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Tian L, Li Q, Cai X, Wang Y, Wang Y, Mao Y. Dynamic distribution and potential transmission of antibiotic resistance genes in activated sludge. Appl Microbiol Biotechnol 2022; 106:6785-6797. [DOI: 10.1007/s00253-022-12162-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/02/2022]
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2
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Wijers CDM, Pham L, Douglass MV, Skaar EP, Palmer LD, Noto MJ. Gram-negative bacteria act as a reservoir for aminoglycoside antibiotics that interact with host factors to enhance bacterial killing in a mouse model of pneumonia. FEMS MICROBES 2022; 3:xtac016. [PMID: 35909464 PMCID: PMC9326624 DOI: 10.1093/femsmc/xtac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 01/28/2023] Open
Abstract
In vitro exposure of multiple Gram-negative bacteria to an aminoglycoside (AG) antibiotic has previously been demonstrated to result in bacterial alterations that interact with host factors to suppress Gram-negative pneumonia. However, the mechanisms resulting in suppression are not known. Here, the hypothesis that Gram-negative bacteria bind and retain AGs, which are introduced into the lung and interact with host defenses to affect bacterial killing, was tested. Following in vitro exposure of one of several, pathogenic Gram-negative bacteria to the AG antibiotics kanamycin or gentamicin, AGs were detected in bacterial cell pellets (up to 208 μg/mL). Using inhibitors of AG binding and internalization, the bacterial outer membrane was implicated as the predominant kanamycin and gentamicin reservoir. Following intranasal administration of gentamicin-bound bacteria or gentamicin solution at the time of infection with live, AG-naïve bacteria, gentamicin was detected in the lungs of infected mice (up to 8 μg/g). Co-inoculation with gentamicin-bound bacteria resulted in killing of AG-naïve bacteria by up to 3-log10, mirroring the effects of intranasal gentamicin treatment. In vitro killing of AG-naïve bacteria mediated by kanamycin-bound bacteria required the presence of detergents or pulmonary surfactant, suggesting that increased bacterial killing inside the murine lung is facilitated by the detergent component of pulmonary surfactant. These findings demonstrate that Gram-negative bacteria bind and retain AGs that can interact with host-derived pulmonary surfactant to enhance bacterial killing in the lung. This may help explain why AGs appear to have unique efficacy in the lung and might expand their clinical utility.
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Affiliation(s)
- Christiaan D M Wijers
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Ly Pham
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Martin V Douglass
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Eric P Skaar
- Department of Pathology, Microbiology, and Immunology, Vanderbilt
University Medical Center, 1161 21st Avenue South, Nashville, TN 37232,
United States,Vanderbilt Institute for Infection, Immunology, and Inflammation,
Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville,
TN 37232, United States
| | - Lauren D Palmer
- Department of Microbiology and Immunology, University of Illinois
Chicago, 835 South Wolcott Avenue, Chicago, IL 60612, United States
| | - Michael J Noto
- Corresponding author: Room 205H Whitehead Biomedical Research Building, Emory
University, 615 Michael Street, Atlanta, GA 30322, United States. Tel: (+404)712-2988;
E-mail:
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Lynch JP, Zhanel GG. Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy. Semin Respir Crit Care Med 2022; 43:191-218. [PMID: 35062038 DOI: 10.1055/s-0041-1740109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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Beta-lactam monotherapy or combination therapy for bloodstream infections or pneumonia due to P. aeruginosa: a meta-analysis. Int J Antimicrob Agents 2021; 59:106512. [PMID: 34971728 DOI: 10.1016/j.ijantimicag.2021.106512] [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: 04/07/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES . The aim of the present meta-analysis was to compare the clinical and microbiological outcomes of patients treated with beta-lactam monotherapy or combination therapy for Pseudomonas aeruginosa infections. DATA SOURCES MEDLINE, Google Scholar and the Cochrane Library STUDY ELIGIBILITY CRITERIA AND INTERVENTIONS: . Experimental and observational studies published as full papers up to December 2020 that compared the efficacy of beta-lactams used in monotherapy or in combination with other active agents as empirical or targeted therapy for bloodstream infections or Hospital-Acquired or Ventilator-Associated Pneumonia (HAP/VAP) due to P. aeruginosa. The outcomes evaluated were hospital-mortality, 14-day- or 30-day-mortality rate, microbiological eradication rate and clinical cure rate. RESULTS . Of a total of 8,363 citations screened, 6 Randomized Controlled Trials (RCTs), 6 prospective cohort studies, and 21 retrospective cohort studies were included in the analysis, accounting for a total of 3,861 subjects. Considering the 14 studies evaluating the empirical therapy, no significant difference in mortality rate was observed between the two groups (RR: 1.06; 95% CI 0.86-1.30, p=0.6). Similar findings were obtained among the 18 studies analysing the targeted therapy (RR: 1.04; 95% CI 0.83-1.31, p=0.708); however, grouping the studies according to the design, a higher mortality among patients receiving monotherapy was observed in 5 prospective studies (RR: 1.37; 95% CI 1.06-1.79, p=0.018). Finally, no difference was observed among groups considering the microbiological and the clinical cure. CONCLUSIONS . Our meta-analysis demonstrated no difference in the mortality rate, clinical cure and microbiological cure in patients treated with beta-lactam monotherapy or combination for P. aeruginosa infections.
