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Gohil SK, Septimus E, Kleinman K, Varma N, Avery TR, Heim L, Rahm R, Cooper WS, Cooper M, McLean LE, Nickolay NG, Weinstein RA, Burgess LH, Coady MH, Rosen E, Sljivo S, Sands KE, Moody J, Vigeant J, Rashid S, Gilbert RF, Smith KN, Carver B, Poland RE, Hickok J, Sturdevant SG, Calderwood MS, Weiland A, Kubiak DW, Reddy S, Neuhauser MM, Srinivasan A, Jernigan JA, Hayden MK, Gowda A, Eibensteiner K, Wolf R, Perlin JB, Platt R, Huang SS. Stewardship Prompts to Improve Antibiotic Selection for Urinary Tract Infection: The INSPIRE Randomized Clinical Trial. JAMA 2024; 331:2018-2028. [PMID: 38639723 PMCID: PMC11185978 DOI: 10.1001/jama.2024.6259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/27/2024] [Indexed: 04/20/2024]
Abstract
Importance Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). Interventions CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration ClinicalTrials.gov Identifier: NCT03697096.
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Affiliation(s)
- Shruti K. Gohil
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Edward Septimus
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Ken Kleinman
- Biostatistics and Epidemiology, University of Massachusetts, Amherst
| | - Neha Varma
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Taliser R. Avery
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Lauren Heim
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Risa Rahm
- HCA Healthcare, Nashville, Tennessee
| | | | | | | | | | | | | | - Micaela H. Coady
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Edward Rosen
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Selsebil Sljivo
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Kenneth E. Sands
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | - Justin Vigeant
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Syma Rashid
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | - Rebecca F. Gilbert
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | | | - Russell E. Poland
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
- HCA Healthcare, Nashville, Tennessee
| | | | | | - Michael S. Calderwood
- Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anastasiia Weiland
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
| | | | - Sujan Reddy
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | - Abinav Gowda
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Robert Wolf
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jonathan B. Perlin
- HCA Healthcare, Nashville, Tennessee
- Now with The Joint Commission, Oakbrook Terrace, Illinois
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Susan S. Huang
- Division of Infectious Diseases, University of California, Irvine School of Medicine, Irvine
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Kang AY, Elkomos M, Pham D, Guerrero M, Kupferwasser D, Miller LG. Effectiveness of empiric carbapenem versus non-carbapenem therapy for extended-spectrum β-lactamase producing Enterobacterales infections in non-intensive care unit patients: a real-world investigation in a hospital with high-prevalence of extended-spectrum β-lactamase producing Enterobacterales. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e100. [PMID: 38836043 PMCID: PMC11149041 DOI: 10.1017/ash.2024.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 06/06/2024]
Abstract
Objective To investigate whether empiric carbapenem therapy, compared to empiric non-carbapenem therapy, was associated with improved clinical outcomes among hospitalized, non-intensive care unit (ICU) patients with extended-spectrum β-lactamase (ESBL)-producing Enterobacterales infections. Methods We performed a retrospective cohort study of adult, non-ICU patients admitted with ESBL-producing Enterobacterales infections. Primary outcome was time to clinical stability from the first empiric antibiotic dose. Secondary outcomes were early clinical response and 30-day all-cause hospital readmission. We used multivariate regression methods to examine time to clinical stability. Results Of the 142 patients, 59 (42%) received empiric carbapenems and 83 (58%) received empiric non-carbapenems, most commonly ceftriaxone (49/83, 59%). Median age was 59 years. The most common infection source was urinary (71%). The carbapenem group had a higher proportion of patients who received antibiotics within 6 months of admission (55% vs 28%, P < .01) and history of ESBL (57% vs 17%, P < .01). There were no significant differences in hours until clinical stability between the carbapenem and non-carbapenem groups (22 (IQR: 0, 85) vs 19 (IQR: 0, 69), P = .54). Early clinical response (88% vs 90%, P = .79) and 30-day all-cause hospital readmission (17% vs 8%, P = .13) were similar between groups. Conclusion Among hospitalized non-ICU patients with ESBL-producing Enterobacterales infection, we found no difference in time to clinical stability after the first empiric antibiotic dose between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-producing Enterobacterales infection.
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Affiliation(s)
- Amy Y Kang
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, USA
- Department of Pharmacy, Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Mary Elkomos
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, USA
| | - Danny Pham
- Department of Pharmacy, University of California Irvine Health, Orange, CA, USA
| | - Michelle Guerrero
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Deborah Kupferwasser
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Loren G Miller
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Infectious Diseases, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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Avendano EE, Blackmon SA, Nirmala N, Chan CW, Morin RA, Balaji S, McNulty L, Argaw SA, Doron S, Nadimpalli ML. Race and ethnicity as risk factors for colonization and infection with key bacterial pathogens: a scoping review. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.24.24306289. [PMID: 38712055 PMCID: PMC11071560 DOI: 10.1101/2024.04.24.24306289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Racial and ethnic disparities in infectious disease burden have been reported in the USA and globally, most recently for COVID-19. It remains unclear whether such disparities also exist for priority bacterial pathogens that are increasingly antibiotic-resistant. We conducted a scoping review to summarize published studies that report on colonization or community-acquired infection with pathogens among different races and ethnicities. Methods We conducted an electronic literature search of MEDLINE®, Daily, Global Health, Embase, Cochrane Central, and Web of Science from inception to January 2022 for eligible observational studies. Abstracts and full-text publications were screened in duplicate for studies that reported data for race or ethnicity for at least one of the pathogens of interest. Results Fifty-four observational studies in 59 publications met our inclusion criteria. Studies reported results for Enterobacterales, Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus, and were conducted in Australia, Brazil, Israel, New Zealand, and USA. USA studies most often examined Black and Hispanic minority groups with studies regularly reporting a higher risk of these pathogens in Black persons and mixed results for Hispanic persons. Ethnic minority groups (e.g. Bedouins in Israel, Aboriginals in Australia) were often reported to be at a higher risk in other countries. Conclusion Sufficient evidence was identified in this scoping review justifying future systematic reviews and meta-analyses evaluating the relationship between community-acquired pathogens and race and ethnicity. However, we noted that only a fraction of studies reported data stratified by race and ethnicity, highlighting a substantial gap in the literature.
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Affiliation(s)
| | - Sarah Addison Blackmon
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Nanguneri Nirmala
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Courtney W. Chan
- University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Rebecca A. Morin
- Hirsh Health Sciences Library, Tufts University, Boston, MA, USA
| | - Sweta Balaji
- Department of Quantitative Theory and Methods, Emory University, Atlanta, GA
| | - Lily McNulty
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Samson Alemu Argaw
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Shira Doron
- Division of Geographic Medicine and Infectious Disease, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance (Levy CIMAR), Tufts University, Boston, MA, USA
| | - Maya L. Nadimpalli
- Stuart B. Levy Center for Integrated Management of Antimicrobial Resistance (Levy CIMAR), Tufts University, Boston, MA, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Shawa M, Paudel A, Chambaro H, Kamboyi H, Nakazwe R, Alutuli L, Zorigt T, Sinyawa T, Samutela M, Chizimu J, Simbotwe M, Hayashida K, Nao N, Kajihara M, Furuta Y, Suzuki Y, Sawa H, Hang’ombe B, Higashi H. Trends, patterns and relationship of antimicrobial use and resistance in bacterial isolates tested between 2015-2020 in a national referral hospital of Zambia. PLoS One 2024; 19:e0302053. [PMID: 38625961 PMCID: PMC11020921 DOI: 10.1371/journal.pone.0302053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/27/2024] [Indexed: 04/18/2024] Open
Abstract
Increased antimicrobial resistance (AMR) among bacteria underscores the need to strengthen AMR surveillance and promote data-based prescribing. To evaluate trends and associations between antimicrobial usage (AMU) and AMR, we explored a dataset of 34,672 bacterial isolates collected between 2015 and 2020 from clinical samples at the University Teaching Hospital (UTH) in Lusaka, Zambia. The most frequently isolated species were Escherichia coli (4,986/34,672; 14.4%), Staphylococcus aureus (3,941/34,672; 11.4%), and Klebsiella pneumoniae (3,796/34,672; 10.9%). Of the 16 drugs (eight classes) tested, only amikacin and imipenem showed good (> 50%) antimicrobial activity against both E. coli and K. pneumoniae, while nitrofurantoin was effective only in E. coli. Furthermore, 38.8% (1,934/4,980) of E. coli and 52.4% (2,079/3,791) of K. pneumoniae isolates displayed multidrug resistance (MDR) patterns on antimicrobial susceptibility tests. Among S. aureus isolates, 44.6% (973/2,181) were classified as methicillin-resistant (MRSA). Notably, all the MRSA exhibited MDR patterns. The annual hospital AMR rates varied over time, while there was a weak positive relationship (r = 0.38, 95% CI = 0.11-0.60) between the monthly use of third-generation cephalosporins (3GCs) and 3GC resistance among Enterobacterales. Overall, the results revealed high AMR rates that fluctuated over time, with a weak positive relationship between 3GC use and resistance. To our knowledge, this is the first report to evaluate the association between AMU and AMR in Zambia. Our results highlight the need to strengthen antimicrobial stewardship programs and optimize AMU in hospital settings.
