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Merdad R, Alyami A, Basalim A, Alzahrani A, Aldainiy A, Awadh A, Ghulam E, Farahat F. Bloodstream gram-negative bacterial infections in adult patients with leukemia: A retrospective review of medical records in a tertiary care hospital in Western Saudi Arabia. J Infect Public Health 2023; 16:1525-1530. [PMID: 37557008 DOI: 10.1016/j.jiph.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/18/2023] [Accepted: 07/17/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Patients with neutropenic cancers are at high risk of acquiring infections, especially if on chemotherapy. Gram-negative bacterial infections are associated with high mortality. This study aimed to assess clinical characteristics, outcomes, and epidemiology of gram-negative bacterial (GNB) bloodstream infections (BSI) in adult patients with leukemia. METHODS This single-center, retrospective study included 102 adult patients diagnosed with leukemia between 2017 and 2019. The patients' demographics, infection diagnosis, leukemia diagnosis, comorbidities, and infection outcomes were collected from electronic medical records. RESULTS The most common GNB were Klebsiella pneumoniae (33.3 %), Pseudomonas aeruginosa (23.5 %), and Escherichia coli (17.6 %). Additionally, 36.7 % of infections were multidrug resistant. The most common comorbidities were cardiovascular diseases (36.7 %), diabetes mellitus (33.3 %), and liver diseases (24.1 %). GNB-infected patients had a higher mortality than noninfected patients (35.3 % and 11.8 %, respectively, p = 0.005). In a multivariable analysis, patients with acute myeloid leukemia and acute lymphoid leukemia were significantly more likely to acquire GNB BSI (p = 0.01), while patients with chronic myelogenous leukemia and chronic lymphocytic leukemia had a lower likelihood of developing GNB BSI. In addition, low hemoglobin level was an independent risk factor of GNB BSI (p = 0.001). Chemotherapeutic agents showed an association with increased risk of GNB BSI. CONCLUSIONS Patients with acute leukemia and low hemoglobin levels have increased risk of GNB BSI, which was associated with increased mortality. Prospective studies are needed to further assess the effect of co-morbidities and chemotherapy medications on the occurrence of GNB BSI according to the type of leukemia.
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Affiliation(s)
- Reyan Merdad
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia; King Abdullah International Medical Research Center, Saudi Arabia
| | - Almuhanad Alyami
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia; King Abdullah International Medical Research Center, Saudi Arabia
| | - Ahmed Basalim
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia; King Abdullah International Medical Research Center, Saudi Arabia
| | - Abdulrahman Alzahrani
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia; King Abdullah International Medical Research Center, Saudi Arabia
| | - Ahmed Aldainiy
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia; King Abdullah International Medical Research Center, Saudi Arabia
| | - Abdullah Awadh
- King Abdullah International Medical Research Center, Saudi Arabia; Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
| | - Enas Ghulam
- King Abdullah International Medical Research Center, Saudi Arabia; Basic Science Department, College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia
| | - Fayssal Farahat
- King Abdullah International Medical Research Center, Saudi Arabia; College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Community and Public Health, Infection Prevention and Control Program, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; Department of Community Medicine and Public Health, College of Medicine, Menoufia University, Egypt.
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Xiao YH, Liu MF, Wu H, Xu DR, Zhao R. Clinical Efficacy and Diagnostic Value of Metagenomic Next-Generation Sequencing for Pathogen Detection in Patients with Suspected Infectious Diseases: A Retrospective Study from a Large Tertiary Hospital. Infect Drug Resist 2023; 16:1815-1828. [PMID: 37016633 PMCID: PMC10066896 DOI: 10.2147/idr.s401707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
Purpose Metagenomic next-generation sequencing (mNGS) is a powerful yet unbiased method to identify pathogens in suspected infections. However, little is known about its clinical effectiveness. The present study aimed to assess the efficacy of mNGS in routine clinical practice. Patients and Methods In this single-center retrospective cohort study, 518 patients with suspected infectious diseases were assessed for inclusion. Among them, each patient had undergone mNGS testing; 407 patients had undergone both microbial culture and mNGS testing. The result of mNGS testing was compared to microbial culture performed concurrently. The diagnostic performance of mNGS was evaluated using the comprehensive clinical diagnosis as the reference standard. Results There was a significant difference in the positive detection rates of pathogens between mNGS and culture (331/407, 81.3% vs 79/407, 19.4%, P < 0.001). The sensitivity of mNGS was much higher than the culture method (79.5% vs 21.3%, P < 0.001), especially in sample types of sputum and bronchoalveolar lavage fluid (BALF). Notably, the sensitivity of blood mNGS was relatively lower than other sample types (67.4% vs 88.9-93.8%). Pathogen cfDNA load based on standardized stringently mapped read number at the species level of microorganisms (SDSMRN) was significantly lower in blood than in other sample types from the same patient (P = 0.0003). Importantly, mNGS directly led to a change of treatment regimen in 142 (27.4%) cases, including antibiotic escalation (15.3%), antibiotic de-escalation (9.1%), and early definitive diagnosis to initiate appropriate treatment (3.1%). Conclusion Our in-house mNGS platform significantly improved the sensitivity for the diagnosis of infectious diseases. mNGS has the potential to improve clinical outcomes by optimizing antimicrobial therapy.