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Thu PNT, Huong MNT, Thi NT, Thanh HN, Minh KP. Combination antibiotic therapy versus monotherapy in the treatment of acute exacerbations of chronic obstructive pulmonary disease: an open-label randomized trial. BMC Infect Dis 2021; 21:1019. [PMID: 34587911 PMCID: PMC8480084 DOI: 10.1186/s12879-021-06687-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/13/2021] [Indexed: 01/21/2023] Open
Abstract
Background The role of antibiotics in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations and their effectiveness in combination have not been clearly established. To determine whether using a combination of fluoroquinolones and beta-lactams improves the clinical and microbiological efficacy of antibiotics on day 20 of treatment, we conducted an open-label randomized trial based on clinical outcomes, microbiological clearance, spirometry tests, and signs of systemic inflammation in patients hospitalized with acute exacerbations of COPD. Methods We enrolled 139 subjects with COPD exacerbations, defined as acute worsening of respiratory symptoms leading to additional treatment. Patients were divided randomly into two groups: 79 patients using beta-lactam antibiotics alone and 60 using beta-lactam antibiotics plus fluoroquinolones. Clinical and microbiological responses, spirometry tests, symptom scores, and serum C-reactive protein (CRP) levels were evaluated.
Results Clinical success, lung function, and symptoms were similar in patients with or without fluoroquinolone administration on days 10 and 20. Combination therapy was superior in terms of microbiological outcomes and reduction in serum CRP value. Although equivalent to monotherapy in terms of clinical success, the combination showed superiority in terms of microbiological success and a decrease in CRP. The combination therapy group had a higher microbiological success rate with gram-negative bacteria than the monotherapy group with Pseudomonas aeruginosa (100% vs. 33.3%, respectively) and Acinetobacter baumanii (100% vs. 20%, respectively) (P < 0.05). Conclusions Concomitant use of fluoroquinolone and beta-lactam antibiotics for bacterial infections during COPD exacerbations caused by gram-negative bacteria appear to be effective and should be applied in clinical practice.
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Affiliation(s)
- Phuong Nguyen Thi Thu
- Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem, Ngo Quyen, Haiphong, Vietnam.,Haiphong International Hospital, 124 Nguyen Duc Canh, Le Chan, Haiphong, Vietnam
| | | | - Ngan Tran Thi
- Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem, Ngo Quyen, Haiphong, Vietnam.,Haiphong International Hospital, 124 Nguyen Duc Canh, Le Chan, Haiphong, Vietnam
| | - Hoi Nguyen Thanh
- Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem, Ngo Quyen, Haiphong, Vietnam.,Haiphong International Hospital, 124 Nguyen Duc Canh, Le Chan, Haiphong, Vietnam
| | - Khue Pham Minh
- Haiphong University of Medicine and Pharmacy, 72A Nguyen Binh Khiem, Ngo Quyen, Haiphong, Vietnam.
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Korang SK, Maagaard M, Feinberg JB, Perner A, Gluud C, Jakobsen JC. The effects of adding quinolones to beta-lactam antibiotics for sepsis. Acta Anaesthesiol Scand 2021; 65:1023-1032. [PMID: 33864250 DOI: 10.1111/aas.13831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sepsis is common, deadly, and a major challenge to treat. Quinolones added to beta-lactam antibiotics are currently recommended as a second-line empiric regimen in sepsis, but the evidence regarding their benefits and harms is unclear. OBJECTIVE To assess the benefits and harms of adding quinolones to standard care for sepsis. DATA SOURCES We conducted a systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-Expanded, and BIOSIS. STUDY SELECTION Randomized clinical trials assessing the effects of adding any quinolone to standard care for children and adults with sepsis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened studies and extracted data. The certainty of the evidence was assessed by GRADE. RESULTS We included three trials randomizing 995 adults. All trials were at overall "high risk of bias." All trials compared a quinolone (moxifloxacin, levofloxacin, or ciprofloxacin) and a beta-lactam antibiotic versus the same beta-lactam antibiotic. We found no evidence of an effect of adding quinolones to beta-lactam antibiotics when assessing all-cause mortality (RR 1.07, 95% CI 0.86 to 1.33; 2 trials; 915 participants; very low certainty of evidence) and serious adverse events (RR 1.00, 95% CI 0.67 to 1.50; 977 participants; two trials; very low certainty of evidence). No trials reported on quality of life. CONCLUSIONS The effects of adding quinolones to beta-lactam antibiotics for the treatment of sepsis were unclear for all outcomes. Additional trial data are warranted to support the recommendation of empirical use of quinolones for sepsis.
