weng
- Department of Neonatal, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical UniversityHaikou 570311, Hainan Province, China
| | - Yi Zhu
- Hospital Infection Management Office, The Hospital of Xinjiang Production and Construction CorpsUrumqi 830002, Xinjiang Uygur Autonomous Region, China
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17
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Pilmis B, de Ponfilly GP, Farfour E, Ranc AG, Fihman V, Bille E, Dortet L, Degand N, Morand P, Potron A, Mizrahi A, Laurent F, Le Brun C, Guillard T, Héry-Arnaud G, Piau C, Barraud O, Ruffier d'Epenoux L, Zahar JR, Le Monnier A. Epidemiology and clinical characteristics of Klebsiella spp. meningitis in France. Infect Dis Now 2021; 52:82-86. [PMID: 34091093 DOI: 10.1016/j.idnow.2021.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the epidemiology of Klebsiella spp. meningitis in France with respect to clinical and bacteriological data. METHODS We performed a four-year multicenter, retrospective, observational study. The primary objective was to provide a clinical description of patients with Klebsiella spp. meningitis. Secondary objectives were to compare community-acquired meningitis and healthcare-associated meningitis and to analyze factors associated with mortality. RESULTS We enrolled 131 patients with Klebsiella spp. meningitis. Eighty-two (62.6%) infections were reported following neurosurgery. Twenty-eight strains (21.4%) were resistant to third-generation cephalosporins (3GC). The median [IQR] cellularity was 980/mm3 [116-5,550], the median protein level was 5.67 [1.62-9] g/L and the median CSF glucose level was 2.5 [0-3.4] mmol/L. The in-hospital mortality rate was 23.6%. Community-acquired meningitis isolates were more frequently susceptible to 3GC than isolates from healthcare-associated meningitis (89.2% versus 72%; p=0.04). Comorbidities reported for patients with community-acquired meningitis were mainly diabetes mellitus and liver cirrhosis. In multivariate analysis, focal neurological disorder at the time of diagnosis was the only factor associated with in-hospital mortality (p=0.01). CONCLUSIONS Purulent meningitis caused by Klebsiella spp. needs to be considered in patients with community-acquired meningitis and pre-existing conditions, as well as in case of meningitis following neurosurgical procedures.
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Affiliation(s)
- B Pilmis
- Équipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France; Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France. Service de microbiologie clinique, GH Paris Saint-Joseph, 75014 Paris, France; Service de Maladies infectieuses et Tropicales, Hôpital Necker Enfants Malades, Paris, France.
| | - G Péan de Ponfilly
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France. Service de microbiologie clinique, GH Paris Saint-Joseph, 75014 Paris, France; Laboratoire de Bactériologie, Département des Agents infectieux, CHU Saint Louis-Lariboisière-Fernand Widal, APHP, 75010 Paris, France
| | - E Farfour
- Service de Biologie Clinique, Hôpital Foch, 92150 Suresnes, France
| | - A-G Ranc
- Institut des Agents Infectieux (IAI), Hospices Civils de Lyon, Lyon, France
| | - V Fihman
- Unité de Bactériologie, Groupe Hospitalier Henri Mondor, 94010 Créteil, France
| | - E Bille
- Laboratoire de Microbiologie, Hôpital Necker-Enfants Malades, 75015 Paris, France
| | - L Dortet
- Service de Bactériologie-Hygiène, CHU de Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - N Degand
- Laboratoire de Bactériologie, Hôpital Larchet, CHU Nice, 06202 Nice, France
| | - P Morand
- Université de Paris, Faculté de Médecine Paris Centre; Groupe hospitalier APHP-CUP, Service de Bactériologie, 75014 Paris, France
| | - A Potron
- Centre National de Référence de la résistance aux antibiotiques, Centre Hospitalier Universitaire de Besançon, UMR6249 CNRS Chrono-Environnement, Université de Franche-Comté, Besançon, France
| | - A Mizrahi
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France. Service de microbiologie clinique, GH Paris Saint-Joseph, 75014 Paris, France; Laboratoire de Microbiologie et Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - F Laurent
- Institut des Agents Infectieux (IAI), Hospices Civils de Lyon, Lyon, France
| | - C Le Brun
- Service de Bactériologie-Virologie-Hygiène, Hôpital Bretonneau, CHRU de Tours, 37000 Tours, France
| | - T Guillard
- Université de Reims-Champagne-Ardenne, Inserm UMR-S 1250 P3Cell, SFR CAP-Santé ; Laboratoire de Bactériologie-Virologie-Hygiène Hospitalière-Parasitologie-Mycologie, Hôpital Robert Debré, CHU Reims, 51000 Reims, France
| | - G Héry-Arnaud
- Université de Brest, Inserm, UMR 1078, Unité de Bactériologie, CHRU de Brest, F-29200 Brest, France
| | - C Piau
- Service de Bactériologie-Hygiène hospitalière, CHU de Rennes, 35033 Rennes, France
| | - O Barraud
- Service de bactériologie, virologie, hygiène, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France
| | - L Ruffier d'Epenoux
- Service de Bactériologie-Hygiène hospitalière, CHU de Nantes, Institut de Biologie, 9 quai Moncousu 44093, Cedex 1, Nantes, France
| | - J-R Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - A Le Monnier
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France. Service de microbiologie clinique, GH Paris Saint-Joseph, 75014 Paris, France; Laboratoire de Bactériologie, Département des Agents infectieux, CHU Saint Louis-Lariboisière-Fernand Widal, APHP, 75010 Paris, France
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18
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Grégoire M, Berteau F, Bellouard R, Lebastard Q, Aubert P, Gonzales J, Javaudin F, Bessard A, Bemer P, Batard É, Lepelletier D, Neunlist M, Montassier E, Dailly É. A murine model to study the gut bacteria parameters during complex antibiotics like cefotaxime and ceftriaxone treatment. Comput Struct Biotechnol J 2021; 19:1423-1430. [PMID: 33777338 PMCID: PMC7961304 DOI: 10.1016/j.csbj.2021.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background The globally increasing resistance due to extended-spectrum beta-lactamase producing Enterobacteriaceae is a major concern. The objective of this work was to develop a murine model to study the gut bacteria parameters during complex antibiotics like cefotaxime and ceftriaxone treatment and to compare the fecal carriage of ESBL-producing Enterobacteriaceae. Methods SWISS mice were treated either with ceftriaxone or with cefotaxime or with NaCl 0.9% as a control group from day 1 to day 5. We performed a gavage at day 4 with a Klebsiella pneumonia CTX-M9. We collected stools and performed pharmacological measurements, cultures and 16S rRNA gene amplification and sequencing during the 12 days of the stool collection. Results Mice treated with ceftriaxone were more colonized than mice treated with cefotaxime after gavage (p-value = 0.008; Kruskal-Wallis test). Ceftriaxone and cefotaxime were both excreted in large quantity in gut lumen but they drove architecture of the gut microbiota in different trajectories. Highest levels of colonization were associated with particular microbiota composition using principal coordinate analysis (PCoA) which were more often achieved in ceftriaxone-treated mice and which were preceded by highest fecal antibiotics concentrations in both cefotaxime or ceftriaxone groups. Using LEfSe, we found that twelve taxa were significantly different between cefotaxime and ceftriaxone-treated mice. Using SplinectomeR, we found that relative abundances of Klebsiella were significantly higher in CRO than in CTX-treated mice (p-value = 0.01). Conclusion Ceftriaxone selects a particular microbial community and its substitution for cefotaxime could prevent the selection of extended-spectrum beta-lactamase producing Enterobacteriaceae.