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Affiliation(s)
- Misheck Shawa
- Hokudai Center for Zoonosis Control in Zambia, Hokkaido University, Lusaka, Zambia
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
| | - Atmika Paudel
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
- GenEndeavor LLC, Hayward, CA, United States of America
| | - Herman Chambaro
- Central Veterinary Research Institute, Ministry of Fisheries and Livestock, Lusaka, Zambia
| | - Harvey Kamboyi
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
| | - Ruth Nakazwe
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Luke Alutuli
- Department of Pharmacy, University Teaching Hospital, Lusaka, Zambia
| | - Tuvshinzaya Zorigt
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
| | - Taona Sinyawa
- Central Veterinary Research Institute, Ministry of Fisheries and Livestock, Lusaka, Zambia
| | - Mulemba Samutela
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Joseph Chizimu
- Zambia National Public Health Institute, Ministry of Health, Lusaka, Zambia
| | - Manyando Simbotwe
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Kyoko Hayashida
- Division of Collaboration and Education, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Naganori Nao
- Hokudai Center for Zoonosis Control in Zambia, Hokkaido University, Lusaka, Zambia
- Division of International Research Promotion, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- One Health Research Center, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Masahiro Kajihara
- Hokudai Center for Zoonosis Control in Zambia, Hokkaido University, Lusaka, Zambia
- Division of International Research Promotion, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Yoshikazu Furuta
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
- Toyota Central R&D Labs., Inc., Nagakute, Japan
| | - Yasuhiko Suzuki
- Division of Bioresources, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- International Collaboration Unit, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- Institute for Vaccine Research and Development (HU-IVReD), Hokkaido University, Kita-ku, Sapporo, Japan
| | - Hirofumi Sawa
- Hokudai Center for Zoonosis Control in Zambia, Hokkaido University, Lusaka, Zambia
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
- Division of International Research Promotion, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- One Health Research Center, Hokkaido University, Kita-ku, Sapporo, Japan
- Division of Bioresources, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- International Collaboration Unit, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
- Institute for Vaccine Research and Development (HU-IVReD), Hokkaido University, Kita-ku, Sapporo, Japan
- Division of Molecular Pathobiology, International Institute for Zoonosis Control, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Bernard Hang’ombe
- Africa Centre of Excellence for Infectious Diseases of Humans and Animals, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
- Department of Para-clinical Studies, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Hideaki Higashi
- Division of Infection and Immunity, International Institute for Zoonosis Control, Hokkaido University, Sapporo, Japan
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Park KS, Kim DR, Baek JY, Shin A, Kim KR, Park H, Son S, Cho H, Kim YJ. Susceptibility to Fosfomycin and Nitrofurantoin of ESBL-Positive Escherichia coli and Klebsiella pneumoniae Isolated From Urine of Pediatric Patients. J Korean Med Sci 2023; 38:e361. [PMID: 38084025 PMCID: PMC10713444 DOI: 10.3346/jkms.2023.38.e361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/14/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Pediatric urinary tract infection (UTI) caused by extended-spectrum β-lactamase (ESBL)-positive gram-negative bacilli (GNB) has limited options for oral antibiotic treatment. The purpose of this study was to investigate the susceptibility of ESBL-positive Escherichia coli and Klebsiella pneumoniae isolates from pediatric urine samples to two oral antibiotics (fosfomycin and nitrofurantoin). METHODS From November 2020 to April 2022, ESBL-positive E. coli and K. pneumoniae isolates from urine samples were collected at Samsung Medical Center, Seoul, Korea. Patients over 18 years of age or with malignancy were excluded. For repeated isolates from the same patient, only the first isolate was tested. Minimum inhibitory concentrations (MICs) were measured using agar (fosfomycin) or broth (nitrofurantoin) dilution methods. MIC50 and MIC90 were measured for fosfomycin and nitrofurantoin in both E. coli and K. pneumoniae. RESULTS There were 117 isolates from 117 patients, with a median age of 7 months (range, 0.0-18.5 years). Among 117 isolates, 92.3% (108/117) were E. coli and 7.7% (9/117) were K. pneumoniae. Isolates from the pediatric intensive care unit (PICU) and general ward (GW) was 11.1% (13/117) and 88.9% (104/117), respectively. Among 108 E. coli isolates, MIC50 and MIC90 for fosfomycin were 0.5 μg/mL and 2 μg/mL, respectively. Fosfomycin susceptibility rate was 97.2% (105/108) with a breakpoint of 128 μg/mL. Fosfomycin susceptibility rate was significantly lower in PICU isolates than in GW isolates (81.8% vs. 99.0%, P = 0.027). For nitrofurantoin, both the MIC50 and MIC90 were 16 μg/mL. Nitrofurantoin susceptibility rate was 96.3% (104/108) with a breakpoint of 64 μg/mL based on Clinical and Laboratory Standards Institute guidelines. Among the nine K. pneumoniae isolates, the MIC50 and MIC90 for fosfomycin was 2 μg/mL and 32 μg/mL, respectively. MIC50 and MIC90 for nitrofurantoin were 64 μg/mL and 128 μg/mL, respectively. CONCLUSION For uncomplicated UTI caused by ESBL-positive GNB in Korean children, treatment with fosfomycin and nitrofurantoin for E. coli infections can be considered as an effective oral therapy option.
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Affiliation(s)
- Ki-Sup Park
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
- Planning Team, SML Genetree, Seoul, Korea
| | - Doo Ri Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Yang Baek
- Asia Pacific Foundation for Infectious Diseases (APFID), Seoul, Korea
| | - Areum Shin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Ran Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Hwanhee Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sohee Son
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.