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Affiliation(s)
- Yang-Hua Xiao
- Department of Clinical Laboratory, Medical Center for Burn and Plastic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- School of Public Health, Nanchang University, Nanchang, People’s Republic of China
| | - Mei-Fang Liu
- Department of Clinical Laboratory, Medical Center for Burn and Plastic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Hongwen Wu
- Department of Clinical Laboratory, Medical Center for Burn and Plastic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Department of Medical Instruments, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - De-Rong Xu
- Department of Clinical Laboratory, Medical Center for Burn and Plastic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
- Correspondence: De-Rong Xu; Rui Zhao, Email ;
| | - Rui Zhao
- Department of Clinical Laboratory, Medical Center for Burn and Plastic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
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Cheng J, Li Q, Zhang G, Xu H, Li Y, Tian X, Chen D, Luo Z. Time to appropriate antimicrobial therapy serves an independent prognostic indicator in children with nosocomial Klebsiella pneumoniae bloodstream infection. BMC Pediatr 2022; 22:568. [PMID: 36192715 PMCID: PMC9531447 DOI: 10.1186/s12887-022-03622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/20/2022] [Indexed: 02/08/2023] Open
Abstract
We tend to investigate the connection between time to appropriate therapy (TTAT) and prognosis in pediatric patients with nosocomial Klebsiella pneumoniae (K. pneumoniae) bloodstream infection, and find the optimal cutoff point for the empirical administration of antimicrobials. This retrospective study was conducted in Children's Hospital of Chongqing Medical University, and inpatients with nosocomial K. pneumoniae bloodstream infection were finally enrolled. We applied the Classification and Regression Tree (CART) analysis to find the TTAT cutoff point and the Logistic Regression analysis to evaluate prognostic indicators. The incidence of septic shock and mortality was 17.91% (12/67) and 13.43% (9/67), respectively. The CART-derived TTAT cutoff point was 10.7 h. The multivariate logistic regression analysis indicated delayed therapy (TTAT ≥ 10.7 h), pediatric risk of mortality (PRISM) III scores ≥ 10, time to positivity (TTP) ≤ 13 h, and requiring for invasive mechanical ventilation were independently associated with the incidence of septic shock (Odds ratio [OR] 9.87, 95% Confidence interval [CI] 1.46-66.59, P = 0.019; OR 9.69, 95% CI 1.15-81.39, P = 0.036; OR 8.28, 95% CI 1.37-50.10, P = 0.021; OR 6.52, 95% CI 1.08-39.51, P = 0.042; respectively) and in-hospital mortality (OR 22.19, 95% CI 1.25-393.94, P = 0.035; OR 40.06, 95% CI 2.32-691.35, P = 0.011; OR 22.60, 95% CI 1.78-287.27, P = 0.016; OR 12.21, 95% CI 1.06-140.67, P = 0.045; respectively).Conclusions: TTAT is an independent predictor of poor outcomes in children with nosocomial K. pneumoniae bloodstream infection. Initial appropriate antimicrobial therapy should be administrated timely and within 10.7 h from the onset of bloodstream infection is recommended.
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Affiliation(s)
- Jie Cheng
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Qinyuan Li
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Guangli Zhang
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Huiting Xu
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Yuanyuan Li
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Xiaoyin Tian
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China
| | - Dapeng Chen
- Department of Clinical Laboratory Center, Children's Hospital of Chongqing Medical University, Chongqing, 401122, China
| | - Zhengxiu Luo
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorder, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 401122, China.
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Ginestra JC, Kohn R, Hubbard RA, Crane-Droesch A, Halpern SD, Kerlin MP, Weissman GE. Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis. Ann Am Thorac Soc 2022; 19:1525-1533. [PMID: 35312462 PMCID: PMC9447380 DOI: 10.1513/annalsats.202112-1360oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.
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Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Palliative and Advanced Illness Research (PAIR) Center
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Crane-Droesch
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
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5
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Kim G, Ahn D, Kang M, Park J, Ryu D, Jo Y, Song J, Ryu JS, Choi G, Chung HJ, Kim K, Chung DR, Yoo IY, Huh HJ, Min HS, Lee NY, Park Y. Rapid species identification of pathogenic bacteria from a minute quantity exploiting three-dimensional quantitative phase imaging and artificial neural network. LIGHT, SCIENCE & APPLICATIONS 2022; 11:190. [PMID: 35739098 PMCID: PMC9226356 DOI: 10.1038/s41377-022-00881-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 05/14/2023]
Abstract
The healthcare industry is in dire need of rapid microbial identification techniques for treating microbial infections. Microbial infections are a major healthcare issue worldwide, as these widespread diseases often develop into deadly symptoms. While studies have shown that an early appropriate antibiotic treatment significantly reduces the mortality of an infection, this effective treatment is difficult to practice. The main obstacle to early appropriate antibiotic treatments is the long turnaround time of the routine microbial identification, which includes time-consuming sample growth. Here, we propose a microscopy-based framework that identifies the pathogen from single to few cells. Our framework obtains and exploits the morphology of the limited sample by incorporating three-dimensional quantitative phase imaging and an artificial neural network. We demonstrate the identification of 19 bacterial species that cause bloodstream infections, achieving an accuracy of 82.5% from an individual bacterial cell or cluster. This performance, comparable to that of the gold standard mass spectroscopy under a sufficient amount of sample, underpins the effectiveness of our framework in clinical applications. Furthermore, our accuracy increases with multiple measurements, reaching 99.9% with seven different measurements of cells or clusters. We believe that our framework can serve as a beneficial advisory tool for clinicians during the initial treatment of infections.
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Affiliation(s)
- Geon Kim
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea
| | - Daewoong Ahn
- Tomocube Inc., Daejeon, 34109, Republic of Korea
| | - Minhee Kang
- Smart Healthcare & Device Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Jinho Park
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea
| | - DongHun Ryu
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea
| | - YoungJu Jo
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea
- Tomocube Inc., Daejeon, 34109, Republic of Korea
- Department of Applied Physics, Stanford University, Stanford, CA, 94305, USA
| | - Jinyeop Song
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea
- Department of Physics, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Jea Sung Ryu
- Graduate School of Nanoscience and Technology, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
| | - Gunho Choi
- Tomocube Inc., Daejeon, 34109, Republic of Korea
| | - Hyun Jung Chung
- Graduate School of Nanoscience and Technology, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
- Department of Biological Sciences, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Bundang CHA Hospital, Seongnam-si, Gyeonggi-Do, 13496, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - In Young Yoo
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | | | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea.
| | - YongKeun Park
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, 34141, Republic of Korea.
- KAIST Institute for Health Science and Technology, KAIST, Daejeon, 34141, Republic of Korea.
- Tomocube Inc., Daejeon, 34109, Republic of Korea.
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6
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Green SB, Stover KR, Barber K, Bouchard JL, Brown ML, Deri CR, Francis BJ, Gauthier TP, Hayes JE, Marx AH, McGee EU, Mediwala K, Musgrove RJ, Slain D, Stramel SA, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2020. Open Forum Infect Dis 2021; 8:ofab422. [PMID: 34557559 PMCID: PMC8454524 DOI: 10.1093/ofid/ofab422] [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: 07/28/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
The number of articles related to antimicrobial stewardship published each year has increased significantly over the last decade. Keeping up with the literature, particularly the most innovative, well-designed, or applicable to one’s own practice area, can be challenging. The Southeastern Research Group Endeavor (SERGE-45) network reviewed antimicrobial stewardship–related, peer-reviewed literature from 2020 that detailed actionable interventions. The top 13 publications were summarized following identification using a modified Delphi technique. This article highlights the selected interventions and may serve as a key resource for teaching and training, and to identify novel or optimized stewardship opportunities within one’s institution.