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Affiliation(s)
- Matthieu Grégoire
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France
| | - Florian Berteau
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France
| | - Ronan Bellouard
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France
| | - Quentin Lebastard
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Emergency Department, CHU Nantes, Nantes, France
| | - Philippe Aubert
- UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, Nantes University, France
| | - Jacques Gonzales
- UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, Nantes University, France
| | - François Javaudin
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Emergency Department, CHU Nantes, Nantes, France
| | - Anne Bessard
- UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, Nantes University, France
| | - Pascale Bemer
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Bacteriology and Infection Control Department, CHU Nantes, Nantes, France
| | - Éric Batard
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Emergency Department, CHU Nantes, Nantes, France
| | - Didier Lepelletier
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Bacteriology and Infection Control Department, CHU Nantes, Nantes, France
| | - Michel Neunlist
- UMR Inserm 1235, The Enteric Nervous System in Gut and Brain Disorders, Nantes University, France
| | - Emmanuel Montassier
- EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France.,Emergency Department, CHU Nantes, Nantes, France
| | - Éric Dailly
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,EE1701, Microbiotas Hosts Antibiotics and Bacterial Resistances, Nantes University, France
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19
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Logre E, Bert F, Khoy-Ear L, Janny S, Giabicani M, Grigoresco B, Toussaint A, Dondero F, Dokmak S, Roux O, Francoz C, Soubrane O, Durand F, Paugam-Burtz C, Weiss E. Risk Factors and Impact of Perioperative Prophylaxis on the Risk of Extended-spectrum β-Lactamase-producing Enterobacteriaceae-related Infection Among Carriers Following Liver Transplantation. Transplantation 2021; 105:338-345. [PMID: 32217945 DOI: 10.1097/tp.0000000000003231] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage is frequent among liver transplant (LT) recipients, thereby fostering a large empirical carbapenem prescription. However, ESBL-E infections occur in only 10%-25% of critically ill patients with rectal colonization. Our aim was to identify risk factors for post-LT ESBL-E infection in colonized patients. The effect of perioperative antimicrobial prophylaxis (AP) was also analyzed in patients with prophylaxis lasting <48 hours and without proven intraoperative infection. METHODS Retrospective study from a prospective database including patients with a positive ESBL-E rectal screening transplanted between 2010 and 2016. RESULTS Among the 749 patients transplanted, 100 (13.3%) were colonized with an ESBL-E strain. Thirty-nine (39%) patients developed an infection related to the same ESBL-E (10 pulmonary, 11 surgical site, 13 urinary, 5 bloodstream) within 11 postoperative days in median. Klebsiella pneumoniae carriage, model for end-stage liver disease ≥25, preoperative spontaneous bacterial peritonitis prophylaxis, and antimicrobial exposure during the previous month were independent predictors of ESBL-E infection. We propose a colonization to infection risk score built on these variables. The prevalence of infection for colonization to infection score of 0, 1, 2, and ≥3 were 7.4%, 26.3%, 61.9%, and 91.3%, respectively. Of note, the incidence of post-LT ESBL-E infection was lower in case of perioperative AP targeting colonizing ESBL-E (P = 0.04). CONCLUSIONS Thirty-nine percentage of ESBL-E carriers develop a related infection after LT. We identified predictors for ESBL-E infection in carriers that may help in rationalizing carbapenem prescription. Perioperative AP targeting colonizing ESBL-E may be associated with a reduced risk of post-LT ESBL-E infections.
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Affiliation(s)
- Elsa Logre
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Frédéric Bert
- Department of Microbiology, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Linda Khoy-Ear
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Sylvie Janny
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Mikhaël Giabicani
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Bénédicte Grigoresco
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Amélie Toussaint
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Fédérica Dondero
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Safi Dokmak
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Olivier Roux
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Claire Francoz
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - François Durand
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
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20
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Outcomes in Participants with Renal Impairment from a Phase 3 Clinical Trial for Ceftolozane/Tazobactam Treatment of Nosocomial Pneumonia (ASPECT-NP). Antimicrob Agents Chemother 2020; 64:AAC.00731-20. [PMID: 32988827 DOI: 10.1128/aac.00731-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/09/2020] [Indexed: 01/05/2023] Open
Abstract
In the phase 3 ASPECT-NP trial (NCT02070757), ceftolozane/tazobactam (C/T) was noninferior to meropenem for treatment of Gram-negative ventilated hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (vHABP/VABP). Here, we report outcomes in participants from ASPECT-NP with renal impairment (RI). Participants were categorized by their baseline renal function as follows: normal renal function (NRF; creatinine clearance [CLCR], ≥80 ml/min), mild RI (CLCR, >50 to <80 ml/min), moderate RI (CLCR, ≥30 to ≤50 ml/min), and severe RI (CLCR, ≥15 to <30 ml/min). Dosing of both study drugs was adjusted based on renal function. The following C/T doses were administered every 8 h: NRF or mild RI, 3 g; moderate RI, 1.5 g; and severe RI, 0.75 g. The primary and key secondary endpoints were day 28 all-cause mortality (ACM) and clinical response at the test-of-cure visit in the intention-to-treat (ITT) population, respectively. In the ITT population, day 28 ACM rates for the C/T arm versus the meropenem arm were 17.6% versus 19.1% (NRF), 36.6% versus 28.6% (mild RI), 31.4% versus 38.5% (moderate RI), and 35.3% versus 61.9% (severe RI). Rates of clinical cure in the ITT population for the C/T arm versus the meropenem arm were 58.1% versus 58.5% (NRF), 54.9% versus 45.5% (mild RI), 37.1% versus 42.3% (moderate RI), and 41.2% versus 47.6% (severe RI). Small sample sizes in the RI groups resulted in large 95% confidence intervals (CIs), limiting conclusive interpretation of the analysis. Both drugs were well tolerated across all renal function groups. Overall, these results support the use of the study dosing regimens of C/T for treatment of vHABP/VABP in patients with RI. (This study has been registered at ClinicalTrials.gov under identifier NCT02070757.).