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Rupp M, Walter N, Baertl S, Lang S, Herbst T, Hitzenbichler F, Alt V. Antibiotic Prophylaxis and Empirical Antibiotic Therapy in Primary Arthroplasty and Periprosthetic Joint Infections: Current Practice and Need for Therapy Optimization. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:654-659. [PMID: 35468647 DOI: 10.1055/a-1773-1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of the present work was to survey the situation of healthcare regarding the use of prophylactic and empirical antibiotics in primary arthroplasty and treatment of periprosthetic joint infections (PJI). For this purpose, a survey was conducted at German university and occupational accident hospitals. Survey data was compared to previously published data on the antimicrobial regimes of PJI (n=81) patients (n=81) treated in our department between 2017 and 2020. A homogeneous picture emerged for the prophylactic administration of antibiotics in the context of primary arthroplasty. In 93.2% (elective) and 88.6% (fracture treatment) of the hospitals, first or second generation cephalosporins were administered perioperatively for infection prophylaxis in primary hip arthroplasty. The empirical antibiotic treatment of PJIs showed a clearly inhomogeneous therapeutic picture. Monotherapy with an aminopenicillin plus a beta-lactamase inhibitor is used most frequently (38.7%); first and second generation cephalosporins are used second most frequently as monotherapy (18.2%). In light of the global problem of antibiotic multi-resistance, clinical use of antibiotics has to be reasonable and effective. The present results highlight the further need to improve awareness and following existing guidelines in the administration of empirical antibiotic therapy in PJI.
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Affiliation(s)
- Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Nike Walter
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Susanne Baertl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Siegmund Lang
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Tanja Herbst
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Florian Hitzenbichler
- Abteilung für Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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7
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Menck-Costa MF, Baptista AAS, Sanches MS, dos Santos BQ, Cicero CE, Kitagawa HY, Justino L, Medeiros LP, de Souza M, Rocha SPD, Nakazato G, Kobayashi RKT. Resistance and Virulence Surveillance in Escherichia coli Isolated from Commercial Meat Samples: A One Health Approach. Microorganisms 2023; 11:2712. [PMID: 38004724 PMCID: PMC10672981 DOI: 10.3390/microorganisms11112712] [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: 10/13/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
Escherichia coli is a key indicator of food hygiene, and its monitoring in meat samples points to the potential presence of antimicrobial-resistant strains capable of causing infections in humans, encompassing resistance profiles categorized as serious threats by the Centers for Disease Control and Prevention (CDC), such as Extended-Spectrum Beta-Lactamase (ESBL)-a problem with consequences for animal, human, and environmental health. The objective of the present work was to isolate and characterize ESBL-producing E. coli strains from poultry, pork, and beef meat samples, with a characterization of their virulence and antimicrobial resistance profiles. A total of 450 meat samples (150 chicken, 150 beef, and 150 pork) were obtained from supermarkets and subsequently cultured in medium supplemented with cefotaxime. The isolated colonies were characterized biochemically, followed by antibiogram testing using the disk diffusion technique. Further classification involved biofilm formation and the presence of antimicrobial resistance genes (blaCTX-M, AmpC-type, mcr-1, and fosA3), and virulence genes (eaeA, st, bfpA, lt, stx1, stx2, aggR, iss, ompT, hlyF, iutA, iroN, fyuA, cvaC, and hylA). Statistical analysis was performed via the likelihood-ratio test. In total, 168 strains were obtained, with 73% originating from chicken, 22% from pork, and 17% from beef samples. Notably, strains exhibited greater resistance to tetracycline (51%), ciprofloxacin (46%), and fosfomycin (38%), apart from β-lactams. The detection of antimicrobial resistance in food-isolated strains is noteworthy, underscoring the significance of antimicrobial resistance as a global concern. More than 90% of the strains were biofilm producers, and strains carrying many ExPEC genes were more likely to be biofilm formers (OR 2.42), which increases the problem since the microorganisms have a greater chance of environment persistence and genetic exchange. Regarding molecular characterization, bovine samples showed a higher prevalence of blaCTX-M-1 (OR 6.52), while chicken strains were more likely to carry the fosA3 gene (OR 2.43, CI 1.17-5.05) and presented between 6 to 8 ExPEC genes (OR 2.5, CI 1.33-5.01) compared to other meat samples. Concerning diarrheagenic E. coli genes, two strains harbored eae. It is important to highlight these strains, as they exhibited both biofilm-forming capacities and multidrug resistance (MDR), potentially enabling colonization in diverse environments and causing infections. In conclusion, this study underscores the presence of β-lactamase-producing E. coli strains, mainly in poultry samples, compared to beef and pork samples. Furthermore, all meat sample strains exhibited many virulence-associated extraintestinal genes, with some strains harboring diarrheagenic E. coli (DEC) genes.
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Affiliation(s)
- Maísa Fabiana Menck-Costa
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Ana Angelita Sampaio Baptista
- Department of Preventive Veterinary Medicine, Center for Agricultural Sciences (CCA), State University of Londrina (UEL), Londrina 86057-970, Brazil; (A.A.S.B.); (B.Q.d.S.); (C.E.C.); (L.J.); (M.d.S.)
| | - Matheus Silva Sanches
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Beatriz Queiroz dos Santos
- Department of Preventive Veterinary Medicine, Center for Agricultural Sciences (CCA), State University of Londrina (UEL), Londrina 86057-970, Brazil; (A.A.S.B.); (B.Q.d.S.); (C.E.C.); (L.J.); (M.d.S.)
| | - Claudinéia Emidio Cicero
- Department of Preventive Veterinary Medicine, Center for Agricultural Sciences (CCA), State University of Londrina (UEL), Londrina 86057-970, Brazil; (A.A.S.B.); (B.Q.d.S.); (C.E.C.); (L.J.); (M.d.S.)
| | - Hellen Yukari Kitagawa
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Larissa Justino
- Department of Preventive Veterinary Medicine, Center for Agricultural Sciences (CCA), State University of Londrina (UEL), Londrina 86057-970, Brazil; (A.A.S.B.); (B.Q.d.S.); (C.E.C.); (L.J.); (M.d.S.)
| | - Leonardo Pinto Medeiros
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Marielen de Souza
- Department of Preventive Veterinary Medicine, Center for Agricultural Sciences (CCA), State University of Londrina (UEL), Londrina 86057-970, Brazil; (A.A.S.B.); (B.Q.d.S.); (C.E.C.); (L.J.); (M.d.S.)
| | - Sergio Paulo Dejato Rocha
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Gerson Nakazato
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
| | - Renata Katsuko Takayama Kobayashi
- Department of Microbiology, Center for Biological Science (CCB), State University of Londrina (UEL), Londrina 86057-970, Brazil; (M.F.M.-C.); (M.S.S.); (H.Y.K.); (L.P.M.); (S.P.D.R.); (G.N.)
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Ilmavirta H, Ollgren J, Räisänen K, Kinnunen T, Hakanen AJ, Jalava J, Lyytikäinen O. Increasing proportions of extended-spectrum β-lactamase-producing isolates among Escherichia coli from urine and bloodstream infections: results from a nationwide surveillance network, Finland, 2008 to 2019. Euro Surveill 2023; 28:2200934. [PMID: 37883040 PMCID: PMC10604539 DOI: 10.2807/1560-7917.es.2023.28.43.2200934] [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: 12/08/2022] [Accepted: 05/09/2023] [Indexed: 10/27/2023] Open
Abstract
BackgroundEscherichia coli is the leading cause of urinary tract infections (UTI) and bloodstream infections (BSI), and the emergence of antimicrobial resistance (AMR) in E. coli causes concern.AimTo investigate changes in the proportion of extended-spectrum β-lactamase (ESBL) producing isolates among E. coli isolated from urine and blood in Finland during 2008-2019.MethodsSusceptibility testing of 1,568,488 urine (90% female, 10% male) and 47,927 blood E. coli isolates (61% female, 39% male) from all Finnish clinical microbiology laboratories during 2008-2019 was performed according to guidelines from the Clinical and Laboratory Standard Institute during 2008-2010 and the European Committee on Antimicrobial Susceptibility Testing during 2011-2019. A binomial regression model with log link compared observed trends over time and by age group and sex.ResultsThe annual proportion of ESBL-producing E. coli isolates among E. coli from blood cultures increased from 2.4% (23/966) to 8.6% (190/2,197) among males (average annual increase 7.7%; 95% CI: 4.4-11.0%, p < 0.01) and from 1.6% (28/1,806) to 6.4% (207/3,218) among females (9.3%; 95% CI: 4.8-14.0%, p < 0.01). In urine cultures, the proportion of ESBL-producing E. coli isolates increased from 2.2% (239/10,806) to 7.2% (1,098/15,297) among males (8.8%; 95% CI: 6.5-11.3%, p < 0.01) and from 1.0% (1,045/108,390) to 3.1% (3,717/120,671) among females (8.6%; 95% CI: 6.3-11.0%, p < 0.01). A significant increase was observed within most age groups.ConclusionsConsidering the ageing population and their risk of E. coli BSI and UTI, the increase in the annual proportions of ESBL-producing E. coli is concerning, and these increasing trends should be carefully monitored.