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Affiliation(s)
- Sarah B Green
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Katie Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Matthew L Brown
- Department of Pharmacy, University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Bailey J Francis
- Department of Pharmacy, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Timothy P Gauthier
- Baptist Health South Florida, Clinical Pharmacy Enterprise, Miami, Florida, USA
| | - Jillian E Hayes
- Department of Pharmacy AdventHealth Orlando, Orlando, Florida, USA
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Edoabasi U McGee
- Department of Pharmacy Practice, Philadelphia College of Osteopathic Medicine-Georgia Campus, School of Pharmacy, Suwanee, Georgia, USA
| | - Krutika Mediwala
- Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Rachel J Musgrove
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, Georgia, USA
| | - Douglas Slain
- Department of Clinical Pharmacy and Section of Infectious Diseases, West Virginia University, Morgantown, West Virginia, USA
| | - Stefanie A Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, Texas, USA
| | - Christopher M Bland
- Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Georgia, USA
| | - P Brandon Bookstaver
- Department of Pharmacy, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA
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Banerjee R, Komarow L, Virk A, Rajapakse N, Schuetz AN, Dylla B, Earley M, Lok J, Kohner P, Ihde S, Cole N, Hines L, Reed K, Garner OB, Chandrasekaran S, de St Maurice A, Kanatani M, Curello J, Arias R, Swearingen W, Doernberg SB, Patel R. Randomized Trial Evaluating Clinical Impact of RAPid IDentification and Susceptibility Testing for Gram-negative Bacteremia: RAPIDS-GN. Clin Infect Dis 2021; 73:e39-e46. [PMID: 32374822 DOI: 10.1093/cid/ciaa528] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/30/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Rapid blood culture diagnostics are of unclear benefit for patients with gram-negative bacilli (GNB) bloodstream infections (BSIs). We conducted a multicenter, randomized, controlled trial comparing outcomes of patients with GNB BSIs who had blood culture testing with standard-of-care (SOC) culture and antimicrobial susceptibility testing (AST) vs rapid organism identification (ID) and phenotypic AST using the Accelerate Pheno System (RAPID). METHODS Patients with positive blood cultures with Gram stains showing GNB were randomized to SOC testing with antimicrobial stewardship (AS) review or RAPID with AS. The primary outcome was time to first antibiotic modification within 72 hours of randomization. RESULTS Of 500 randomized patients, 448 were included (226 SOC, 222 RAPID). Mean (standard deviation) time to results was faster for RAPID than SOC for organism ID (2.7 [1.2] vs 11.7 [10.5] hours; P < .001) and AST (13.5 [56] vs 44.9 [12.1] hours; P < .001). Median (interquartile range [IQR]) time to first antibiotic modification was faster in the RAPID arm vs the SOC arm for overall antibiotics (8.6 [2.6-27.6] vs 14.9 [3.3-41.1] hours; P = .02) and gram-negative antibiotics (17.3 [4.9-72] vs 42.1 [10.1-72] hours; P < .001). Median (IQR) time to antibiotic escalation was faster in the RAPID arm vs the SOC arm for antimicrobial-resistant BSIs (18.4 [5.8-72] vs 61.7 [30.4-72] hours; P = .01). There were no differences between the arms in patient outcomes. CONCLUSIONS Rapid organism ID and phenotypic AST led to faster changes in antibiotic therapy for gram-negative BSIs. CLINICAL TRIALS REGISTRATION NCT03218397.
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Affiliation(s)
- Ritu Banerjee
- Division of Pediatric Infectious Diseases, Vanderbilt University, Nashville, Tennessee, USA
| | - Lauren Komarow
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Abinash Virk
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nipunie Rajapakse
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Audrey N Schuetz
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brenda Dylla
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle Earley
- Biostatistics Center, George Washington University, Rockville, Maryland, USA
| | - Judith Lok
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA
| | - Peggy Kohner
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherry Ihde
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicolynn Cole
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Hines
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Katelyn Reed
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Omai B Garner
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Sukantha Chandrasekaran
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Annabelle de St Maurice
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Meganne Kanatani
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Jennifer Curello
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Rubi Arias
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - William Swearingen
- Divisions of Pathology and Infectious Diseases, University of California, Los Angeles, California, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, University of California, San Francisco, California, USA
| | - Robin Patel
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
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Irwin AD, Coin LJM, Harris PNA, Cotta MO, Bauer MJ, Buckley C, Balch R, Kruger P, Meyer J, Shekar K, Brady K, Fourie C, Sharp N, Vlad L, Whiley D, Beatson SA, Forde BM, Paterson D, Clark J, Hajkowicz K, Raman S, Bialasiewicz S, Lipman J, Schlapbach LJ, Roberts JA. Optimising Treatment Outcomes for Children and Adults Through Rapid Genome Sequencing of Sepsis Pathogens. A Study Protocol for a Prospective, Multi-Centre Trial (DIRECT). Front Cell Infect Microbiol 2021; 11:667680. [PMID: 34249774 PMCID: PMC8261237 DOI: 10.3389/fcimb.2021.667680] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Sepsis contributes significantly to morbidity and mortality globally. In Australia, 20,000 develop sepsis every year, resulting in 5,000 deaths, and more than AUD$846 million in expenditure. Prompt, appropriate antibiotic therapy is effective in improving outcomes in sepsis. Conventional culture-based methods to identify appropriate therapy have limited yield and take days to complete. Recently, nanopore technology has enabled rapid sequencing with real-time analysis of pathogen DNA. We set out to demonstrate the feasibility and diagnostic accuracy of pathogen sequencing direct from clinical samples, and estimate the impact of this approach on time to effective therapy when integrated with personalised software-guided antimicrobial dosing in children and adults on ICU with sepsis. Methods The DIRECT study is a pilot prospective, non-randomized multicentre trial of an integrated diagnostic and therapeutic algorithm combining rapid direct pathogen sequencing and software-guided, personalised antibiotic dosing in children and adults with sepsis on ICU. Participants and interventions DIRECT will collect microbiological and pharmacokinetic samples from approximately 200 children and adults with sepsis admitted to one of four ICUs in Brisbane. In Phase 1, we will evaluate Oxford Nanopore Technologies MinION sequencing direct from blood in 50 blood culture-proven sepsis patients recruited from consecutive patients with suspected sepsis. In Phase 2, a further 50 consecutive patients with suspected sepsis will be recruited in whom MinION sequencing will be combined with Bayesian software-guided (ID-ODS) personalised antimicrobial dosing. Outcome measures The primary outcome is time to effective antimicrobial therapy, defined as trough drug concentrations above the MIC of the pathogen. Secondary outcomes are diagnostic accuracy of MinION sequencing from whole blood, time to pathogen identification and susceptibility testing using sequencing direct from whole blood and from positive blood culture broth. Discussion Rapid pathogen sequencing coupled with antimicrobial dosing software has great potential to overcome the limitations of conventional diagnostics which often result in prolonged inappropriate antimicrobial therapy. Reduced time to optimal antimicrobial therapy may reduce sepsis mortality and ICU length of stay. This pilot study will yield key feasibility data to inform further, urgently needed sepsis studies. Phase 2 of the trial protocol is registered with the ANZCTR (ACTRN12620001122943). Trial registration Registered with the Australia New Zealand Clinical Trials Registry Number ACTRN12620001122943