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Risk stratification for multidrug-resistant Gram-negative infections in ICU patients. Curr Opin Infect Dis 2020; 32:626-637. [PMID: 31567570 DOI: 10.1097/qco.0000000000000599] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Antimicrobial resistance among Gram-negative microorganisms has alarmingly increased in the past 10 years worldwide. Infections caused by these microorganisms are difficult to treat, especially in critically ill patients.The present review examines how to accurately predict which patients carry a greater risk of colonization or infection on which to base the timely choice of an effective empirical antibiotic treatment regimen and avoid antibiotic overuse. RECENT FINDINGS There are many risk factors for acquiring one of many multidrug-resistant Gram-negative microorganisms (MDR-GN); however, scores anticipating colonization, infection among those colonized, or mortality among those infected have a variable accuracy. Accuracy of scores anticipating colonization is low. Scores predicting infections among colonized patients are, in general, better, and ICU patients infected with MDR-GN have a worse prognosis than those infected by non-resistant microorganisms. Scores are, in general, better at excluding patients. SUMMARY Despite these limitations, scores continue to gain popularity including those by Giannella, Tumbarello, Johnson, or the scores INCREMENT carbapenem-producing Enterobacteriaceae score, Cano, Tartof, or CarbaSCORE.
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Zahar JR, Blot S, Nordmann P, Martischang R, Timsit JF, Harbarth S, Barbier F. Screening for Intestinal Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae in Critically Ill Patients: Expected Benefits and Evidence-based Controversies. Clin Infect Dis 2020; 68:2125-2130. [PMID: 30312366 DOI: 10.1093/cid/ciy864] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022] Open
Abstract
The rising burden of intensive care unit (ICU)-acquired infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) strengthens the requirement for efficient prevention strategies. The detection of intestinal carriage of ESBL-E through active surveillance cultures (ASC) and the implementation of contact precautions (CP) in carriers are currently advocated in most high-income countries, to prevent cross-transmission and subsequent ESBL-E infections in critically-ill patients. Yet, recent studies have challenged the benefit of ASC and CP in controlling the spread of ESBL-E in ICUs with high compliance to standard hygiene precautions and no ongoing outbreak of ESBL-producing Klebsiella pneumoniae or Enterobacter spp. Besides, given their debated performance to positively predict which patients are at risk of ESBL-E infections, ASC results appear of limited value to rationalize the empirical use of carbapenems in the ICU, emphasizing the urgent need for novel anticipatory and diagnostic approaches. This Viewpoint article summarizes the available evidence on these issues.
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Affiliation(s)
- Jean-Ralph Zahar
- Infection Control Unit, Avicenne University Hospital, Assistance Publique - Hôpitaux de Paris, Bobigny.,INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France
| | - Stijn Blot
- Department of Internal Medicine, Ghent University, Belgium.,Burns, Trauma and Critical Care Research Centre, Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Patrice Nordmann
- Medical and Molecular Microbiology Unit, Department of Medicine, Faculty of Science, INSERM European Unit.,Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg.,Institute for Microbiology, University of Lausanne and University Hospital Centre
| | - Romain Martischang
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Jean-François Timsit
- INSERM, Infection Antimicrobial Modelling Evolution, UMR 1137, Paris Diderot, Sorbonne Paris Cité University, France.,Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, APHP, Paris
| | - Stephan Harbarth
- Infection Control Program and World Health Organization Collaborating Center, Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, Orléans, France
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23
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Abstract
Hospital-acquired infections are a known menace to the primary disease, for which a patient is admitted. These infections are twenty times more common in developing countries than in the developed ones. Surveillance for colonised patients can be passive or active process. In many hospitals, active surveillance culture for certain sentinel organisms followed by contact precautions for the same is an important part of infection control policy. Specific measures can be taken on early detection of multidrug-resistant organism, allowing prevention of widespread transmission in hospitals. Cultures are the most conventional and economical microbiological method of detection. The cost of active surveillance is a major challenge, especially for developing nations. These nations lack basic infrastructure and have logistic issues. The guidelines regarding this are not very clearly delineated for developing countries. Each hospital has its own challenges and the process is to be tailor-made accordingly. The following review delineates the various aspects of active surveillance for the colonisation of various organisms and the advantages and disadvantages of the same.