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Affiliation(s)
- Heikki Ilmavirta
- University of Eastern Finland (UEF), Kuopio, Finland
- ISLAB Laboratory Centre, Kuopio, Finland
- Department of health security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Jukka Ollgren
- Department of health security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Kati Räisänen
- Department of health security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Tuure Kinnunen
- University of Eastern Finland (UEF), Kuopio, Finland
- ISLAB Laboratory Centre, Kuopio, Finland
| | - Antti J Hakanen
- Tyks Laboratories, Turku University Hospital (TYKS) and University of Turku (UTU), Turku, Finland
| | - Jari Jalava
- Department of health security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Outi Lyytikäinen
- Department of health security, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
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9
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Dwiyanto J, Huët MAL, Hussain MH, Su TT, Tan JBL, Toh KY, Lee JWJ, Rahman S, Chong CW. Social demographics determinants for resistome and microbiome variation of a multiethnic community in Southern Malaysia. NPJ Biofilms Microbiomes 2023; 9:55. [PMID: 37573460 PMCID: PMC10423249 DOI: 10.1038/s41522-023-00425-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 08/03/2023] [Indexed: 08/14/2023] Open
Abstract
The prevalence of antibiotic-resistant bacteria in Southeast Asia is a significant concern, yet there is limited research on the gut resistome and its correlation with lifestyle and environmental factors in the region. This study aimed to profile the gut resistome of 200 individuals in Malaysia using shotgun metagenomic sequencing and investigate its association with questionnaire data comprising demographic and lifestyle variables. A total of 1038 antibiotic resistance genes from 26 classes were detected with a mean carriage rate of 1.74 ± 1.18 gene copies per cell per person. Correlation analysis identified 14 environmental factors, including hygiene habits, health parameters, and intestinal colonization, that were significantly associated with the resistome (adjusted multivariate PERMANOVA, p < 0.05). Notably, individuals with positive yeast cultures exhibited a reduced copy number of 15 antibiotic resistance genes. Network analysis highlighted Escherichia coli as a major resistome network hub, with a positive correlation to 36 antibiotic-resistance genes. Our findings suggest that E. coli may play a pivotal role in shaping the resistome dynamics in Segamat, Malaysia, and its abundance is strongly associated with the community's health and lifestyle habits. Furthermore, the presence of yeast appears to be associated with the suppression of antibiotic-resistance genes.
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Affiliation(s)
- J Dwiyanto
- AMILI, Singapore, 118261, Singapore.
- Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia.
| | - M A L Huët
- Faculty of Science, University of Mauritius, Reduit, 80837, Mauritius
| | - M H Hussain
- School of Science, Monash University Malaysia, Bandar Sunway, 47500, Malaysia
| | - T T Su
- South East Asia Community Observatory, Segamat, 85000, Malaysia
| | - J B L Tan
- School of Science, Monash University Malaysia, Bandar Sunway, 47500, Malaysia
| | - K Y Toh
- AMILI, Singapore, 118261, Singapore
| | - J W J Lee
- AMILI, Singapore, 118261, Singapore
- Department of Medicine, National University Hospital, Singapore, 119228, Singapore
| | - S Rahman
- School of Science, Monash University Malaysia, Bandar Sunway, 47500, Malaysia
- Tropical Medicine and Biology Platform, Monash University Malaysia, Bandar Sunway, 47500, Malaysia
| | - C W Chong
- AMILI, Singapore, 118261, Singapore.
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, 47500, Malaysia.
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10
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Lodise TP, Chen LH, Wei R, Im TM, Contreras R, Bruxvoort KJ, Rodriguez M, Friedrich L, Tartof SY. Clinical Risk Scores to Predict Nonsusceptibility to Trimethoprim-Sulfamethoxazole, Fluoroquinolone, Nitrofurantoin, and Third-Generation Cephalosporin Among Adult Outpatient Episodes of Complicated Urinary Tract Infection. Open Forum Infect Dis 2023; 10:ofad319. [PMID: 37534299 PMCID: PMC10390854 DOI: 10.1093/ofid/ofad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023] Open
Abstract
Background Clinical risk scores were developed to estimate the risk of adult outpatients having a complicated urinary tract infection (cUTI) that was nonsusceptible to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone, nitrofurantoin, or third-generation cephalosporin (3-GC) based on variables available on clinical presentation. Methods A retrospective cohort study (1 December 2017-31 December 2020) was performed among adult members of Kaiser Permanente Southern California with an outpatient cUTI. Separate risk scores were developed for TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC. The models were translated into risk scores to quantify the likelihood of nonsusceptibility based on the presence of final model covariates in a given cUTI outpatient. Results A total of 30 450 cUTIs (26 326 patients) met the study criteria. Rates of nonsusceptibility to TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC were 37%, 20%, 27%, and 24%, respectively. Receipt of prior antibiotics was the most important predictor across all models. The risk of nonsusceptibility in the TMP-SMX model exceeded 20% in the absence of any risk factors, suggesting that empiric use of TMP-SMX may not be advisable. For fluoroquinolone, nitrofurantoin, and 3-GC, clinical risk scores of 10, 7, and 11 predicted a ≥20% estimated probability of nonsusceptibility in the models that included cumulative number of prior antibiotics at model entry. This finding suggests that caution should be used when considering these agents empirically in patients who have several risk factors present in a given model at presentation. Conclusions We developed high-performing parsimonious risk scores to facilitate empiric treatment selection for adult outpatients with cUTIs in the critical period between infection presentation and availability of susceptibility results.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Lie Hong Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Theresa M Im
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Richard Contreras
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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11
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Ku JH, Bruxvoort KJ, Salas SB, Varley CD, Casey JA, Raphael E, Robinson SC, Nachman KE, Lewin BJ, Contreras R, Wei RX, Pomichowski ME, Takhar HS, Tartof SY. Multidrug Resistance of Escherichia coli From Outpatient Uncomplicated Urinary Tract Infections in a Large United States Integrated Healthcare Organization. Open Forum Infect Dis 2023; 10:ofad287. [PMID: 37426945 PMCID: PMC10326677 DOI: 10.1093/ofid/ofad287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 07/11/2023] Open
Abstract
Background Urinary tract infections (UTIs) cause significant disease and economic burden. Uncomplicated UTIs (uUTIs) occur in otherwise healthy individuals without underlying structural abnormalities, with uropathogenic Escherichia coli (UPEC) accounting for 80% of cases. With recent transitions in healthcare toward virtual visits, data on multidrug resistance (MDR) (resistant to ≥3 antibiotic classes) by care setting are needed to inform empiric treatment decision making. Methods We evaluated UPEC resistance over time by care setting (in-person vs virtual), in adults who received outpatient care for uUTI at Kaiser Permanente Southern California between January 2016 and December 2021. Results We included 174 185 individuals who had ≥1 UPEC uUTI (233 974 isolates) (92% female, 46% Hispanic, mean age 52 years [standard deviation 20]). Overall, prevalence of UPEC MDR decreased during the study period (13% to 12%) both in virtual and in-person settings (P for trend <.001). Resistance to penicillins overall (29%), coresistance to penicillins and trimethoprim-sulfamethoxazole (TMP-SMX) (12%), and MDR involving the 2 plus ≥1 antibiotic class were common (10%). Resistance to 1, 2, 3, and 4 antibiotic classes was found in 19%, 18%, 8%, and 4% of isolates, respectively; 1% were resistant to ≥5 antibiotic classes, and 50% were resistant to none. Similar resistance patterns were observed over time and by care setting. Conclusions We observed a slight decrease in both class-specific antimicrobial resistance and MDR of UPEC overall, most commonly involving penicillins and TMP-SMX. Resistance patterns were consistent over time and similar in both in-person and virtual settings. Virtual healthcare may expand access to UTI care.