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Affiliation(s)
- Steven K. Korang
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - Mathias Maagaard
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Anaesthesiology Centre for Anaesthesiological Research Zealand University HospitalThe Zealand Region of Denmark Koge Denmark
| | - Joshua B. Feinberg
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care RigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Clinical Medicine The Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- The Cochrane Hepato‐Biliary Group Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Regional Health Research The Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research The Capital Region of DenmarkRigshospitaletCopenhagen University Hospital Copenhagen Denmark
- Department of Regional Health Research The Faculty of Health Sciences University of Southern Denmark Odense Denmark
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Heffernan AJ, Sime FB, Sun J, Lipman J, Kumar A, Andrews K, Ellwood D, Grimwood K, Roberts J. β-lactam antibiotic versus combined β-lactam antibiotics and single daily dosing regimens of aminoglycosides for treating serious infections: A meta-analysis. Int J Antimicrob Agents 2019; 55:105839. [PMID: 31704215 DOI: 10.1016/j.ijantimicag.2019.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Combining aminoglycosides with β-lactam antibiotics for treating serious infections has not been associated with reduced mortality in previous meta-analyses. However, the multiple daily aminoglycoside dosing regimen principally used in most of the included studies is inconsistent with current practice. OBJECTIVE To determine if a combination of an aminoglycoside administered as a single daily dose and a β-lactam antibiotic reduces all-cause mortality in patients compared with β-lactam antibiotic monotherapy. METHODS A systematic review and meta-analysis of clinical studies was performed (Prospero registration number #68506). Studies were included if they compared β-lactam antibiotic monotherapy with combined β-lactam and single daily dose aminoglycoside therapy for treating serious infections. Studies investigating multiple daily dosing aminoglycoside regimens, infective endocarditis and febrile neutropaenia were excluded. Study quality was assessed using the PEDro and Newcastle-Ottawa scoring systems. The end points for outcome analyses were 30-day all-cause mortality, clinical cure and nephrotoxicity. RESULTS Four randomised controlled trials and five retrospective cohort studies were analysed. Compared with β-lactam antibiotic monotherapy, single daily aminoglycoside dosing in combination with β-lactam antibiotics was not associated with reduced mortality compared with β-lactam antibiotic monotherapy (n = 3686, OR 0.82, 95% CI 0.63-1.08, P = 0.10, I2 42%). A subgroup analysis of cohort studies suggested reduced mortality with combination therapy (n = 3563, OR 0.79, 95% CI 0.64-0.99, P = 0.04, I2 32%). No increased risk of nephrotoxicity was identified (n = 1110, OR 1.31, 95% CI 0.83-2.09, P = 0.40, I2 0%). CONCLUSIONS The existing evidence suggests no added survival benefit from a single daily dosing regimen of an aminoglycoside when combined with β-lactam antibiotics.
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Affiliation(s)
| | - Fekade Bruck Sime
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jing Sun
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anand Kumar
- Sections of Critical Care Medicine and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Katherine Andrews
- Griffith Institute for Drug Discovery, Griffith University, Nathan, Queensland, Australia
| | - David Ellwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Department of Maternal-Foetal Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Keith Grimwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Departments of Paediatrics and Infectious Diseases, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Jason Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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8
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Shi Q, Huang C, Xiao T, Wu Z, Xiao Y. A retrospective analysis of Pseudomonas aeruginosa bloodstream infections: prevalence, risk factors, and outcome in carbapenem-susceptible and -non-susceptible infections. Antimicrob Resist Infect Control 2019; 8:68. [PMID: 31057792 PMCID: PMC6485151 DOI: 10.1186/s13756-019-0520-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Pseudomonas aeruginosa (PA) is a leading cause of nosocomial infections, and carbapenem non-susceptible strains are a major threat to patient safety. Methods A single center, retrospective comparative analysis of carbapenem-non-susceptible PA (CnSPA) and carbapenem-susceptible PA (CSPA) bloodstream infections (BSIs) was conducted between January 1, 2007, and December 31, 2016. Prevalence and risk factors associated with CnSPA BSIs were examined. Results The study enrolled 340 patients with PA BSIs; 30.0% (N = 101) of patients had CnSPA. High APACHE II scores (≥15), central venous catheterization, and delayed application of appropriate definitive therapy were independently associated with higher risk of mortality in PA BSIs. Multivariate analysis revealed that respiratory disease and exposure to carbapenems within the previous 90 days to onset of BSI were independent risk factors for acquisition of CnSPA BSIs. Overall all-cause 30-day mortality associated with PA BSIs was 26.8% (91/340). In addition, mortality was higher in patients with CnSPA than in those with CSPA (37.6% vs. 22.2%, respectively; P = 0.003). Corticosteroid therapy and delayed receipt of effective definitive therapy were independent risk factors for death from CnSPA BSIs. Conclusion Increased incidence of CnSPA BSIs was observed during the study period, with higher mortality seen in patients with these infections. Respiratory disease and exposure to carbapenems were independent risk factors for development of CnSPA BSIs. Appropriate definitive therapy reduced mortality rates. BLBLIs were as effective as carbapenems as a treatment for PA BSIs.