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Affiliation(s)
- Manisha Biswal
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rimjhim Kanaujia
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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24
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Andremont O, Armand-Lefevre L, Dupuis C, de Montmollin E, Ruckly S, Lucet JC, Smonig R, Magalhaes E, Ruppé E, Mourvillier B, Lebut J, Lermuzeaux M, Sonneville R, Bouadma L, Timsit JF. Semi-quantitative cultures of throat and rectal swabs are efficient tests to predict ESBL-Enterobacterales ventilator-associated pneumonia in mechanically ventilated ESBL carriers. Intensive Care Med 2020; 46:1232-1242. [PMID: 32313993 PMCID: PMC7222166 DOI: 10.1007/s00134-020-06029-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/26/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE In ICU patients with carriage of extended spectrum beta-lactamase producing Enterobacterales (ESBL-E) and suspected Gram-negative bacilli ventilator-associated pneumonia (GNB-VAP), the quantification of the rectal and throat ESBL-E carriage might predict the ESBL-E involvement in GNB-VAP. Our aim was to evaluate whether a semi-quantitative assessment of rectal/throat ESBL-E carriage can predict ESBL-E-associated VAP in medical ICU patients. METHODS From May 2014 to May 2017, all ESBL-E carriers had a semi-quantitative assessment of ESBL-E density in swabs cultures. For those who developed GNB-VAP (diagnosed using bronchoalveolar lavage or plugged telescopic catheter with significant quantitative culture), the last positive swab collected at least 48 h before GNB-VAP onset was selected. Clinical data were extracted from a prospectively collected database. RESULTS Among 365 ESBL-E carriers, 82 developed 107 episodes of GNB-VAP (ESBL-E VAP, n = 50; and non-ESBL-E GNB-VAP, n = 57) after 13 days of mechanical ventilation in median. Antimicrobials use before VAP onset was similar between groups. The last swabs were collected 5 days in median before VAP onset. ESBL-E. coli carriers developed ESBL-E VAP less frequently (n = 13, 34%) than others (n = 32, 67.3%, p < .01). Throat swab positivity (39 (78%) vs. 12 (23%), p < .01) was more frequent for ESBL-E VAP. ESBL-E VAP was associated with significantly higher ESBL-E density in rectal swabs. In multivariate models, non-E. coli ESBL-E carriage and rectal ESBL-E carriage density, or throat carriage, remained associated with ESBL-E VAP. CONCLUSION In carriers of ESBL-E other than E. coli, ESBL-E throat carriage or a high-density ESBL-E rectal carriage are risk factors of ESBL-E VAP in case of GNB-VAP.
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Affiliation(s)
- Olivier Andremont
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Laurence Armand-Lefevre
- UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Bacteriological Department, Bichat-Claude Bernard university hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Claire Dupuis
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Etienne de Montmollin
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | - Roland Smonig
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eric Magalhaes
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Etienne Ruppé
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Bacteriological Department, Bichat-Claude Bernard university hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bruno Mourvillier
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jordane Lebut
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mathilde Lermuzeaux
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Sonneville
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1148, Laboratory for Vascular and Translational Science, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases ICU (MI2), Bichat-Claude Bernard University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France. .,UMR 1137, IAME, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med 2020; 46:888-906. [PMID: 32157357 PMCID: PMC7095206 DOI: 10.1007/s00134-020-05980-0] [Citation(s) in RCA: 337] [Impact Index Per Article: 84.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, Hôpitaux de Marseille, Chemin des Bourrely, 13015, Marseille, France. .,Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Groupe de recherche en Réanimation et Anesthésie de Marseille pluridisciplinaire (GRAM +), Faculté de médecine, Aix-Marseille Université, 13005, Marseille, France.
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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26
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Quantifying risk of disease due to extended-spectrum β-lactamase producing Enterobacteriaceae in patients who are colonized at ICU admission. J Infect 2020; 80:504-510. [PMID: 32142931 DOI: 10.1016/j.jinf.2020.02.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has globally increased and spread to the community. No clinical score is available to select carriers in whom these organisms can be empirically targeted at ICU admission. METHODS We prospectively assessed between 2009 and 2017 the prevalence of ESBL-PE infection in carriers at ICU admission. A logistic regression was used to determine independent risk factors associated with ESBL-PE infection, and to build a clinical risk score. RESULTS Of the 8,061 admissions over the study 7-year period, 745 (9%) patients were ESBL-PE carriers at admission, of whom 395 had infections at ICU admission including 59 (15%) who had culture-proven ESBL-PE related infection. By multivariable analysis, age >60 years, cirrhosis, being on broad-spectrum antibiotics within the past three months, urinary or intra-abdominal source of infection, and the absence of chronic pulmonary disease, were the five independent factors associated with ESBL-PE infection in carriers. A clinical risk score ranging from 0 to 7 was built based on these variables, with an area under the receiver operating characteristic curve (ROC) of 0.82 (95% CI 0.78-0.86); p <0.001. The prevalence of ESBL-PE infection for clinical risk scores of 0-1, 2-3, 4-5, or 6-7 was 0%, 4%, 26%, and 49%, respectively. The negative predictive value when Mondor ESBL risk score is <4 was 97%. CONCLUSION ESBL-PE related infection was not common in carriers at ICU admission. A clinical risk score may spare ESBL-PE carriers with lower risk of ESBL-PE infection at ICU admission unnecessary empiric carbapenem therapy.
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Shamsrizi P, Gladstone BP, Carrara E, Luise D, Cona A, Bovo C, Tacconelli E. Variation of effect estimates in the analysis of mortality and length of hospital stay in patients with infections caused by bacteria-producing extended-spectrum beta-lactamases: a systematic review and meta-analysis. BMJ Open 2020; 10:e030266. [PMID: 31964661 PMCID: PMC7044956 DOI: 10.1136/bmjopen-2019-030266] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess the variation of effect estimates in the analysis of mortality and length of stay (LOS) in patients with infections caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. DESIGN Systematic review and meta-analysis METHODS: Literature search for clinical studies from 1 January 1960 to 1 October 2018 was conducted in PubMed. Primary outcomes were risk ratios (RRs) of all-cause and attributable mortality and weighted mean differences (WMDs) in LOS in patients with bloodstream infections (BSIs) and non-invasive infections. Any change in the effect estimates was assessed by grouping studies according to design, setting, economy-based country classification, reporting period, microbiological aetiology, infection type and adjustment for appropriateness of empirical treatment. The impact of ESBL production was calculated using random-effect meta-analysis and heterogeneity was evaluated by I2 statistics and metaregression. RESULTS Eighty-four studies including 22 030 patients and 149 outcome measures were included in the meta-analysis. Most studies were retrospective cohorts from high-income countries, providing unadjusted estimates. ESBL production in patients with BSIs (56 studies) increased the RR for all-cause mortality by a factor of 1.70 (95% CI 1.52 to 1.90; p<0.001), attributable mortality (16 studies) by 1.75 (95% CI 1.448 to 2.108; p<0.001) and WMD in the intensive care unit by 3.07 days (95% CI 1.61 to 4.54; p<0.001). WMD in hospital LOS was significantly higher in BSIs (4.41 days; 95% CI 3.37 to 5.46; p<0.001) and non-invasive (2.19 days; 95% CI 1.56 to 2.81; p<0.001). Subgroup analyses showed variation of estimates by study design, population, strain and assessment of appropriateness of empiric treatment. High heterogeneity was observed in all analyses. CONCLUSIONS Current evidence of the clinical burden of infections caused by ESBL-producing bacteria is highly heterogeneous and based mainly on unadjusted estimates derived from retrospective studies. Despite these limitations, ESBL production in strains causing BSIs seems associated with higher all-cause and attributable mortality and longer hospitalisation.