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Affiliation(s)
- Jennifer H Ku
- Correspondence: Jennifer H. Ku, PhD, MPH, Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, 2nd Floor, Pasadena, CA 91101 ()
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - S Bianca Salas
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Cara D Varley
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Oregon Health & Science University-Portland State University, School of Public Health, Portland, Oregon, USA
| | - Joan A Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, Washington, USA
| | - Eva Raphael
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sarah C Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Keeve E Nachman
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruno J Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Kaiser Permanente Southern California and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rong X Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Magdalena E Pomichowski
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Harpreet S Takhar
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Djim-Adjim-Ngana K, Mbiakop BW, Oumar LA, Munshili Njifon HL, Tchinda Fossi C, Enyegue ELE, Mouiche Mouliom MM, Fodouop Chegaing SP, Deweerdt L, Yanou NN, Nguinkal JA. Phenotypic characterization and epidemiology of extended-spectrum β-lactamase-producing Enterobacteriaceae strains from urinary tract infections in Garoua, Cameroon. Front Public Health 2023; 11:1187934. [PMID: 37457273 PMCID: PMC10343957 DOI: 10.3389/fpubh.2023.1187934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background and objectives The emergence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) is causing increased morbidity and mortality around the world as a result of therapeutic failures. ESBL-E are priority pathogens due to their multidrug resistance (MDR). In Northern Cameroon, ESBL-producing bacteria, particularly in urinary tract infections (UTIs), are being increasingly isolated. This study aimed to retrospectively determine the prevalence of multi-drug resistant ESBL strains isolated from UTIs in Northern Cameroon and to evaluate the effectiveness of the ATB UR Gallery of BioMérieux in diagnosing ESBL-E in clinical settings. Methods Standard microbiology protocols and statistical tools were utilized to identify ESBL-producing bacteria and characterize their phenotypic susceptibility and resistance profiles in the study population. Results Out of the 144 enterobacteria isolates successfully cultured, 59 (41%) were identified as MDR strains. The ATB UR EU gallery identified 33 (23%) multi-drug resistant ESBL-producing strains, while the double synergy test identified 35 strains without disc reconciliation and 38 strains after reconciliation. The most prevalent ESBL-E isolate was Escherichia coli, accounting for 77.1% of the isolates, followed by Klebsiella pneumoniae (20%) and Enterobacter aerogenes (2.9%). Additionally, the study revealed the emergence of Imipenem resistance (5.7%), a critical last-resort antibiotic. However, all ESBL strains were sensitive to Fosfomycin (FSF/FOS), demonstrating its potential as an effective therapeutic option. Moreover, 37% of the ESBL producers exhibited co-resistance to over 20 different antibiotics. Conclusion This study provides valuable insights into the prevalence and susceptibility patterns of ESBL-E associated with UTIs in Northern Cameroon. These insights emphasizes the importance of implementing appropriate treatment guidelines and antimicrobial stewardship measures to mitigate the spread and impact of MDR ESBL-producing strains on public health.
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Affiliation(s)
- Karyom Djim-Adjim-Ngana
- Centre for Research on Health and Priority Pathologies, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
- Department of Veterinary Public Health, School of Veterinary Medicine and Sciences, University of Ngaoundere, Ngaoundere, Cameroon
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | - Brunel W. Mbiakop
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
- Department of Biomedical Sciences, University of Ngaoundere, Ngaoundere, Cameroon
| | - Leila A. Oumar
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | | | - Cedric Tchinda Fossi
- Centre for Research on Medicinal Plants and Traditional Medicine, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
| | - Elisee L. Embolo Enyegue
- Centre for Research on Medicinal Plants and Traditional Medicine, Institute of Medical Research and Medicinal Plant Studies, Yaounde, Cameroon
| | - Mohamed M. Mouiche Mouliom
- Department of Veterinary Public Health, School of Veterinary Medicine and Sciences, University of Ngaoundere, Ngaoundere, Cameroon
| | | | - Louis Deweerdt
- Centre Pasteur of Cameroon Annex of Garoua, Garoua, Cameroon
| | | | - Julien A. Nguinkal
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
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13
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Parzen-Johnson S, Sun S, Scardina T, Patel SJ. Fluoroquinolone Use Among Hospitalized Children: Diagnosis-Based Stratification to Identify Stewardship Targets. Open Forum Infect Dis 2023; 10:ofad297. [PMID: 37323425 PMCID: PMC10264067 DOI: 10.1093/ofid/ofad297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
Background As FQ (fluoroquinolone) use has shifted in pediatric populations, better metrics are needed to guide targeted antibiotic stewardship interventions and limit development of adverse events and resistance, particularly in medically complex children. In this study, we identify high-utilization groups based on underlying medical conditions and describe their relative FQ use over time. Methods This study is a retrospective analysis of data from the Pediatric Health Information System database from 2016 to 2020. We identify high-utilization groups based on underlying medical conditions using International Classification of Diseases, Ninth or Tenth Revision codes. We delineate overall trends in the use of FQs in the inpatient setting, including rate and proportional use by each patient group. Results Patients with an oncology diagnosis represent a large (25%-44%) and rising proportion (+4.8%/year, P = .001) of national FQ use over the study period. Patients with intra-abdominal infections, including appendicitis, have had a significant increase in both their relative proportional use of FQs (+0.6%/year, P = .037) and proportion of FQ use per admission encounter over the study period (+0.6%/year, P = .008). Patients with cystic fibrosis represent a decreasing proportion of overall use (-2.1%/year, P = .011) and have decreasing FQ use per inpatient encounter (-0.8%/year, P = .001). Conclusions Patients with an oncology diagnosis and patients with an intra-abdominal infection appear to be targets for FQ stewardship. Patients with cystic fibrosis have decreasing inpatient FQ use. Key Points: This study describes fluoroquinolone use among hospitalized children from 2016 to 2020, stratified by underlying diagnoses. These trends are used to identify high-yield antibiotic stewardship targets.
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Affiliation(s)
- Simon Parzen-Johnson
- Correspondence: Simon Parzen-Johnson, MD, Division of Infectious Diseases, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611 ()
| | - Shan Sun
- Division of Infectious Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tonya Scardina
- Department of Pharmacy, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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14
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Stone TJ, Kilic A, Williamson JC, Palavecino EL. In Vitro Activity of Omadacycline and Comparator Antibiotics against Extended-Spectrum Beta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae Urinary Isolates. Antibiotics (Basel) 2023; 12:953. [PMID: 37370272 DOI: 10.3390/antibiotics12060953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/11/2023] [Accepted: 05/20/2023] [Indexed: 06/29/2023] Open
Abstract
Limited oral antibiotic options exist for urinary tract infections (UTI) caused by ESBL-producing Enterobacterales. The aim of the study was to evaluate in vitro activity of omadacycline and comparator antibiotics against clinical ESBL-producing and non-ESBL-producing E. coli and K. pneumoniae urinary isolates. 102 isolates each of E. coli and K. pneumoniae were collected from clinical urine specimens in 2019. By design, an equal number of each species were included that tested positive and negative for ESBL production. Omadacycline MICs were determined using gradient test strips and compared to MICs of comparator antibiotics as determined by an automated broth microdilution system. Isolates were considered susceptible to omadacycline if the MIC was ≤4 µg/mL for each species. 54.9% of all ESBL-producing isolates were susceptible to omadacycline, but better susceptibility was observed for ESBL-producing E. coli (74.5%). Omadacycline MICs were 2-4 fold lower for E. coli and K. pneumoniae strains not producing ESBL. The omadacycline MIC 50 and 90 values were 4 and 16 µg/mL, respectively, for all isolates studied. 74.5% of all isolates were considered susceptible to omadacycline. MICs were generally lower for E. coli strains with MIC 50 and 90 values of 4 and 8 µg/mL, respectively (87.3% susceptible), compared with K. pneumoniae. Overall, the most active agents were omadacycline and nitrofurantoin, while other comparator antibiotics were less active. Omadacycline represents a promising oral antibiotic for treating UTI caused by ESBL-producing E. coli, particularly when resistance limits other oral options. Prospective, controlled clinical trials are needed to validate these in vitro results.