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Affiliation(s)
- Qingyi Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Chen Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- Department of Respiratory medicine, Ningbo Medical Treatment Center Li huili Hospital, Ningbo, People’s Republic of China
| | - Tingting Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Zhenzhu Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
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Callejas-Díaz A, Fernández-Pérez C, Ramos-Martínez A, Múñez-Rubio E, Sánchez-Romero I, Vargas Núñez JA. Impact of Pseudomonas aeruginosa bacteraemia in a tertiary hospital: Mortality and prognostic factors. Med Clin (Barc) 2018; 152:83-89. [PMID: 29885868 DOI: 10.1016/j.medcli.2018.04.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/21/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Pseudomonas aeruginosa bacteraemia is associated with a very high mortality, conditioned by comorbidity, source, severity of the episode and lack of adequate treatment. The aim of the study is to know the mortality and prognostic factors of bacteraemia by P.aeruginosa in our hospital. PATIENTS AND METHODS We conducted a retrospective study of P.aeruginosa bacteraemia detected between 2009 and 2014. Epidemiological, clinical and microbiological characteristics were described. A risk factor analysis for mortality was performed. RESULTS We analysed 110 episodes of bacteraemia, which was more frequent in men of advanced age and with a history of hospitalisation, comorbidity and immunosuppression. Most of the bacteraemias were secondary (mainly of respiratory or urinary source) and led to a significant clinical deterioration. The presence of antibiotic resistance was very high, with 27.3% of multiresistant strains. Empirical treatment was adequate in 60.0% and 92.3% for definite treatment. Overall mortality was 37.3% and attributable mortality was 29.1%. The most important prognostic factors were Charlson index ≥3, history of haematologic malignancy, neutropenia and previous use of corticosteroids, source of bacteraemia, Pitt index ≥4, renal insufficiency, adequate definite treatment, empiric treatment with piperacillin/tazobactam in severe episodes and focus control. CONCLUSION P.aeruginosa bacteraemia is associated with a very high mortality, possibly more related to previous comorbidity and severity of the episode than to the treatment chosen. However, the main goal in management remains to optimise treatment, including focus control.
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Affiliation(s)
- Alejandro Callejas-Díaz
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Unidad de Enfermedades Infecciosas, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España.
| | | | - Antonio Ramos-Martínez
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Unidad de Enfermedades Infecciosas, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | - Elena Múñez-Rubio
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Unidad de Enfermedades Infecciosas, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España
| | - Isabel Sánchez-Romero
- Servicio de Microbiología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España
| | - Juan Antonio Vargas Núñez
- Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
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10
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Wu PF, Lin YT, Wang FD, Yang TC, Fung CP. Is fluoroquinolone monotherapy a useful alternative treatment for Pseudomonas aeruginosa bacteraemia? Infection 2018; 46:365-373. [PMID: 29556979 DOI: 10.1007/s15010-018-1131-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/13/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Pseudomonas aeruginosa bacteraemia is associated with high mortality, and most monotherapies are beta-lactam-based. We aimed to investigate clinical outcomes of definitive fluoroquinolone monotherapy versus beta-lactam monotherapy for P. aeruginosa bacteraemia. METHODS This retrospective study enrolled adult patients receiving definitive monotherapy with beta-lactam or fluoroquinolone between November 2013 and November 2014 at Taipei Veterans General Hospital. The independent risk factors for 28-day mortality were analyzed by logistic regression and propensity score-adjusted analysis. RESULTS Among the 105 patients enrolled, 78 patients received beta-lactams and 27 received fluoroquinolones (20 with ciprofloxacin and 7 with levofloxacin). Primary bacteraemia (39.0%) and urinary tract infections (37.1%) were the most common sources of bacteraemia. The 28-day mortality rate was 11.1% for those receiving fluoroquinolones and 32.1% for those receiving beta-lactams (P = 0.062). The 28-day mortality rate between the two groups stratified by APACHE II and Pitt bacteraemia scores showed no significant differences in each category. Propensity score-adjusted multivariate analysis revealed that definitive therapy with a fluoroquinolone was not associated with 28-day mortality (OR 0.42; 95% CI 0.08-2.23; P = 0.305). CONCLUSIONS Fluoroquinolone might be an alternative to beta-lactam as a definitive monotherapy for P. aeruginosa bacteraemia provided they are active in vitro. Our results could be a basis for further studies and provide a possible target for antibiotic stewardship interventions in P. aeruginosa bacteraemia.