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Affiliation(s)
- Parichehr Shamsrizi
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
| | - Beryl Primrose Gladstone
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
| | - Elena Carrara
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Dora Luise
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Andrea Cona
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, Milano, Italy
| | - Chiara Bovo
- Medical Direction, Integrated University Hospital of Verona, Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
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Jean SS, Chang YC, Lin WC, Lee WS, Hsueh PR, Hsu CW. Epidemiology, Treatment, and Prevention of Nosocomial Bacterial Pneumonia. J Clin Med 2020; 9:jcm9010275. [PMID: 31963877 PMCID: PMC7019939 DOI: 10.3390/jcm9010275] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 12/17/2022] Open
Abstract
Septicaemia likely results in high case-fatality rates in the present multidrug-resistant (MDR) era. Amongst them are hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), two frequent fatal septicaemic entities amongst hospitalised patients. We reviewed the PubMed database to identify the common organisms implicated in HAP/VAP, to explore the respective risk factors, and to find the appropriate antibiotic choice. Apart from methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Enterobacteriaceae spp., MDR or extensively drug-resistant (XDR)-Acinetobacter baumannii complex spp., followed by Stenotrophomonas maltophilia, Chryseobacterium indologenes, and Elizabethkingia meningoseptica are ranked as the top Gram-negative bacteria (GNB) implicated in HAP/VAP. Carbapenem-resistant Enterobacteriaceae notably emerged as an important concern in HAP/VAP. The above-mentioned pathogens have respective risk factors involved in their acquisition. In the present XDR era, tigecycline, colistin, and ceftazidime-avibactam are antibiotics effective against the Klebsiella pneumoniae carbapenemase and oxacillinase producers amongst the Enterobacteriaceae isolates implicated in HAP/VAP. Antibiotic combination regimens are recommended in the treatment of MDR/XDR-P. aeruginosa or A. baumannii complex isolates. Some special patient populations need prolonged courses (>7-day) and/or a combination regimen of antibiotic therapy. Implementation of an antibiotic stewardship policy and the measures recommended by the United States (US) Institute for Healthcare were shown to decrease the incidence rates of HAP/VAP substantially.
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Affiliation(s)
- Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Department of Emergency Medicine, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medicine University, Taipei 110, Taiwan
- Correspondence: ; Tel.: +886-2-29307930 (ext. 1262)
| | - Yin-Chun Chang
- Division of Thoracic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (Y.-C.C.); (W.-C.L.)
| | - Wei-Cheng Lin
- Division of Thoracic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; (Y.-C.C.); (W.-C.L.)
| | - Wen-Sen Lee
- Division of Infectious Diseases, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan;
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan;
- Department Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan
| | - Chin-Wan Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Department of Emergency Medicine, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medicine University, Taipei 110, Taiwan
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Massart N, Camus C, Benezit F, Moriconi M, Fillatre P, Le Tulzo Y. Incidence and risk factors for acquired colonization and infection due to extended-spectrum beta-lactamase-producing Gram-negative bacilli: a retrospective analysis in three ICUs with low multidrug resistance rate. Eur J Clin Microbiol Infect Dis 2020; 39:889-895. [PMID: 31898797 PMCID: PMC7222057 DOI: 10.1007/s10096-019-03800-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/17/2019] [Indexed: 12/20/2022]
Abstract
The purpose of this study is to assess risk factors for the acquisition of extended-spectrum β-lactamase-producing Gram-negative bacilli (ESBL-GNB) colonization and infection (AI) in ICUs with low ESBL-GNB prevalence rate. We conducted a retrospective observational study in three ICUs in Bretagne, France. All patients admitted from January 2016 to September 2017 with a length of stay of 2 days or more were included. Universal screening for ESBL-GNB colonization was performed in all participating ICUs. Of the 3250 included patients, 131 (4.0%) were colonized at admission, 59 acquired colonization while hospitalized (1.9%; 95% CI [1.5–2.5%]), and 15 (0.5%; 95% CI [0.3–0.8%]) acquired ESBL-GNB infections. In the case of infection, the specificity and the negative predictive values of preexistent colonization for the ESBL-GNB etiology were 93.2% [91.5–95.1%] and 95.2% [93.5–97.1%], respectively. Colonization was the main risk factor for ESBL-GNB AI (OR = 9.61; 95% CI [2.86–32.29]; p < 0.001). Antimicrobial susceptibility of non-ESBL-GNB isolates responsible for AI was similar for any non-carbapenem β-lactam (95%) and imipenem (94%). ESBL-GNB AIs were rare in ICUs with low ESBL-GNB prevalence rate. Prior colonization was the main risk factor for subsequent infection. Empirical carbapenem therapy could be avoided in non ESBL-GNB colonized patients with suspected AI.
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Affiliation(s)
- Nicolas Massart
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France. .,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.