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Affiliation(s)
- Adam D Irwin
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Lachlan J M Coin
- Department of Microbiology and Immunology, University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Patrick N A Harris
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Menino Osbert Cotta
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Michelle J Bauer
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Cameron Buckley
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Ross Balch
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Jason Meyer
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kiran Shekar
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Kara Brady
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Cheryl Fourie
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Brisbane, QLD, Australia
| | - Natalie Sharp
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Luminita Vlad
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - David Whiley
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Scott A Beatson
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Brian M Forde
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - David Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Julia Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Krispin Hajkowicz
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, Brisbane, QLD, Australia
| | - Sainath Raman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | - Seweryn Bialasiewicz
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.,Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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9
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Yiang GT, Tzeng IS, Shui HA, Wu MY, Peng MY, Chan CY, Chan ED, Wu YK, Lan CC, Yang MC, Huang KL, Wu CW, Chang CH, Su WL. Early Screening of Risk for Multidrug-Resistant Organisms in the Emergency Department in Patients With Pneumonia and Early Septic Shock: Single-Center, Retrospective Cohort Study. Shock 2021; 55:198-209. [PMID: 32694392 DOI: 10.1097/shk.0000000000001599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Pneumonia is the fourth leading cause of death globally, with rapid progression during sepsis. Multidrug-resistant organisms (MDROs) are becoming more common with some healthcare-associated pneumonia events. Early detection of MDRO risk improves the outcomes; however, MDROs risk in pneumonia with sepsis is unknown. This study investigated the disease outcomes of pneumonia with septic shock in patients admitted in the emergency department (ED) intensive care unit (ICU), a population with a high prevalence of MDROs, after early screening of MDROs risk. METHODS In this retrospective cohort study, patients with pneumonia and early septic shock (n = 533) admitted to the ED at the Taipei Tzu Chi Hospital from 2013 to 2019 were selected. The study population was divided into four subgroups after the MDROs risk and screening procedure were completed within 1 or 6 h of admission. ICU mortality and multidrug antibiotic therapy were compared. RESULTS The high-risk MDROs groups had higher percentage of P aeruginosa than the low-risk group. Furthermore, the appropriate ED first antibiotics were higher in the 1-h subgroup than in the 6-h subgroup of the high-risk MDROs group. In multivariate analysis, the 6-h high-risk MDROs group had an adjusted odds ratio of 7.191 (95% CI: 2.911-17.767, P < 0.001) and 2.917 (95% CI: 1.456-5.847, P = 0.003) for ICU mortality and multidrug therapy in the ICU, respectively, after adjusting for other confounding factors. CONCLUSIONS MDRO screening within 1 h is recommended following admission of patients with pneumonia and early septic shock in the ED, especially in areas with a high prevalence of MDROs.
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Affiliation(s)
- Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - I-Shiang Tzeng
- Department of Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Yieh Peng
- Division of Infectious Disease, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Yu Chan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Edward D Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver at Anschutz Medical Center, Denver, Colorado
- Denver Veterans Affairs Medical Center, Denver, Colorado
- Department of Medicine, Division of the Mycobacterial and Respiratory Infections, National Jewish Health, Denver, Colorado
| | - Yao-Kuang Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chou-Chin Lan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Mei-Chen Yang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Kuo-Liang Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Wei Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chia-Hui Chang
- Divisions of Endocrine and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Wen-Lin Su
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
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10
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Messina JA, Moehring RW, Schmader KE, Anderson DJ. Impact of Location of Acquisition of Gram-Positive Bloodstream Infections on Clinical Outcomes Among Patients Admitted to Community Hospitals. Infect Drug Resist 2020; 13:3023-3031. [PMID: 32922048 PMCID: PMC7457735 DOI: 10.2147/idr.s259185] [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: 04/23/2020] [Accepted: 08/07/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We investigated the association between location of acquisition (LOA) of gram-positive (GP) bloodstream infections (BSI) in community hospitals and clinical outcomes. Methods We performed a multicenter cohort study of adult inpatients with GP BSI in nine community hospitals from 2003 to 2006. LOA was defined by CDC criteria: 1) community-acquired (CA), 2) healthcare-associated (HCA) such as BSI <48 hours after admission plus hospitalization, surgery, dialysis, invasive device, or residence in a long-term care facility in the prior 12 months, and 3) hospital-acquired (HA) as BSI ≥48 hours after hospital admission. Results A total of 750 patients were included. Patients with HCA or HA GP BSI were significantly more likely to require assistance with ≥1 activity of daily living, have higher Charlson scores, and die during the hospitalization. Patients with HCA or HA GP BSI were more likely to have BSI due to a multidrug-resistant GP organism, but less likely to receive appropriate antibiotics within 24 hours of BSI presentation. Those with CA BSI were more likely to have a streptococcal BSI and to be discharged home following hospitalization. HA BSI was a risk factor for requiring a procedure for BSI and receiving inappropriate antibiotics within 24 hours of BSI. Both HA and HCA GP BSI were risk factors for in-hospital mortality. Conclusion LOA for patients with GP BSI in community hospitals was significantly associated with differences in clinical outcomes including receiving inappropriate antibiotics and in-hospital mortality. Distinguishing LOA in a patient presenting with suspected GP BSI is a critical assessment that should influence empiric treatment patterns.