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Affiliation(s)
- Ping-Feng Wu
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan. .,Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Fu-Der Wang
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 112, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tsuey-Ching Yang
- Department of Biotechnology and Laboratory Science in Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chang-Phone Fung
- Division of Infectious Diseases, Sijhih Cathay General Hospital, New Taipei City, Taiwan
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11
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Mensa J, Barberán J, Soriano A, Llinares P, Marco F, Cantón R, Bou G, del Castillo JG, Maseda E, Azanza JR, Pasquau J, García-Vidal C, Reguera JM, Sousa D, Gómez J, Montejo M, Borges M, Torres A, Alvarez-Lerma F, Salavert M, Zaragoza R, Oliver A. Antibiotic selection in the treatment of acute invasive infections by Pseudomonas aeruginosa: Guidelines by the Spanish Society of Chemotherapy. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:78-100. [PMID: 29480677 PMCID: PMC6159363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pseudomonas aeruginosa is characterized by a notable intrinsic resistance to antibiotics, mainly mediated by the expression of inducible chromosomic β-lactamases and the production of constitutive or inducible efflux pumps. Apart from this intrinsic resistance, P. aeruginosa possess an extraordinary ability to develop resistance to nearly all available antimicrobials through selection of mutations. The progressive increase in resistance rates in P. aeruginosa has led to the emergence of strains which, based on their degree of resistance to common antibiotics, have been defined as multidrug resistant, extended-resistant and panresistant strains. These strains are increasingly disseminated worldwide, progressively complicating the treatment of P. aeruginosa infections. In this scenario, the objective of the present guidelines was to review and update published evidence for the treatment of patients with acute, invasive and severe infections caused by P. aeruginosa. To this end, mechanisms of intrinsic resistance, factors favoring development of resistance during antibiotic exposure, prevalence of resistance in Spain, classical and recently appeared new antibiotics active against P. aeruginosa, pharmacodynamic principles predicting efficacy, clinical experience with monotherapy and combination therapy, and principles for antibiotic treatment were reviewed to elaborate recommendations by the panel of experts for empirical and directed treatment of P. aeruginosa invasive infections.
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Affiliation(s)
- José Mensa
- Servicio de Enfermedades Infecciosas, Hospital Clinic, Barcelona, Spain
| | - José Barberán
- Servicio de Medicina Enfermedades infecciosas, Hospital Universitario HM Montepríncipe, Universidad San Pablo CEU. Madrid, Spain
| | - Alex Soriano
- Servicio de Enfermedades Infecciosas, Hospital Clinic, Barcelona, Spain
| | - Pedro Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, Spain
| | - Francesc Marco
- Servicio de Microbiología, Hospital Clinic, Barcelona, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid, Spain
| | - German Bou
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, Spain
| | | | - Emilio Maseda
- Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, Spain
| | - José Ramón Azanza
- Servicio de Farmacología, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Juan Pasquau
- Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen de la Nieves, Granada, Spain
| | | | - José María Reguera
- Servicio de Enfermedades Infecciosas, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Dolores Sousa
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, Spain
| | - Joaquín Gómez
- Servicio de Enfermedades Infecciosas, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Miguel Montejo
- Servicio de Enfermedades Infecciosas, Hospital Universitario Cruces, Bilbao, Spain
| | - Marcio Borges
- Servicio de Medicina Intensiva, Hospital Son Llátzer, Palma de Mallorca, Spain
| | - Antonio Torres
- Departamento de Neumología, Hospital Clinic, Barcelona, Spain
| | | | - Miguel Salavert
- Unidad de Enfermedades Infecciosas. Hospital Univeristario la Fe, Valencia, Spain
| | - Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria Illes Balears (idISBa), Palma de Mallorca, Spain
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Tang SY, Zhang SW, Wu JD, Wu F, Zhang J, Dong JT, Guo P, Zhang DL, Yang JT, Zhang WJ. Comparison of mono- and combination antibiotic therapy for the treatment of Pseudomonas aeruginosa bacteraemia: A cumulative meta-analysis of cohort studies. Exp Ther Med 2018; 15:2418-2428. [PMID: 29456647 PMCID: PMC5795571 DOI: 10.3892/etm.2018.5727] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 08/04/2017] [Indexed: 12/14/2022] Open
Abstract
It is currently unknown whether antibiotic monotherapy or combination therapy is a more effective treatment for patients with Pseudomonas aeruginosa bacteraemia. The present study consists of a systematic review and meta-analysis of cohort studies in associated studies. The treatment options of monotherapy and combination therapy have been compared, to determine which is more effective against P. aeruginosa bacteraemia. Several electronic bibliographic databases were systematically searched and clinical studies that compared combination therapy with monotherapy for P. aeruginosa bacteraemia were identified. Dersimonian and Laird's random-effects models were used to generate summary estimates of the effects and to assess their association according to different patient characteristics and research quality standards. A total of 17 studies were selected, 3 of which were prospective while the remaining 14 were retrospective. The studies involved a total of 2,504 patients. Significant differences between combination therapy and monotherapy treatment were not found when the data were combined (odds ratio (OR)=0.81, 95% confidence interval (CI)=0.61–1.08; P=0.035). The results demonstrated strength in a number of stratification and sensitivity analyses. The variables used included study type, treatment quality score and survival rate of subgroup analysis. To conduct cumulative meta-analysis, the number of years and samples were calculated. The OR value and 95% CI were stable and demonstrated good change trend. According to the size of the sample order following accumulation, OR values and 95% CI (0.89, 0.76–1.04) exhibited a narrow range. Neither combination therapy or monotherapy exhibited significant effects on the mortality of patients with P. aeruginosa bacteraemia. Future research is required and should include large, well-designed prospective cohorts, and grouped clinical studies.