| | - Christophe Camus
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
| | - François Benezit
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
| | - Mikael Moriconi
- Service de Réanimation, CH de Quimper, 14bis Avenue Yves Thépot, 29107, Quimper, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St Brieuc, 10, rue Henry le Guilloux, 22000, Saint-Brieuc, France
| | - Yves Le Tulzo
- Service de Maladie Infectieuse et de Réanimation Médicale CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France.,Faculté de Médecine, Biosit, Université Rennes 1, F-35043, Rennes, France.,Inserm-CIC-1414, Faculté de Médecine, Université Rennes I, IFR 140, F-35033, Rennes, France
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Denkel LA, Maechler F, Schwab F, Kola A, Weber A, Gastmeier P, Pfäfflin F, Weber S, Werner G, Pfeifer Y, Pietsch M, Leistner R. Infections caused by extended-spectrum β-lactamase-producing Enterobacterales after rectal colonization with ESBL-producing Escherichia coli or Klebsiella pneumoniae. Clin Microbiol Infect 2019; 26:1046-1051. [PMID: 31809805 DOI: 10.1016/j.cmi.2019.11.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/20/2019] [Accepted: 11/24/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Infections as a result of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) are considered infections with a high public health burden. In this study, we aimed to identify incidences of and risk factors for healthcare-associated infections (HAIs) after rectal colonization with ESBL-producing Escherichia coli (ESBL-EC) or Klebsiella pneumoniae (ESBL-KP). METHODS This prospective cohort study was performed in 2014 and 2015. Patients colonized with ESBL-EC or ESBL-KP were monitored for subsequent HAI with ESBL-E and other pathogens. In the case of an ESBL-E infection, rectal and clinical isolates were compared using pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) for ESBL-KP isolates. Proportional hazard models were applied to identify risk factors for HAIs, and to analyse competing risks. RESULTS Among all patients admitted to the hospital during the study period, 13.6% were rectally screened for third-generation cephalosporin-resistant Enterobacterales (3GCREB). A total of 2386 rectal carriers of ESBL-EC and 585 of ESBL-KP were included in the study. Incidence density (ID) for HAI with ESBL-E was 2.74 per 1000 patient days at risk (95% confidence interval (CI) 2.16-3.43) among carriers of ESBL-EC, while it was 4.44 per 1000 patient days at risk (95% CI 3.17-6.04) among carriers of ESBL-KP. In contrast, ID for HAI with other pathogens was 4.36 per 1000 patient days at risk (95% CI 3.62-5.21) among carriers of ESBL-EC, and 5.00 per 1000 patient days at risk (95% CI 3.64-6.69) among carriers of ESBL-KP. Cox proportional hazard regression analyses identified colonization with ESBL-KP (HR = 1.58, 95% CI 1.068-2.325) compared with ESBL-EC as independent risk factor for HAI with ESBL-E. The results were consistent over all competing risk analyses. CONCLUSIONS Clinicians should be aware of the increased risk of ESBL-E infections among patients colonized with ESBL-KP compared with ESBL-EC that might be caused by underlying diseases, higher pathogenicity of ESBL-KP and other factors.
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Affiliation(s)
- L A Denkel
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - F Maechler
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - F Schwab
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - A Kola
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - A Weber
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - P Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - F Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - S Weber
- Institute of Medical Biometry and Statistics (IMBI), Faculty of Medicine and Medical Centre University of Freiburg, Freiburg, Germany
| | - G Werner
- Unit of Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - Y Pfeifer
- Unit of Nosocomial Pathogens and Antibiotic Resistances, Department of Infectious Diseases, Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - M Pietsch
- Unit of Enteropathogenic Bacteria and Legionella, Department of Infectious Diseases, Robert Koch Institute, Wernigerode Branch, Wernigerode, Germany
| | - R Leistner
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; National Reference Centre for the Surveillance of Nosocomial Infections, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.
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Risk stratification and treatment of ICU-acquired pneumonia caused by multidrug- resistant/extensively drug-resistant/pandrug-resistant bacteria. Curr Opin Crit Care 2019; 24:385-393. [PMID: 30156569 DOI: 10.1097/mcc.0000000000000534] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Describe the risk factors and discuss the management of multidrug-resistant (MDR) bacteria responsible for pneumonia among critically ill patients, including methicillin-resistant Staphylococcus aureus, extended spectrum beta-lactamase-producing Enterobactericeae, carbapenem-resistant Enterobactericeae, multidrug resistant Pseudomonas aeruginosa, and Acinetobacter baumannii. RECENT FINDINGS Multiple factors have been associated with infections because of MDR bacteria, including prolonged hospital stay, presence of invasive devices, mechanical ventilation, colonization with resistant pathogens, and use of broad-spectrum antibiotics. Management of these infections includes the prompt use of appropriate antimicrobial therapy, implementation of antimicrobial stewardship protocols, and targeted active microbiology surveillance. Combination therapy and novel molecules have been used for the treatment of severe infections caused by resistant bacteria. SUMMARY The exponential increase of antimicrobial resistance among virulent pathogens currently represents one of the main challenges for clinicians in the intensive care unit. Knowledge of the local epidemiology, patient risk stratification, and infection-control policies remain key elements for the management of MDR infections. Results from clinical trials on new molecules are largely awaited.
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Microbial cause of ICU-acquired pneumonia: hospital-acquired pneumonia versus ventilator-associated pneumonia. Curr Opin Crit Care 2019; 24:332-338. [PMID: 30036192 DOI: 10.1097/mcc.0000000000000526] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Successful treatment of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains a difficult and complex undertaking. Better knowledge of the pathogens involved in that setting may allow reassessment of our current modalities of therapy and definition of better protocols. RECENT FINDINGS Microorganisms responsible for HAP/VAP differ according to geographic areas, ICU patients' specific characteristics, durations of hospital and ICU stays before onset of the disease, and risk factors for MDR pathogens. However, a number of studies have shown that Gram-negative bacilli (GNB) - particularly Pseudomonas aeruginosa and Enterobacteriaceae - cause many of the respiratory infections in this setting, with minimal differences between HAP and VAP, indicating that the cause depends more on the underlying clinical condition of patients rather than previous intubation. SUMMARY When selecting initial antimicrobial therapy in patients with HAP/VAP, more attention should be paid to individual risk factors for MDR pathogens, severity of the clinical situation, and the local epidemiology than to the type of pneumonia.
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Prevel R, Boyer A, M’Zali F, Cockenpot T, Lasheras A, Dubois V, Gruson D. Extended spectrum beta-lactamase producing Enterobacterales faecal carriage in a medical intensive care unit: low rates of cross-transmission and infection. Antimicrob Resist Infect Control 2019; 8:112. [PMID: 31333839 PMCID: PMC6617905 DOI: 10.1186/s13756-019-0572-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Background Extended-spectrum beta-lactamases-producing Enterobacterales (ESBL-E) are disseminating worldwide especially in Intensive Care Units (ICUs) and are responsible for increased health costs and mortality. The aims of this work were to study ESBL-E dissemination in ICU and to assess the impact of ESBL-E fecal carriage on subsequent infections during a non-outbreak situation. Methods We therefore screened every patient at admission then once a week in a medical ICU between January and June 2015. Each ESBL-E isolate was characterized by ESBL genes PCR amplification and the clonal dissemination was assessed by Pulsed-Field Gel Electrophoresis (PFGE). Results Among the 608 screened patients, 55 (9%) were colonized by ESBL-E. Forty-four isolates were available for further analysis. Most of them (43/44, 98%) contained a ESBL gene from the CTX-M group. Only one case of ESBL-E cross-transmission occurred, even for acquired ESBL-E colonization. Subsequent infection by ESBL-E occurred in 6/55 (11%) patients and infecting ESBL-E strains were the colonizing ones. ESBL-E faecal carriage had a negative predictive value of 100% and a positive predictive value of 40% to predict ESBL-E ventilator associated-pneumonia (VAP). Alternatives to carbapenems consisting in piperacillin-tazobactam, ceftolozane-tazobactam and ceftazidime-avibactam were all active on this panel of ESBL-E. Conclusions ESBL-E expansion and acquisition in ICU in a non-outbreak situation are not any more fully explained by cross-transmission. Mechanisms underlying ESBL-E dissemination in ICU are still to investigate. Interestingly, as far as we know, our study demonstrates for the first time by PFGE that the colonizing strain is indeed the infecting one in case of subsequent ESBL-E infection. Nevertheless, subsequent ESBL-E infection remains a rare event conferring poor positive predictive value for ESBL-E colonization to predict ESBL-E VAP. Relevance of systematic ESBL-E faecal screening at ICU admission and during ICU stay needs further investigation.