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Affiliation(s)
- Julia A Messina
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
| | - Rebekah W Moehring
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
| | - Kenneth E Schmader
- Duke University Medical Center, Department of Medicine, Division of Geriatrics and GRECC, Durham VA Health Care System, Durham, NC, USA
| | - Deverick J Anderson
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Division of Infectious Diseases, Durham, NC, USA
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11
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Mertins S, Higgins PG, Rodríguez MG, Borlon C, Gilleman Q, Mertens P, Seifert H, Krönke M, Klimka A. Generation and selection of antibodies for a novel immunochromatographic lateral flow test to rapidly identify OXA-23-like-mediated carbapenem resistance in Acinetobacter baumannii. J Med Microbiol 2019; 68:1021-1032. [PMID: 31188094 DOI: 10.1099/jmm.0.001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The spread of carbapenem-resistant Acinetobacter baumannii has led to a worldwide healthcare problem. Carbapenem resistance in A. baumannii is mainly mediated by the acquisition of the carbapenem-hydrolyzing oxacillinase OXA-23. The phenotypic detection of carbapenem-producing A. baumannii is challenging and time-consuming. Hence, there is an unmet medical need for reliable and rapid diagnostic tools to detect OXA-23-producing Acinetobacter isolates to enable successful patient management. AIM Development of an immunochromatographic lateral flow test (ICT) for the rapid and reliable detection of OXA-23-producing carbapenem-resistant Acinetobacter isolates. METHODOLOGY For the development of an antibody-based ICT, we generated anti-OXA-23 monoclonal antibodies (MoAbs) and screened them sequentially for their ability to bind native OXA-23. Selected OXA-23-specific MoAbs were tested in different combinations for their capacity to capture and detect OXA-23His6 by sandwich enzyme-linked immunosorbent assay (ELISA) and ICT. A well-characterized collection of carbapenem-resistant Acinetobacter isolates with defined carbapenem resistance mechanisms were used to evaluate the specificity of the final OXA-23 ICT prototype. RESULTS The antibody pairs best suited for the sandwich ELISA format did not match the best pairs in the ICT format selected during the development process of the final prototype OXA-23 ICT. This prototype was able to differentiate between OXA-23 subfamily-mediated carbapenem resistance and carbapenem-resistant Acinetobacter isolates overexpressing other OXAs with 100 % specificity and a turnaround time of 20 min from culture plate to result. CONCLUSION With this rapid detection assay one can save 12-48 h of diagnostic time, which could help avoid inappropriate use of carbapenems and enable earlier intervention to control the transmission of OXA-23-producing carbapenem-resistant Acinetobacter isolates to other patients and healthcare workers.
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Affiliation(s)
- Sonja Mertins
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Paul G Higgins
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - María González Rodríguez
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Céline Borlon
- Coris BioConcept, Science Park CREALYS, Rue Jean Sonet 4A, B-5032 Gembloux, Belgium
| | - Quentin Gilleman
- Coris BioConcept, Science Park CREALYS, Rue Jean Sonet 4A, B-5032 Gembloux, Belgium
| | - Pascal Mertens
- Coris BioConcept, Science Park CREALYS, Rue Jean Sonet 4A, B-5032 Gembloux, Belgium
| | - Harald Seifert
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Martin Krönke
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
| | - Alexander Klimka
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute for Medical Microbiology, Immunology and Hygiene, Goldenfelsstr. 19-21, 50935 Cologne, Germany
- German Center for Infection Research (DZIF), partner site Bonn-Cologne, Cologne, Germany
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12
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Haddad N, Kanj SS, Awad LS, Abdallah DI, Moghnieh RA. The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance. BMC Infect Dis 2019; 19:293. [PMID: 30925909 PMCID: PMC6441166 DOI: 10.1186/s12879-019-3829-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 02/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM) is involved in antimicrobial stewardship. In an attempt at guiding clinicians across Lebanon in regards to the proper use of antimicrobial agents, members of this society are in the process of preparing national guidelines for common infectious diseases, among which are the guidelines for empiric and targeted antimicrobial therapy of complicated intra-abdominal infections (cIAI). The aims of these guidelines are optimizing patient care based on evidence-based literature and local antimicrobial susceptibility data, together with limiting the inappropriate use of antimicrobials thus decreasing the emergence of antimicrobial resistance (AMR) and curtailing on other adverse outcomes. METHODS Recommendations in these guidelines are adapted from other international guidelines but modeled based on locally derived susceptibility data and on the availability of pharmaceutical and other resources. RESULTS These guidelines propose antimicrobial therapy of cIAI in adults based on risk factors, site of acquisition of infection, and clinical severity of illness. We recommend using antibiotic therapy targeting third-generation cephalosporin (3GC)-resistant gram negative organisms, with carbapenem sparing as much as possible, for community-acquired infections when the following risk factors exist: prior (within 90 days) exposure to antibiotics, immunocompromised state, recent history of hospitalization or of surgery and invasive procedure all within the preceding 90 days. We also recommend antimicrobial de-escalation strategy after culture results. Prompt and adequate antimicrobial therapy for cIAI reduces morbidity and mortality; however, the duration of therapy should be limited to no more than 4 days when adequate source control is achieved and the patient is clinically stable. The management of acute pancreatitis is conservative, with a role for antibiotic therapy only in specific situations and after microbiological diagnosis. The use of broad-spectrum antimicrobial agents including systemic antifungals and newly approved antibiotics is preferably restricted to infectious diseases specialists. CONCLUSION These guidelines represent a major step towards initiating a Lebanese national antimicrobial stewardship program. The LSIDCM emphasizes on development of a national AMR surveillance network, in addition to a national antibiogram for cIAI stratified based on the setting (community, hospital, unit-based) that should be frequently updated.
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Affiliation(s)
- Nicholas Haddad
- Internal Medicine-Infectious Disease, Central Michigan University, Saginaw, MI 48602 USA
| | - Souha S. Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lyn S. Awad
- Pharmacy Department, Makassed General Hospital, Beirut, Lebanon
| | | | - Rima A. Moghnieh
- Division of Infectious Diseases, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
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13
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Morales A, Campos M, Juarez JM, Canovas-Segura B, Palacios F, Marin R. A decision support system for antibiotic prescription based on local cumulative antibiograms. J Biomed Inform 2018; 84:114-122. [PMID: 29981885 DOI: 10.1016/j.jbi.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/12/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Local cumulative antibiograms are useful tools with which to select appropriate empiric or directed therapies when treating infectious diseases at a hospital. However, data represented in traditional antibiograms are static, incomplete and not well adapted to decision-making. METHODS We propose a decision support method for empiric antibiotic therapy based on the Number Needed to Fail (NNF) measure. NNF indicates the number of patients that would need to be treated with a specific antibiotic for one to be inadequately treated. We define two new measures, Accumulated Efficacy and Weighted Accumulated Efficacy in order to determine the efficacy of an antibiotic. We carried out two experiments: the first during which there was a suspicion of infection and the patient had empiric therapy, and the second by considering patients with confirmed infection and directed therapy. The study was performed with 15,799 cultures with 356,404 susceptibility tests carried out over a four-year period. RESULTS The most efficient empiric antibiotics are Linezolid and Vancomycin for blood samples and Imipenem and Meropenem for urine samples. In both experiments, the efficacies of recommended antibiotics are all significantly greater than the efficacies of the antibiotics actually administered (P < 0.001). The highest efficacy is obtained when considering 2 years of antibiogram data and 80% of the cumulated prevalence of microorganisms. CONCLUSION This extensive study on real empiric therapies shows that the proposed method is a valuable alternative to traditional antibiograms as regards developing clinical decision support systems for antimicrobial stewardship.