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Affiliation(s)
- Su Yu Tang
- Intensive Care Unit, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Shun Wen Zhang
- Department of First Clinical Medicine, The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu 211166, P.R. China
| | - Jiang Dong Wu
- Department of Pathophysiology, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Fang Wu
- Department of Pathophysiology, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Jie Zhang
- Intensive Care Unit, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Jiang Tao Dong
- Intensive Care Unit, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Peng Guo
- Intensive Care Unit, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Da Long Zhang
- Intensive Care Unit, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Jun Ting Yang
- Department of Pathophysiology, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
| | - Wan Jiang Zhang
- Department of Pathophysiology, The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang 832002, P.R. China
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McCarthy KL, Cherian JD, Avent ML, Paterson DL. Combination antibiotic therapy for Pseudomonas aeruginosa bacteremia in febrile neutropenic patients? The question still remains. Infect Dis (Lond) 2017; 50:403-406. [PMID: 29205079 DOI: 10.1080/23744235.2017.1411605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Kate L McCarthy
- a University of Queensland Centre for Clinical Research , Brisbane , Australia
| | - Jacob D Cherian
- a University of Queensland Centre for Clinical Research , Brisbane , Australia
| | - Minyon L Avent
- a University of Queensland Centre for Clinical Research , Brisbane , Australia
| | - David L Paterson
- a University of Queensland Centre for Clinical Research , Brisbane , Australia
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14
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Salmonella and Campylobacter : Antimicrobial resistance and bacteriophage control in poultry. Food Microbiol 2016; 53:104-9. [DOI: 10.1016/j.fm.2015.09.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/12/2015] [Accepted: 09/10/2015] [Indexed: 01/21/2023]
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15
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Bassetti M, De Waele JJ, Eggimann P, Garnacho-Montero J, Kahlmeter G, Menichetti F, Nicolau DP, Paiva JA, Tumbarello M, Welte T, Wilcox M, Zahar JR, Poulakou G. Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria. Intensive Care Med 2015; 41:776-95. [PMID: 25792203 PMCID: PMC7080151 DOI: 10.1007/s00134-015-3719-z] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/24/2015] [Indexed: 01/06/2023]
Abstract
The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy,
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16
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Characteristics, risk factors and outcomes of adult cancer patients with extensively drug-resistant Pseudomonas aeruginosa infections. Infection 2014; 42:721-8. [DOI: 10.1007/s15010-014-0635-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 05/10/2014] [Indexed: 02/05/2023]
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17
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Bowers DR, Tam VH. Pseudomonas aeruginosatreatment and transmission reduction. Expert Rev Anti Infect Ther 2014; 11:831-7. [DOI: 10.1586/14787210.2013.816463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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18
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Paul M, Lador A, Grozinsky‐Glasberg S, Leibovici L. Beta lactam antibiotic monotherapy versus beta lactam-aminoglycoside antibiotic combination therapy for sepsis. Cochrane Database Syst Rev 2014; 2014:CD003344. [PMID: 24395715 PMCID: PMC6517128 DOI: 10.1002/14651858.cd003344.pub3] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Optimal antibiotic treatment for sepsis is imperative. Combining a beta lactam antibiotic with an aminoglycoside antibiotic may provide certain advantages over beta lactam monotherapy. OBJECTIVES Our objectives were to compare beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy in patients with sepsis and to estimate the rate of adverse effects with each treatment regimen, including the development of bacterial resistance to antibiotics. SEARCH METHODS In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11); MEDLINE (1966 to 4 November 2013); EMBASE (1980 to November 2013); LILACS (1982 to November 2013); and conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (1995 to 2013). We scanned citations of all identified studies and contacted all corresponding authors. In our previous review, we searched the databases to July 2004. SELECTION CRITERIA We included randomized and quasi-randomized trials comparing any beta lactam monotherapy versus any combination of a beta lactam with an aminoglycoside for sepsis. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause mortality. Secondary outcomes included treatment failure, superinfections and adverse events. Two review authors independently collected data. We pooled risk ratios (RRs) with 95% confidence intervals (CIs) using the fixed-effect model. We extracted outcomes by intention-to-treat analysis whenever possible. MAIN RESULTS We included 69 trials that randomly assigned 7863 participants. Twenty-two trials compared the same beta lactam in both study arms, while the remaining trials compared different beta lactams using a broader-spectrum beta lactam in the monotherapy arm. In trials comparing the same beta lactam, we observed no difference between study groups with regard to all-cause mortality (RR 0.97, 95% CI 0.73 to 1.30) and clinical failure (RR 1.11, 95% CI 0.95 to 1.29). In studies comparing different beta lactams, we observed a trend for benefit with monotherapy for all-cause mortality (RR 0.85, 95% CI 0.71 to 1.01) and a