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Affiliation(s)
- Renaud Prevel
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
| | - Fatima M’Zali
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
| | | | | | - Véronique Dubois
- UMR 5234 CNRS, Bordeaux University, F-33000 Bordeaux, France
- Bacteriology laboratory, CHU Bordeaux, F-33000 Bordeaux, France
| | - Didier Gruson
- Medical Intensive Care Unit, CHU Bordeaux, Pellegrin universitary hospital, Place Amélie Raba-Léon, F-33000 Bordeaux, France
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Prevel R, Boyer A, M'Zali F, Lasheras A, Zahar JR, Rogues AM, Gruson D. Is systematic fecal carriage screening of extended-spectrum beta-lactamase-producing Enterobacteriaceae still useful in intensive care unit: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:170. [PMID: 31088542 PMCID: PMC6518813 DOI: 10.1186/s13054-019-2460-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide leading to increased hospital length of stay and mortality in intensive care units (ICU). ESBL-E dissemination was first due to outbreaks in hospital settings which led to the implementation of systematic fecal carriage screening to improve hygiene procedures by contact precautions. ESBLs have since spread in the community, and the relevance of contact precautions is questioned. ESBL-E dissemination led to an overuse of carbapenems triggering the emergence of carbapenem-resistant Enterobacteriaceae. Empirical antimicrobial therapy based on ESBL-E fecal carriage has been proposed but is debated as it could increase the consumption of carbapenems among ESBL-E carriers without any clinical benefit. Finally, selective decontamination among ESBL-E fecal carriers is evoked to decrease the risk for subsequent ESBL-E infection, but its efficacy remains debated. We propose to systematically review the evidence to recommend or not such systematic ESBL-E fecal carriage screening in adult ICU. METHODS Every article focusing on ESBL-E and ICU available on the MEDLINE database was assessed. Articles were included if focusing on cross-transmission, efficacy of hygiene procedures, link between ESBL-E colonization and infection or guidance of empirical therapy or selective decontamination efficacy. RESULTS Among 330 articles referenced on PubMed, 39 abstracts were selected for full-text assessment and 25 studies were included. Systematic screening of ESBL-E fecal carriage to guide contact precautions do not seem to decrease the rate of ESBL-E cross-transmission. It has a very good negative predictive value for subsequent ESBL-E infections but a positive predictive value between 40 and 50% and so does not help to spare carbapenems. Cessation of ESBL-E carriage systematic screening could decrease the use of carbapenems in ICU without any clinical harm. Nevertheless, further studies are needed to validate these results from monocentric before-after study. Selective decontamination strategy applied to ESBL-E fecal carriers could be helpful, but available data are conflicting. CONCLUSION Current knowledge lacks of high-quality evidence to strongly recommend in favor of or against a systematic ESBL-E fecal carriage screening policy for ICU patients in a non-outbreak situation. Further evaluation of selective decontamination or fecal microbiota transplantation among ESBL-E fecal carriers is needed.
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Affiliation(s)
- Renaud Prevel
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France. .,UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France. .,, Bordeaux, France.
| | - Alexandre Boyer
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
| | - Fatima M'Zali
- UMR 5234 CNRS, Bordeaux University, F-33000, Bordeaux, France
| | - Agnès Lasheras
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France
| | - Jean-Ralph Zahar
- Unité INSERM - IAME UMR 1137, Université Paris-13, Bobigny, France
| | - Anne-Marie Rogues
- Univ. Bordeaux, CHU Bordeaux, Hygiène hospitalière, F-33000, Bordeaux, France.,Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000, Bordeaux, France
| | - Didier Gruson
- CHU Bordeaux, Medical Intensive Care Unit, Pellegrin Hospital, F-33000, Bordeaux, France
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Pilmis B, Zahar JR. Ventilator-associated pneumonia related to ESBL-producing gram negative bacilli. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:424. [PMID: 30581832 DOI: 10.21037/atm.2018.09.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent cause of intensive care unit (ICU) acquired infections. The worldwide spreading of extended spectrum beta-lactamase producing enterobacteriaceae (ESBL-PE) represents a major problem encountered more and more frequently in ICU. Among ICU patients, between 5% to 25% are ESBL-PE carriers. Whereas, previous carriage is the major risk factors associated with VAP related to ESBL-PE, among carriers, only 5% to 20% will develop a VAP related to ESBL-PE. Also, diagnosis and therapeutic delay are associated with length of stay and higher morbidity, and mortality, therefore, early identification of patients at risk of ESBL-PE related infections is crucial for early implementation of effective antibiotic therapy. VAP related to ESBL-PE should be considered in: previous colonized patients in case of late onset pneumonia and/or when several antibiotic courses precede the infectious episode or even in patients with shock. Among non-colonized patients, if VAP occurs, the risk being related to ESBL-PE is less than 1%. In the future, new rapid microbiological diagnostic tests will allow an early diagnosis. According to recent data, empirical antibiotic therapy should be based on carbapenems. Other alternative antibiotic classes could be used for de-escalation. However, several pharmacodynamic and pharmacokinetics precautions should be taken to achieve drug concentrations at site of infection and except to cure the infected patient.