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Affiliation(s)
- Antonio Morales
- Department of Informatics and Systems, University of Murcia, Facultad de Informatica, Campus de Espinardo, 30100 Murcia, Spain.
| | - Manuel Campos
- Department of Informatics and Systems, University of Murcia, Facultad de Informatica, Campus de Espinardo, 30100 Murcia, Spain.
| | - Jose M Juarez
- Department of Information and Communications Engineering, University of Murcia, Facultad de Informatica, Campus de Espinardo, 30100 Murcia, Spain.
| | - Bernardo Canovas-Segura
- Department of Informatics and Systems, University of Murcia, Facultad de Informatica, Campus de Espinardo, 30100 Murcia, Spain.
| | - Francisco Palacios
- Intensive Care Unit, University Hospital of Getafe. Carretera de Toledo Km 12, 500, 28905 Getafe (Madrid), Spain.
| | - Roque Marin
- Department of Information and Communications Engineering, University of Murcia, Facultad de Informatica, Campus de Espinardo, 30100 Murcia, Spain.
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14
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Descours G, Desmurs L, Hoang TLT, Ibranosyan M, Baume M, Ranc AG, Fuhrmann C, Dauwalder O, Salka W, Vandenesch F. Evaluation of the Accelerate Pheno™ system for rapid identification and antimicrobial susceptibility testing of Gram-negative bacteria in bloodstream infections. Eur J Clin Microbiol Infect Dis 2018; 37:1573-1583. [PMID: 29808350 DOI: 10.1007/s10096-018-3287-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/16/2018] [Indexed: 12/22/2022]
Abstract
Identification and antimicrobial susceptibility testing (AST) are critical steps in the management of bloodstream infections. Our objective was to evaluate the performance of the Accelerate Pheno™ System, CE v1.2 software, for identification and AST of Gram-negative pathogens from positive blood culture bottles. A total of 104 bottles positive for Gram-negative bacteria collected from inpatients throughout our institution were randomly selected after Gram staining. The time-to-identification and AST results, and the raw AST results obtained by the Accelerate Pheno™ system and routine techniques (MALDI-TOF MS and VITEK®2, EUCAST guidelines) were compared. Any discrepant AST result was tested by microdilution. The Pheno™ significantly improved turn-around times for identification (5.3 versus 23.7 h; p < 0.0001) and AST (10.7 versus 35.1 h; p < 0.0001). Complete agreement between the Accelerate Pheno™ system and the MALDI-TOF MS for identification was observed for 96.2% of samples; it was 99% (98/99) for monomicrobial samples versus 40% (3/5) for polymicrobial ones. The overall categorical agreement for AST was 93.7%; it was notably decreased for beta-lactams (cefepime 84.4%, piperacillin-tazobactam 86.5%, ceftazidime 87.6%) or Pseudomonas aeruginosa (71.9%; with cefepime 33.3%, piperacillin-tazobactam 77.8%, ceftazidime 0%). Analysis of discrepant results found impaired performance of the Accelerate Pheno™ system for beta-lactams (except cefepime) in Enterobacteriales (six very major errors) and poor performance in P. aeruginosa. The Accelerate Pheno™ system significantly improved the turn-around times for bloodstream infection diagnosis. Nonetheless, improvements in the analysis of polymicrobial samples and in AST algorithms, notably beta-lactam testing in both P. aeruginosa and Enterobacteriales, are required for implementation in routine workflow.
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Affiliation(s)
- Ghislaine Descours
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France. .,Inserm, U1111, CNRS, UMR5308, École Normale Supérieure de Lyon, Université Lyon 1, Lyon, France. .,Université Lyon 1, Lyon, France.
| | - Laurent Desmurs
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - Thi Lam Thuy Hoang
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - Marine Ibranosyan
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - Maud Baume
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - Anne-Gaëlle Ranc
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - Christine Fuhrmann
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France.,Department of Hygiene, Centre Léon Bérard, Lyon, France
| | - Olivier Dauwalder
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France.,Inserm, U1111, CNRS, UMR5308, École Normale Supérieure de Lyon, Université Lyon 1, Lyon, France
| | - Waël Salka
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France
| | - François Vandenesch
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Microbiology Laboratory, Institute for Infectious Agents, Lyon, France.,Inserm, U1111, CNRS, UMR5308, École Normale Supérieure de Lyon, Université Lyon 1, Lyon, France.,Université Lyon 1, Lyon, France
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15
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Xie Y, Tu B, Zhang X, Bi J, Shi L, Zhao P, Chen W, Liu S, Xu D, Qin E. Investigation on outcomes and bacterial distributions of liver cirrhosis patients with gram-negative bacterial bloodstream infection. Oncotarget 2017; 9:3980-3995. [PMID: 29423099 PMCID: PMC5790516 DOI: 10.18632/oncotarget.23582] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/04/2017] [Indexed: 12/26/2022] Open
Abstract
Objective The study aimed at analyzing the epidemiology and outcomes of liver cirrhosis patients undergoing gram-negative bacterial bloodstream infection. Results Totally 508 eligible patients were collected, with 25.79% 30-day mortality, and 58.86% patients were confirmed as nosocomial infection. The most common isolates were Escherichia coli (48.29%) and Klebsiella pneumoniae (19.29%), and multidrug-resistant isolates accounted for 36.61%. The bacterial distributions were similar between survivors and non-survivors (P>0.05), but showed close association with acquisition sites of infection (P<0.05). Nosocomial infection (HR=1.589, 95% CI=1.004-2.517), Child-Pugh grade (HR=2.471, 95% CI=1.279-4.772), septic shock (HR=1.966, 95% CI=1.228-3.146), complications (HR=3.529, 95% CI=2.140-5.818), and WBC (HR=1.065, 95% CI=1.018-1.114) were independent indicators for 30-day mortality. β-lactamase inhibitor antibiotics exerted a high antibacterial activity. Methods The inpatients with liver cirrhosis developed gram-negative bacterial bloodstream infection were collected. The clinical characteristics, bacterial distribution and drug sensitivity results of patients were compared according to their 30-day survival status and acquisition sites of infections. Cox regression model was applied to evaluate the risk factors for 30-day mortality. Conclusion Escherichia coli and Klebsiella pneumoniae are frequently isolated from gram-negative bacterial bloodstream infection episodes in cirrhosis patients. Acquisition site of infection can influence clinical characteristics and etiological distribution. β-lactamase inhibitor antibiotics may be the first choice for empirical treatments.