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Affiliation(s)
- Tyler J Stone
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, USA
| | - Abdullah Kilic
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
| | - John C Williamson
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, NC 27157, USA
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA
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Vance MK, Cretella DA, Ward LM, Vijayvargiya P, Garrigos ZE, Wingler MJB. Risk Factors for Bloodstream Infections Due to ESBL-Producing Escherichia coli, Klebsiella spp., and Proteus mirabilis. PHARMACY 2023; 11:pharmacy11020074. [PMID: 37104080 PMCID: PMC10143278 DOI: 10.3390/pharmacy11020074] [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: 03/13/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023] Open
Abstract
(1) Background: Risk factors for extended-spectrum beta-lactamase (ESBL) infections could vary geographically. The purpose of this study was to identify local risk factors for ESBL production in patients with Gram-negative bacteremia. (2) Methods: This retrospective observational study included adult patients admitted from January 2019 to July 2021 and had positive blood cultures for E. coli, K. pneumoniae, K. oxytoca, and P. mirabilis. Patients with ESBL infection were matched to a non-ESBL-producing infection with the same organism. (3) Results: A total of 150 patients were included: 50 in the ESBL group and 100 in the non-ESBL group. Patients in the ESBL group had a longer length of stay (11 vs. 7 days, p < 0.001), but not increased mortality (14% vs. 15%, p = 0.87) Multivariate analysis identified the receipt of >1 antibiotic in the last 90 days as a risk factor for ESBL infection (OR = 3.448, 95% CI = 1.494-7.957; p = 0.004); (4) Conclusions: Recent antimicrobial use was identified as an independent risk factors for ESBL-producing Enterobacterales infections. Knowledge of this risk may improve empirical therapy and reduce inappropriate use.
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Affiliation(s)
- Mary Kathryn Vance
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David A Cretella
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Lori M Ward
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Mary Joyce B Wingler
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Mendes RE, Arends SJR, Streit JM, Critchley I, Cotroneo N, Castanheira M. Contemporary Evaluation of Tebipenem In Vitro Activity against Enterobacterales Clinical Isolates Causing Urinary Tract Infections in US Medical Centers (2019-2020). Microbiol Spectr 2023; 11:e0205722. [PMID: 36625644 PMCID: PMC9927459 DOI: 10.1128/spectrum.02057-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Tebipenem pivoxil is an oral broad-spectrum carbapenem. This study evaluated the activity of tebipenem and comparators against UTI Enterobacterales from US hospitals (2019-2020). 3,576 Enterobacterales causing UTI in 52 centers in 9 US Census Divisions were included. Susceptibility testing followed the CLSI broth microdilution method. Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis with an MIC of ≥2 μg/mL for ceftazidime, ceftriaxone, and/or aztreonam were designated ESBL. Isolates were also grouped based on MDR phenotype. Tebipenem, meropenem, and ertapenem had MIC90 against Enterobacterales of 0.06 μg/mL, 0.06 μg/mL and 0.03 μg/mL, respectively. Low susceptibility results for aztreonam (87.1% susceptible), cefazidime (88.1%), ceftriaxone (84.8%), and other agents were observed. Tebipenem and ertapenem were equally potent (MIC90, 0.015 to 0.03 μg/mL) against E. coli and K. pneumoniae, whereas ertapenem showed an MIC 8-fold lower than tebipenem against P. mirabilis. Oral agents, such as amoxicillin-clavulanate, levofloxacin, and trimethoprim-sulfamethoxazole, showed elevated nonsusceptibility rates in the Middle Atlantic region (26, 45, 47, and 41%, respectively). ESBL prevalence varied from 7% to 16%, except in the Middle Atlantic region (42%). The carbapenems were active against ESBL and MDR isolates (93.7 to 96.8% susceptible). Elevated rates of ESBL in UTI pathogens in US hospitals were noted as well as a uniform in vitro potency (MIC90) of tebipenem and the intravenous carbapenems, regardless of phenotype. IMPORTANCE The occurrence of urinary-tract Enterobacterales pathogens producing ESBL enzymes in community and nosocomial settings continues to increase, as does the coresistance to fluoroquinolones, trimethoprim-sulfamethoxazole and nitrofurantoin often exhibited by these pathogens. This scenario complicates the clinical empirical and guided management of UTI by precluding the use of oral and many intravenous options. Oral options appear compromised even among some ESBL-negative isolates, against which the use of parenteral agents may be required. In addition, the interregional variability of susceptibility results of US UTI pathogens provides a less predictable susceptibility pattern to inform empirical treatment decisions. This study evaluated the in vitro activity of tebipenem against contemporary uropathogens, including those resistant to currently available oral options.
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Trends in the Rates of Extended-Spectrum-β-Lactamase-Producing Enterobacterales Isolated from Urine Cultures during the COVID-19 Pandemic in Ontario, Canada. Microbiol Spectr 2023; 11:e0312422. [PMID: 36645285 PMCID: PMC9927304 DOI: 10.1128/spectrum.03124-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Worldwide, extended-spectrum β-lactamase (ESBL) rates are increasing at an alarming level with increasing rates of health care exposures, international travel, and antibiotic usage. In this study, we investigated whether enhanced social isolation, travel restrictions, and the reduced use of antibiotics in Ontario, Canada during coronavirus disease 2019 (COVID-19) pandemic had an impact on ESBL rates in urine cultures collected from the community and long-term-care (LTC) facilities across the province. Data from a total of 8.6 million urine cultures performed at LifeLabs Ontario from 2016 to 2021 were utilized for analysis. ESBL-producing Escherichia coli (ESBL Escherichia coli) and ESBL Klebsiella pneumoniae were identified using standard operating procedures. Data trends were estimated by interrupted time series (ITS) regression analysis. Among 2.3 million positive urine cultures, 48.9% and 7.2% grew E. coli and K. pneumoniae, of which 5.8% and 3.3% produced ESBLs, respectively. While the overall rate of ESBL isolation was higher in the pandemic period than in the prepandemic period, by ITS regression analysis of the monthly rates of ESBL isolation, decreasing trends were noted for ESBL E. coli in both the community and LTC facilities and for ESBL K. pneumoniae in the community. The ESBL K. pneumoniae rates in LTC facilities continued to increase throughout the COVID-19 period. By subgroup analysis for different genders, age groups, and local health integration network (LHIN) units, similar trends were seen in most cases (P < 0.05), except for a few densely populated LHINs where rate changes were not statistically significant. IMPORTANCE Community-onset urinary tract infections (UTIs) caused by ESBL-producing Enterobacterales, particularly E. coli and K. pneumoniae, are a major public health concern. In this study, we assessed the impact of COVID-19 on ESBL rates in urine cultures in Ontario, Canada. Our results show the recent epidemiology of ESBL-producing Enterobacterales in urine cultures from both the community and LTC facilities in Ontario, Canada, and the impact of COVID-19 restrictions on ESBL trends for the entire province as well as different subgroups of the population based on demographic and geographic characteristics. Our results may have important public health implications in the context of the gradual easing of COVID-19 restrictions.