significant advantage for clinical failure (RR 0.75, 95% CI 0.67 to 0.84). No significant disparities emerged from subgroup and sensitivity analyses, including assessment of participants with Gram-negative infection. The subgroup of Pseudomonas aeruginosa infections was underpowered to examine effects. Results for mortality were classified as low quality of evidence mainly as the result of imprecision. Results for failure were classified as very low quality of evidence because of indirectness of the outcome and possible detection bias in non-blinded trials. We detected no differences in the rate of development of resistance. Nephrotoxicity was significantly less frequent with monotherapy (RR 0.30, 95% CI 0.23 to 0.39). We found no heterogeneity for all these comparisons.We included a small subset of studies addressing participants with Gram-positive infection, mainly endocarditis. We identified no difference between monotherapy and combination therapy in these studies. AUTHORS' CONCLUSIONS The addition of an aminoglycoside to beta lactams for sepsis should be discouraged. All-cause mortality rates are unchanged. Combination treatment carries a significant risk of nephrotoxicity.
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Affiliation(s)
- Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Adi Lador
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Simona Grozinsky‐Glasberg
- Dept of Medicine, Hadassah‐Hebrew University Medical CenterNeuroendocrine Tumors Unit, Endocrinology & Metabolism ServicePOB 12000JerusalemIsrael91120
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
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Hu Y, Li L, Li W, Xu H, He P, Yan X, Dai H. Combination antibiotic therapy versus monotherapy for Pseudomonas aeruginosa bacteraemia: A meta-analysis of retrospective and prospective studies. Int J Antimicrob Agents 2013; 42:492-6. [DOI: 10.1016/j.ijantimicag.2013.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/19/2013] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
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Petrosillo N, Giannella M, Lewis R, Viale P. Treatment of carbapenem-resistant Klebsiella pneumoniae: the state of the art. Expert Rev Anti Infect Ther 2013; 11:159-77. [PMID: 23409822 DOI: 10.1586/eri.12.162] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The increasing incidence of carbapenem-resistant Klebsiella pneumoniae (CR-KP) fundamentally alters the management of patients at risk to be colonized or infected by such microorganisms. Owing to the limitation in efficacy and potential for toxicity of the alternative agents, many experts recommend using combination therapy instead of monotherapy in CR-KP-infected patients. However, in the absence of well-designed comparative studies, the best combination for each infection type, the continued role for carbapenems in combination therapy and when combination therapy should be started remain open questions. Herein, the authors revise current microbiological and clinical evidences supporting combination therapy for CR-KP infections to address some of these issues.
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Affiliation(s)
- Nicola Petrosillo
- 2nd Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
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Poulikakos P, Falagas ME. Aminoglycoside therapy in infectious diseases. Expert Opin Pharmacother 2013; 14:1585-97. [DOI: 10.1517/14656566.2013.806486] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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22
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Risk factors influencing mortality related to Stenotrophomonas maltophilia infection in hematology-oncology patients. Int J Hematol 2013; 97:414-20. [PMID: 23430671 DOI: 10.1007/s12185-013-1296-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 02/07/2013] [Accepted: 02/08/2013] [Indexed: 10/27/2022]
Abstract
Stenotrophomonas maltophilia infection is of concern in patients with cancer. Antibiotics active against S. maltophilia are rarely used in the treatment of febrile neutropenia, making it important to identify the factors influencing mortality in cancer patients with S. maltophilia infection. The objective of this study was to analyze the clinical characteristics and outcomes of cancer and hemopathic patients with S. maltophilia infection and assess the factors influencing the mortality. The microbiology laboratory records of Erciyes University, Faculty of Medicine Hospital were reviewed to retrospectively identify patients with S. maltophilia infection between January 2007 and June 2011. A total of 38 patients (25 male, 13 female) were eligible for the study. The median age of the patients was 53 years. The underlying disease was hematological malignancy and disorders in 76.3 % (29 cases), solid tumors in 15.8 % (six cases), aplastic anemia in 7.9 % (three cases), while 18.4 % (seven cases) were hematopoietic stem cell transplantation (HSCT) recipients. An indwelling central venous catheter was used in 32 cases (84.2 %). Twenty-seven patients (71.1 %) were neutropenic at the onset of infection. Nine patients (23.7 %) were receiving corticosteroid therapy. The overall 14-day mortality rate was 50 %. Three of the patients received empirical antibacterial treatment, and three HSCT recipients received trimethoprim-sulfamethoxazole prophylaxis, which is active against S. maltophilia. Severe sepsis (OR 13.24, 95 % confidence interval (CI) 1.62-108.57) and the duration of the treatment (OR 0.73, 95 % CI 0.60-0.90) were related to death based on logistic regression analysis findings. In immunocompromised hematology-oncology patients with severe sepsis, S. maltophilia should be considered as a possible cause of infection, and should be given effective empirical antibiotic treatment immediately; the antimicrobial spectrum may be narrowed according to results of antibiotic susceptibility test.