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Affiliation(s)
- Yangxin Xie
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China.,Chinese PLA General Hospital, Medical School, Beijing, China
| | - Bo Tu
- Chinese PLA General Hospital, Medical School, Beijing, China
| | - Xin Zhang
- Chinese PLA General Hospital, Medical School, Beijing, China
| | - Jingfeng Bi
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Lei Shi
- Chinese PLA General Hospital, Medical School, Beijing, China
| | - Peng Zhao
- Chinese PLA General Hospital, Medical School, Beijing, China
| | - Weiwei Chen
- Chinese PLA General Hospital, Medical School, Beijing, China
| | - Suxia Liu
- Treatment and Research Center for Liver Failure, Beijing 302 Hospital, Beijing, China
| | - Dongping Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Enqiang Qin
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
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Zahar JR, Lesprit P, Ruckly S, Eden A, Hikombo H, Bernard L, Harbarth S, Timsit JF, Brun-Buisson C. Predominance of healthcare-associated cases among episodes of community-onset bacteraemia due to extended-spectrum β-lactamase-producing Enterobacteriaceae. Int J Antimicrob Agents 2016; 49:67-73. [PMID: 27890442 DOI: 10.1016/j.ijantimicag.2016.09.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/03/2016] [Accepted: 09/24/2016] [Indexed: 01/09/2023]
Abstract
Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are endemic pathogens worldwide. Infection with ESBL-PE may be associated with inadequate antibiotic therapy and a poor outcome. However, risk factors for ESBL-PE community-acquired infections are ill-defined. An observational multicentre study was performed in 50 hospitals to identify the prevalence of and risk factors for community-acquired ESBL-PE bacteraemia. All patients presenting with community-onset Enterobacteriaceae bacteraemia were recorded over a 2-month period (between June and November 2013). Risk factors and 14-day outcomes of patients were investigated. Among 682 Enterobacteriaceae bacteraemia episodes recorded, 58 (8.5%) were caused by ESBL-PE. The most frequent species isolated were Escherichia coli (537; 76.7%) and Klebsiella spp. (68; 9.7%), of which 49 (9.1%) and 8 (11.8%), respectively, were ESBL-producers. Most ESBL-PE episodes were healthcare-associated, and only 22 (38%) were apparently community-acquired. The main risk factor for community-acquired ESBL-PE bacteraemia was a prior hospital stay of ≥5 days within the past year. The overall 14-day survival was 90%; only 4 (6.9%) of 58 patients with ESBL-PE bacteraemia died. Inadequate initial antibiotic therapy was administered to 55% of patients with ESBL-PE bacteraemia but was not associated with increased 14-day mortality. Although many patients had community-onset ESBL-PE bacteraemia, almost two-thirds of the episodes were actually healthcare-associated, and true community-acquired ESBL-PE bacteraemia remains rare. In our essentially non-severely ill population, inappropriate initial therapy was not associated with a higher risk of mortality.
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Affiliation(s)
- Jean-Ralph Zahar
- Infection Control Unit, Avicenne University Hospital, APHP, Paris-Nord University (UFR SMBH), Bobigny, France; IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France
| | - Philippe Lesprit
- Antibiotic Team, Department of Biology, Hôpital Foch, Suresnes, France
| | - Stephane Ruckly
- IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France; Department of Biostatistics, Outcomerea, Bobigny, France
| | - Aurelia Eden
- Infectious and Tropical Diseases Department, Perpignan General Hospital, Perpignan, France
| | - Hitoto Hikombo
- Infectious and Tropical Diseases Department, Le Mans General Hospital, Le Mans, France
| | - Louis Bernard
- Internal Medicine and Infectious Diseases, Bretonneau University Hospital, Tours, France
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jean-François Timsit
- IAME U1137 Decision Science in Infectious Diseases, Inserm, Paris Diderot University, Paris, France; Department of Biostatistics, Outcomerea, Bobigny, France; Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Christian Brun-Buisson
- Medical Intensive Care Unit and Infection Control Unit, Henri Mondor University Hospital, APHP, Paris-Est Créteil University (UPEC), 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France.
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Amzalag J, Mizrahi A, Naouri D, Nguyen JC, Ganansia O, Le Monnier A. Optimization of the β LACTA test for the detection of extended-spectrum-β-lactamase-producing bacteria directly in urine samples. Infect Dis (Lond) 2016; 48:695-8. [PMID: 27225534 DOI: 10.1080/23744235.2016.1186831] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The β LACTA™ test (BLT) is a chromogenic test detecting resistance to third-generation cephalosporins on bacterial colonies. Some studies have shown that this test can be used directly in urine samples. The aim of this study was to determine the optimal conditions of use of this test in order to detect the ESBL-producing bacteria directly in urine samples. During a 4-months period, a total of 365 consecutive urine samples were tested with the BLT using the recommendation of the manufacturer. We isolated 56 ESBL-producing bacteria and 17 AmpC-overproducing bacteria. ESBL- and/or AmpC β-lactamase-producing bacteria isolates were systematically characterized by disc diffusion antibiotic susceptibility testing interpreted according to the guidelines of EUCAST. The sensitivity and the specificity for 3GC-resistance detection, regardless the mechanism of resistance, were, respectively, 60.3% and 100%, whereas for ESBL detection, it was, respectively, 75.4% and 99.7%. We applied then modification of the initial protocol considering urines with a bacteriuria >1000/μL, a reading time at 30 min and considering any change of the initial colour as positive. The overall sensitivity was 81% and the sensitivity for ESBL-detection raised to 95.7%.