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Affiliation(s)
- Benoit Pilmis
- Antimicrobial Stewardship Team, Hospital Paris Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
| | - Jean-Ralph Zahar
- Department of Microbiology, Hospital Paris Seine Saint Denis, 125 rue de Stalingrad 93000 Bobigny, France.,UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, UFR SMBH, Paris 13, Paris Cité University, Paris, France
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Mascitti H, Duran C, Nemo EM, Bouchand F, Câlin R, Descatha A, Gaillard JL, Lawrence C, Davido B, Barbier F, Dinh A. Factors associated with bacteraemia due to multidrug-resistant organisms among bacteraemic patients with multidrug-resistant organism carriage: a case control study. Antimicrob Resist Infect Control 2018; 7:116. [PMID: 30288256 PMCID: PMC6162938 DOI: 10.1186/s13756-018-0412-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Infections caused by multidrug-resistant organisms (MDRO) are emerging worldwide. Physicians are increasingly faced with the question of whether patients need empiric antibiotic treatment covering these pathogens. This question is especially essential among MDRO carriers. We aim to determine the occurrence of MDRO bacteraemia among bacteraemic patients colonized with MDRO, and the associated factors with MDRO bacteraemia among this population. Methods We performed a retrospective monocentric study among MDRO carriers hospitalized with bacteraemia between January 2013 and August 2016 in a French hospital. We compared characteristics of patients with MDRO and non-MDRO bacteraemia. Results Overall, 368 episodes of bacteraemia were reviewed; 98/368 (26.6%) occurred among MDRO carriers. Main colonizing bacteria were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (40/98; 40.8%), ESBL-producing Klebsiella pneumoniae (35/98; 35.7%); methicillin-resistant Staphylococcus aureus (26/98; 26.5%) and multidrug-resistant Pseudomonas aeruginosa (PA) (12/98; 12.2%). There was no significant difference considering population with MDRO bacteraemia vs. non-MDRO bacteraemia, except for immunosuppression [OR 2.86; p = 0.0207], severity of the episode [OR 3.13; p = 0.0232], carriage of PA [OR 5.24; p = 0.0395], and hospital-acquired infection [OR 2.49; p = 0.034]. In the multivariate analysis, factors significantly associated with MDRO bacteraemia among colonized patient were only immunosuppression [OR = 2.96; p = 0.0354] and the hospital-acquired origin of bacteraemia [OR = 2.62; p = 0.0427]. Conclusions According to our study, occurrence of bacteraemia due to MDRO among MDRO carriers was high. Factors associated with MDRO bacteraemia were severity of the episode and hospital-acquired origin of the bacteraemia. Thus, during bacteraemia among patients colonized with MDRO, if such characteristics are present, broad-spectrum antimicrobial treatment is recommended.
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Affiliation(s)
- Hélène Mascitti
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Clara Duran
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Elisabeth-Marie Nemo
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Frédérique Bouchand
- 2Pharmacy department, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Ruxandra Câlin
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Alexis Descatha
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Jean-Louis Gaillard
- 3Microbiological laboratory, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Christine Lawrence
- 3Microbiological laboratory, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - Benjamin Davido
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
| | - François Barbier
- Intensive care unit, Orléans Hospital, 14 Avenue de l'Hôpital, 45067 Orléans, France
| | - Aurélien Dinh
- 1Infectious disease unit, Raymond Poincaré University Hospital, AP-HP, Versailles Saint-Quentin University, 104 Bd R. Poincaré, 92380 Garches, France
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Barbier F, Bailly S, Schwebel C, Papazian L, Azoulay É, Kallel H, Siami S, Argaud L, Marcotte G, Misset B, Reignier J, Darmon M, Zahar JR, Goldgran-Toledano D, de Montmollin É, Souweine B, Mourvillier B, Timsit JF. Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae. Intensive Care Med 2018; 44:616-626. [PMID: 29663045 DOI: 10.1007/s00134-018-5154-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/27/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE). METHODS Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997-2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration > 48 h and ≥ 1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented. RESULTS The 318 enrolled ESBLE carriers (median age 68 years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3 days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05-0.6; P < 0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P = 0.43). CONCLUSIONS IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.
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Affiliation(s)
| | - Sébastien Bailly
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, Paris Diderot, Sorbonne Paris Cité University, Paris, France
| | - Carole Schwebel
- Medical ICU, Albert Michallon University Hospital, Grenoble, France
| | - Laurent Papazian
- Respiratory and Infectious Diseases ICU, North Hospital, Marseille, France
| | - Élie Azoulay
- Medical ICU, Saint-Louis Hospital, APHP, Paris, France
| | - Hatem Kallel
- Medical Surgical ICU, Andrée Rosemon Hospital, Cayenne, France
| | - Shidasp Siami
- Medical Surgical ICU, Corbeil-Essone Hospital, Corbeil-Essone, France
| | - Laurent Argaud
- Medical ICU, Edouard-Herriot University Hospital, Lyon, France
| | | | - Benoît Misset
- Medical ICU, Charles Nicolle University Hospital, Rouen, France
| | - Jean Reignier
- Medical ICU, Hôtel-Dieu University Hospital, Nantes, France
| | | | | | | | | | | | - Bruno Mourvillier
- Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France
| | - Jean-François Timsit
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, Paris Diderot, Sorbonne Paris Cité University, Paris, France. .,Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
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Abstract
Appropriate antimicrobial therapy is essential to ensuring positive patient outcomes. Inappropriate or suboptimal utilization of antibiotics can lead to increased length of stay, multidrug-resistant infections, and mortality. Critically ill intensive care patients, particularly those with severe sepsis and septic shock, are at risk of antibiotic failure and secondary infections associated with incorrect antibiotic use. Through the initiation of active empiric antibiotic therapy based upon local susceptibilities, daily evaluation of signs and symptoms of infection and narrowing of antibiotic therapy when feasible, providers can streamline the treatment of common intensive care unit (ICU) infections. Optimizing antibiotic dosing through prolonged infusions can be beneficial in intensive care populations with altered pharmacokinetics. Antimicrobial stewardship teams can assist ICU providers in managing and implementing these tactics. This review will discuss the current literature on antibiotic use in the ICU applying antimicrobial stewardship strategies. Based upon the most recent evidence, ICUs would benefit from employing empiric guidelines for antibiotic use, collecting appropriate specimens and implementing molecular diagnostics, optimizing the dosing of antibiotics, and reducing the duration of total therapy. These strategies for antibiotic use have the potential to enhance patient care while preventing adverse outcomes.
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Affiliation(s)
- Maureen Campion
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gail Scully
- 1 Division of Infectious Disease, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
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