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β-Lactam plus aminoglycoside or fluoroquinolone combination versus β-lactam monotherapy for Pseudomonas aeruginosa infections: a meta-analysis. Int J Antimicrob Agents 2013; 41:301-10. [PMID: 23410791 DOI: 10.1016/j.ijantimicag.2012.12.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/11/2012] [Indexed: 11/24/2022]
Abstract
The objective of this review was to compare the effectiveness and safety of β-lactam combined with aminoglycoside or fluoroquinolone with that of β-lactam monotherapy for the treatment of Pseudomonas aeruginosa infections. We searched Scopus and PubMed databases and synthesised the outcomes of the individual studies in a meta-analysis. Both non-randomised studies and randomised controlled trials (RCTs) that evaluated outcomes of patients with P. aeruginosa infections receiving treatment with β-lactams alone or in combination with an aminoglycoside or a fluoroquinolone were included. Studies including patients with cystic fibrosis were excluded. Nineteen articles (eight RCTs) were included (1721 patients with P. aeruginosa infections). Patients receiving combination therapy had no difference in mortality compared with patients receiving β-lactam monotherapy either as definitive (risk ratio=0.97, 95% confidence interval 0.77-1.22) or as empirical treatment (1.02, 0.78-1.34). In the definitive treatment group, no difference in mortality was found between combination therapy and monotherapy for patients with bacteraemia (0.95, 0.67-1.34) or severe infections (0.96, 0.75-1.24). Patients receiving definitive combination therapy had non-significantly higher clinical cure compared with patients receiving β-lactam monotherapy (1.36, 0.99-1.86). A higher clinical cure rate was observed for patients receiving empirical treatment with combination therapy (1.23, 1.05-1.43). There was no difference in clinical cure either for RCTs (1.29, 0.91-1.83) or for non-randomised studies (1.18, 0.97-1.45). In conclusion, no benefit in mortality was observed in patients receiving combination therapy for P. aeruginosa infections. A well-designed multicentre RCT is warranted to address this important issue.
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Outcomes of appropriate empiric combination versus monotherapy for Pseudomonas aeruginosa bacteremia. Antimicrob Agents Chemother 2012; 57:1270-4. [PMID: 23263001 DOI: 10.1128/aac.02235-12] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pseudomonas aeruginosa bacteremia is associated with high hospital mortality. Empirical combination therapy is commonly used to increase the likelihood of appropriate therapy, but the benefits of employing >1 active agent have yet to be established. The purpose of this study was to compare outcomes of patients receiving appropriate empirical combination versus monotherapy for P. aeruginosa bacteremia. This was a retrospective, multicenter, cohort study of hospitalized adult patients with P. aeruginosa bacteremia from 2002 to 2011. The primary endpoint (30-day mortality) was assessed using multivariate logistic regression, adjusting for underlying confounding variables. Secondary endpoints of hospital mortality and time to mortality were assessed by Fisher's exact test and the Cox proportional hazards model, respectively. A total of 384 patients were analyzed. Thirty-day mortality was higher for patients receiving inappropriate therapy than for those receiving appropriate empirical therapy (43.8% versus 21.5%; P = 0.03). However, there were no statistical differences in 30-day mortality following appropriate empirical combination versus monotherapy after adjusting for baseline APACHE II scores and lengths of hospital stay prior to the onset of bacteremia (P = 0.55). Observed hospital mortality was 36.6% for patients administered combination therapy, compared with 28.7% for monotherapy patients (P = 0.17). After adjusting for baseline APACHE II scores, the relationship between time to mortality and combination therapy was not statistically significant (P = 0.59). Overall, no significant differences were observed for 30-day mortality, hospital mortality, and time to mortality between combination and monotherapy for P. aeruginosa bacteremia. Empirical combination therapy did not appear to offer an additional benefit, as long as the isolate was susceptible to at least one antimicrobial agent.
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Falagas ME, Tansarli GS, Ikawa K, Vardakas KZ. Clinical Outcomes With Extended or Continuous Versus Short-term Intravenous Infusion of Carbapenems and Piperacillin/Tazobactam: A Systematic Review and Meta-analysis. Clin Infect Dis 2012; 56:272-82. [DOI: 10.1093/cid/cis857] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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