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18
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Mills EG, Martin MJ, Luo TL, Ong AC, Maybank R, Corey BW, Harless C, Preston LN, Rosado-Mendez JA, Preston SB, Kwak YI, Backlund MG, Bennett JW, Mc Gann PT, Lebreton F. A one-year genomic investigation of Escherichia coli epidemiology and nosocomial spread at a large US healthcare network. Genome Med 2022; 14:147. [PMID: 36585742 PMCID: PMC9801656 DOI: 10.1186/s13073-022-01150-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Extra-intestinal pathogenic Escherichia coli (ExPEC) are a leading cause of bloodstream and urinary tract infections worldwide. Over the last two decades, increased rates of antibiotic resistance in E. coli have been reported, further complicating treatment. Worryingly, specific lineages expressing extended-spectrum β-lactamases (ESBLs) and fluoroquinolone resistance have proliferated and are now considered a serious threat. Obtaining contemporary information on the epidemiology and prevalence of these circulating lineages is critical for containing their spread globally and within the clinic. METHODS Whole-genome sequencing (WGS), phylogenetic analysis, and antibiotic susceptibility testing were performed for a complete set of 2075 E. coli clinical isolates collected from 1776 patients at a large tertiary healthcare network in the USA between October 2019 and September 2020. RESULTS The isolates represented two main phylogenetic groups, B2 and D, with six lineages accounting for 53% of strains: ST-69, ST-73, ST-95, ST-131, ST-127, and ST-1193. Twenty-seven percent of the primary isolates were multidrug resistant (MDR) and 5% carried an ESBL gene. Importantly, 74% of the ESBL-E.coli were co-resistant to fluoroquinolones and mostly belonged to pandemic ST-131 and emerging ST-1193. SNP-based detection of possible outbreaks identified 95 potential transmission clusters totaling 258 isolates (12% of the whole population) from ≥ 2 patients. While the proportion of MDR isolates was enriched in the set of putative transmission isolates compared to sporadic infections (35 vs 27%, p = 0.007), a large fraction (61%) of the predicted outbreaks (including the largest cluster grouping isolates from 12 patients) were caused by the transmission of non-MDR clones. CONCLUSION By coupling in-depth genomic characterization with a complete sampling of clinical isolates for a full year, this study provides a rare and contemporary survey on the epidemiology and spread of E. coli in a large US healthcare network. While surveillance and infection control efforts often focus on ESBL and MDR lineages, our findings reveal that non-MDR isolates represent a large burden of infections, including those of predicted nosocomial origins. This increased awareness is key for implementing effective WGS-based surveillance as a routine technology for infection control.
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Affiliation(s)
- Emma G. Mills
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Melissa J. Martin
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Ting L. Luo
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Ana C. Ong
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Rosslyn Maybank
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Brendan W. Corey
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Casey Harless
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Lan N. Preston
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Joshua A. Rosado-Mendez
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Scott B. Preston
- grid.414467.40000 0001 0560 6544Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Yoon I. Kwak
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Michael G. Backlund
- grid.414467.40000 0001 0560 6544Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Jason W. Bennett
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Patrick T. Mc Gann
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Francois Lebreton
- grid.507680.c0000 0001 2230 3166Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD USA
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Hasan SM, Ibrahim KS. Molecular Characterization of Extended Spectrum β-Lactamase (ESBL) and Virulence Gene-Factors in Uropathogenic Escherichia coli (UPEC) in Children in Duhok City, Kurdistan Region, Iraq. Antibiotics (Basel) 2022; 11:antibiotics11091246. [PMID: 36140025 PMCID: PMC9495206 DOI: 10.3390/antibiotics11091246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/10/2022] [Accepted: 09/11/2022] [Indexed: 12/16/2022] Open
Abstract
Background: The presence of extended-spectrum β-lactamase (ESBL)-producing bacteria among uropathogens is significantly increasing in children all over the world. Thus, this research was conducted to investigate the prevalence of E. coli and their antimicrobial susceptibility pattern, and both genes of ESBL-producing E. coli resistant and virulence factor in UTIs patients among children in Duhok Province, Kurdistan, Iraq. Method: a total of 67 E. coli were identified from 260 urine samples of pediatric patients diagnosed with UTIs aged (0−15 years) which were collected from Heevi Pediatric Teaching Hospital, from August 2021 to the end of February 2022. Result: a high proportion of UPEC infections at ages <5 years and the rates among girls (88%) were significantly higher than those among the boys. A wide variety of E. coli are resistant to most antibiotics, such as Amoxicillin, Ampicillin and Tetracycline, and 64% of them were positive for ESBL. Interestingly, the presence of both the ESBL marker genes (blaTEM, and blaCTX-M) as well as both virulence marker genes (pai and hly) were detected in above 90% of E. coli. Conclusion: the data illustrate an alarming increase in UPEC with ESBL production and the emergence of multidrug-resistant drugs in the early age of children. The public health sectors should further monitor the guidelines of using antibiotics in Kurdistan, Iraq.
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Affiliation(s)
- Salwa Muhsin Hasan
- Department of Medical Lab Technology, College of Health and Medical Technology/Shekhan, Duhok Polytechnic University, Duhok 42001, Kurdistan Region, Iraq
| | - Khalid S. Ibrahim
- Department of Biology, Faculty of Sciences, University of Zakho, Zakho 42002, Kurdistan Region, Iraq
- Correspondence: ; Tel.: +964-750-450-4417
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Suich J, Mawer D, van der Woude M, Wearmouth D, Burns P, Smeets T, Barlow G. Evaluation of in vitro activity of fosfomycin, and synergy in combination, in Gram-negative bloodstream infection isolates in a UK teaching hospital. J Med Microbiol 2022; 71. [PMID: 35476672 DOI: 10.1099/jmm.0.001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Fosfomycin has retained activity against many multi-drug resistant (MDR) Gram-negatives, and may be useful against extended spectrum beta-lactamase (ESBL) producing and carbapenem-resistant Enterobacterales to improve clinical outcomes.Hypothesis/Gap Statement. There are few data from the UK on the susceptibility of invasive Gram-negative isolates to fosfomycin, especially in the era of increasing use of oral fosfomycin for urinary tract infections (UTIs).Aim. We evaluated fosfomycin susceptibility against 100 consecutive Gram-negative bloodstream isolates, both individually, and in combination with other mechanistically similar and differing antibiotics. The aim was to investigate the synergy between antibiotic combinations against several E. coli, K. pneumoniae and P. aeruginosa isolates with variable levels of resistance.Methodology. Disc diffusion and MIC test strip methods applying revised EUCAST guidelines for Fosfomycin were used, followed by the MTS™ 'cross synergy' method for 'resistant' isolates as defined below: (a) Fosfomycin resistant by MIC test strip; (b) MDR isolates defined as being resistant to ≥3 classes of antibiotics (based on routine sensitivity testing; beta lactams were considered as a single class), and/or (c) AMP C or ESBL or carbapenemase producers (or carbapenem resistant). FIC Index (Fractional Inhibitory Concentration Index) calculations were used to interpret findings, whereby: FIC = (MICA combination A+B/ MIC agent A) + (MICB combination A+B/ MIC agent B). A result of ≤0.5 was taken to indicate 'synergy', >0.5 and ≤1.0 to indicate 'additive' effect, >1.0 and ≤4.0 to indicate 'indifference', and >4.0 to indicate 'antagonism'.Results. We found that 95/100 isolates were susceptible to fosfomycin by MIC test strip, with 88/100 isolates susceptible to fosfomycin by disc, based on EUCAST guideline breakpoints. A total of 30/100 isolates (the more 'resistant' of the 100) were eligible for synergy testing according to our definitions (see Methodology), with the remaining 70 isolates not tested further. Seventeen out of 30 were MDR, 2/30 were AMP C producers and 9/30 were ESBL producers. Overall, 34/300 (11 %) of all combination tests showed synergy and 161/300 (54 %) were additive. Synergy was most commonly detected between fosfomycin and beta-lactam antibiotics, including piperacillin/tazobactam (10/30; 33 %), ceftazidime/avibactam (10/30; 30 %), and temocillin (8/30; 27 %). An additive effect was most commonly detected with aztreonam (25/30; 83 %) and meropenem (25/30; 83 %), but 100 % indifference was found with tigecycline (30/30). No antagonism was identified with any antibiotic combination.Conclusion. Fosfomycin non-susceptibility by MIC test strip was unusual. Synergy was variable when combining fosfomycin with other antibiotics against the more 'resistant' isolates. Synergistic/additive effects were detected for beta-lactam/fosfomycin combinations in >80 % of all such combinations, suggesting beta-lactams may be the preferred partner for fosfomycin. Agents with a discordant site of action were more likely to result in indifference. Antagonism was not detected.