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Affiliation(s)
- Jonas Amzalag
- a Laboratoire de Microbiologie clinique , Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Assaf Mizrahi
- a Laboratoire de Microbiologie clinique , Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Diane Naouri
- b Service des Urgences , Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Jean Claude Nguyen
- a Laboratoire de Microbiologie clinique , Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Olivier Ganansia
- b Service des Urgences , Groupe Hospitalier Paris Saint-Joseph , Paris , France
| | - Alban Le Monnier
- a Laboratoire de Microbiologie clinique , Groupe Hospitalier Paris Saint-Joseph , Paris , France
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18
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Pérez XL, Liu KD. Critical Care Updates for the Nephrologist, 2016. Adv Chronic Kidney Dis 2016; 23:136-40. [PMID: 27113688 DOI: 10.1053/j.ackd.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/08/2016] [Accepted: 03/08/2016] [Indexed: 11/11/2022]
Abstract
With improvements in supportive care, mortality from sepsis and the acute respiratory distress syndrome has declined over the past 20 years. However, mortality associated with these conditions is still high. We will review the latest clinical trial findings in these fields, along with implications for the nephrologist. Very recently, there have been significant changes with regard to the management of anterior ischemic strokes; given the high rate of cerebrovascular disease in patients with CKD or ESRD, we will review those studies here. Finally, we will comment on best care practices in the intensive care unit, which are relevant to the nephrologist.
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19
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Self WH, Wunderink RG, Williams DJ, Barrett TW, Baughman AH, Grijalva CG. Comparison of clinical prediction models for resistant bacteria in community-onset pneumonia. Acad Emerg Med 2015; 22:730-40. [PMID: 25996620 DOI: 10.1111/acem.12672] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/24/2014] [Accepted: 12/04/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Six recently published algorithms classify pneumonia patients presenting from the community into high- and low-risk groups for resistant bacteria. Our objective was to compare performance of these algorithms for identifying patients infected with bacteria resistant to traditional community-acquired pneumonia antibiotics. METHODS This was a retrospective study of consecutive adult patients diagnosed with pneumonia in an emergency department and subsequently hospitalized. Each patient was classified as high or low risk for resistant bacteria according to the following algorithms: original health care-associated pneumonia (HCAP) criteria, Summit criteria, Brito and Niederman strategy, Shorr model, Aliberti model, and Shindo model. The reference for comparison was detection of resistant bacteria, defined as methicillin-resistant Staphylococcus aureus or Gram-negative bacteria resistant to ceftriaxone or levofloxacin. RESULTS A total of 614 patients were studied, including 36 (5.9%) with resistant bacteria. The HCAP criteria classified 304 (49.5%) patients as high risk, with an area under the receiver operating characteristic curve (AUC) of 0.63 (95% confidence interval [CI] = 0.54 to 0.72), sensitivity of 0.69 (95% CI = 0.52 to 0.83), and specificity of 0.52 (95% CI = 0.48 to 0.56). None of the other algorithms improved both sensitivity and specificity or significantly improved the AUC. Compared to the HCAP criteria, the Shorr and Aliberti models classified more patients as high risk, resulting in higher sensitivity and lower specificity. The Shindo model classified fewer patients as high risk, with lower sensitivity and higher specificity. CONCLUSIONS All algorithms for identification of resistant bacteria included in this study had suboptimal performance to guide antibiotic selection. New strategies for selecting empirical antibiotics for community-onset pneumonia are necessary.
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Affiliation(s)
- Wesley H. Self
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine; Department of Medicine; Feinberg School of Medicine; Northwestern University; Chicago IL
| | - Derek J. Williams
- Department of Pediatrics; Vanderbilt University School of Medicine; Nashville TN
| | - Tyler W. Barrett
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Adrienne H. Baughman
- Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
| | - Carlos G. Grijalva
- Department of Health Policy; Vanderbilt University School of Medicine; Nashville TN
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20
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Irwin AD, Drew RJ, Marshall P, Nguyen K, Hoyle E, Macfarlane KA, Wong HF, Mekonnen E, Hicks M, Steele T, Gerrard C, Hardiman F, McNamara PS, Diggle PJ, Carrol ED. Etiology of childhood bacteremia and timely antibiotics administration in the emergency department. Pediatrics 2015; 135:635-42. [PMID: 25755240 DOI: 10.1542/peds.2014-2061] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bacteremia is now an uncommon presentation to the children's emergency department (ED) but is associated with significant morbidity and mortality. Its evolving etiology may affect the ability of clinicians to initiate timely, appropriate antimicrobial therapy. METHODS A retrospective time series analysis of bacteremia was conducted in the Alder Hey Children's Hospital ED between 2001 and 2011. Data on significant comorbidities, time to empirical therapy, and antibiotic susceptibility were recorded. RESULTS A total of 575 clinical episodes were identified, and Streptococcus pneumoniae (n = 109), Neisseria meningitidis (n = 96), and Staphylococcus aureus (n = 89) were commonly isolated. The rate of bacteremia was 1.42 per 1000 ED attendances (95% confidence interval: 1.31-1.53). There was an annual reduction of 10.6% (6.6%-14.5%) in vaccine-preventable infections, and an annual increase of 6.7% (1.2%-12.5%) in Gram-negative infections. The pneumococcal conjugate vaccine was associated with a 49% (32%-74%) reduction in pneumococcal bacteremia. The rate of health care-associated bacteremia increased from 0.17 to 0.43 per 1000 ED attendances (P = .002). Susceptibility to empirical antibiotics was reduced (96.3%-82.6%; P < .001). Health care-associated bacteremia was associated with an increased length of stay of 3.9 days (95% confidence interval: 2.3-5.8). Median time to antibiotics was 184 minutes (interquartile range: 63-331) and 57 (interquartile range: 27-97) minutes longer in Gram-negative bacteremia than in vaccine-preventable bacteremia. CONCLUSIONS Changes in the etiology of pediatric bacteremia have implications for prompt, appropriate empirical treatment. Increasingly, pediatric bacteremia in the ED is health care associated, which increases length of inpatient stay. Prompt, effective antimicrobial administration requires new tools to improve recognition, in addition to continued etiological surveillance.
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Affiliation(s)
- Adam D Irwin
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom;
| | | | - Philippa Marshall
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Kha Nguyen
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Emily Hoyle
- Pediatrics, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom; and
| | - Kate A Macfarlane
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Hoying F Wong
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ellen Mekonnen
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Matthew Hicks
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Tom Steele
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Paul S McNamara
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Enitan D Carrol
- Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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21
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Tillotson GS. Light at the end of the tunnel of antibiotic development. THE LANCET. INFECTIOUS DISEASES 2013; 13:1008-1009. [PMID: 24252481 DOI: 10.1016/s1473-3099(13)70316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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