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Affiliation(s)
- Joseph Suich
- Hull University Teaching Hospitals NHS Trust, Hull, UK.,Hull York Medical School, York, UK.,The University of York, York, UK
| | | | | | | | | | - Ton Smeets
- Nordic Pharma B. V., Baam, The Netherlands
| | - Gavin Barlow
- Hull York Medical School, York, UK.,The University of York, York, UK
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Liu H, Qiu S, Chen M, Lyu J, Yu G, Xue L. A clinical prediction tool for extended-spectrum β-lactamase-producing Enterobacteriaceae urinary tract infection. BMC Infect Dis 2022; 22:50. [PMID: 35027010 PMCID: PMC8756698 DOI: 10.1186/s12879-022-07040-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 01/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Prevalence of extended-spectrum beta-lactamase-producing-Enterobacteriaceae (ESBL-E) has risen in patients with urinary tract infections. The objective of this study was to determine explore the risk factors of ESBL-E infection in hospitalized patients and establish a predictive model. Methods This retrospective study included all patients with an Enterobacteriaceae-positive urine sample at the first affiliated hospital of Jinan university from January 2018 to December 2019. Antimicrobial susceptibility patterns of ESBL-E were analyzed, and multivariate analysis of related factors was performed. From these, a nomogram was established to predict the possibility of ESBL-E infection. Simultaneously, susceptibility testing of a broad array of carbapenem antibiotics was performed on ESBL-E cultures to explore possible alternative treatment options. Results Of the total 874 patients with urinary tract infections (UTIs), 272 (31.1%) were ESBL-E positive. In the predictive analysis, five variables were identified as independent risk factors for ESBL-E infection: male gender (OR = 1.607, 95% CI 1.066–2.416), older age (OR = 4.100, 95% CI 1.678–12.343), a hospital stay in preceding 3 months (OR = 1.872, 95% CI 1.141–3.067), invasive urological procedure (OR = 1.810, 95% CI 1.197–2.729), and antibiotic use within the previous 3 months (OR = 1.833, 95% CI 1.055–3.188). In multivariate analysis, the data set was divided into a training set of 611 patients and a validation set of 263 patients The model developed to predict ESBL-E infection was effective, with the AuROC of 0.650 (95% CI 0.577–0.725). Among the antibiotics tested, several showed very high effectiveness against ESBL-E: amikacin (85.7%), carbapenems (83.8%), tigecycline (97.1%) and polymyxin (98.2%). Conclusions The nomogram is useful for estimating a UTI patient’s likelihood of infection with ESBL-E. It could improve clinical decision making and enable more efficient empirical treatment. Empirical treatment may be informed by the results of the antibiotic susceptibility testing.
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22
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AL Mamari Y, Sami H, Siddiqui K, Tahir HB, AL Jabri Z, AL Muharrmi Z, Rizvi SGA, Rizvi M. Trends of antimicrobial resistance in patients with complicated urinary tract infection: Suggested empirical therapy and lessons learned from a retrospective observational study in Oman. Urol Ann 2022; 14:345-352. [PMID: 36505995 PMCID: PMC9731183 DOI: 10.4103/ua.ua_67_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
Background Complicated urinary tract infection (cUTI) is defined as an infection associated with structural, functional, or metabolic abnormalities of the genitourinary tract. These infections are caused frequently by multidrug-resistant Gram-negative bacilli. The rapid emergence of extended-spectrum beta-lactamase (ESBL), AmpC, and carbapenemase (CR) producers has made the treatment of such infections increasingly more challenging. Objectives The aims of the present study were threefold: to assess the clinical profile, trends in etiology, and antimicrobial susceptibility profile in cUTI over the past 10 years at a tertiary care center in Oman as an interrupted time series on the one hand and to develop guidelines for empirical management of such cases on the other. Materials and Methods We conducted a retrospective analysis of cUTI in patients presenting at Sultan Qaboos University Hospital over 3 years (2008, 2013, and 2018) covering a span of 10 years. Data were obtained from the patient's electronic records in the hospital information system. Analysis was done using the Statistical Package for Social Sciences program (SPSS), version 23. Results Among the 650 cases of cUTI, 284 (44%) were males and 366 (56%) were females, with dysuria being the most common symptom (34%). The biggest risk factor for developing cUTI was diabetes (35%). The predominant pathogen was Escherichia coli (53%), followed by Klebsiella spp. (16%), Enterococcus faecalis (7%), Pseudomonas aeruginosa (7%), Candida spp. (2%), and Enterobacter cloacae (2%). Over the years, E. coli emerged as the predominant ESBL and AmpC producer, Acinetobacter baumannii as the multidrug-resistant bug, and Klebsiella pneumoniae as the major carbapenem-resistant Enterobacterales (CRE) producer. Nitrofurantoin emerged as the most effective drug for cystitis. Aminoglycosides, piperacillin-tazobactam, and carbapenems demonstrated the highest activity with an overall resistance of less than 10%. Higher resistance (30%) was observed against cephalosporins, fluoroquinolones, and trimethoprim/sulfamethoxazole. Analysis of the 10-year trend threw up some unexpected results. As expected, resistance increased from 2008 to 2013. Surprisingly, however, antimicrobial resistance in 2018 was lower against majority of the antimicrobials compared to 2013. Conclusion There is a paucity of data for developing evidence-based guidelines management of cUTI. Targeted antibiograms and not cumulative antibiograms are essential for promoting appropriate prescribing and optimizing patient care. The welcome decline in resistance may be attributed cascade reporting, introduction of more ID physicians. Another possibility is increased utilization of fluoroquinolones which spared the other groups of antimicrobials. Judicious heterogeneous mixing of antimicrobials should be spearheaded in both cystitis and pyelonephritis so that there is no undue pressure on one drug. We strongly recommend carbapenem-sparing protocols in treatment of cUTI when anticipating augmented resistance due to AmpC production. Synergistic combinations such as piperacillin-tazobactam plus aminoglycosides/fluoroquinolones may be prescribed. In sepsis, however, carbapenems are the drugs of choice.
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Affiliation(s)
- Yousuf AL Mamari
- Medical Student / Senior Clerk MD Program, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Hiba Sami
- Department of Microbiology, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
| | - Khurram Siddiqui
- Department of Surgery, Division of Urology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Hashim Ba Tahir
- Department of Medicine, Division of Infectious Diseases, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Zaaima AL Jabri
- Department of Microbiology and Immunology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Zakariya AL Muharrmi
- Department of Microbiology and Immunology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Syed Gauhar A. Rizvi
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Meher Rizvi
- Department of Microbiology and Immunology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman,Address for correspondence: Dr. Meher Rizvi, Department of Microbiology and Immunology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman. E-mail:
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