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Sendra E, Fernández-Muñoz A, Zamorano L, Oliver A, Horcajada JP, Juan C, Gómez-Zorrilla S. Impact of multidrug resistance on the virulence and fitness of Pseudomonas aeruginosa: a microbiological and clinical perspective. Infection 2024; 52:1235-1268. [PMID: 38954392 PMCID: PMC11289218 DOI: 10.1007/s15010-024-02313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/30/2024] [Indexed: 07/04/2024]
Abstract
Pseudomonas aeruginosa is one of the most common nosocomial pathogens and part of the top emergent species associated with antimicrobial resistance that has become one of the greatest threat to public health in the twenty-first century. This bacterium is provided with a wide set of virulence factors that contribute to pathogenesis in acute and chronic infections. This review aims to summarize the impact of multidrug resistance on the virulence and fitness of P. aeruginosa. Although it is generally assumed that acquisition of resistant determinants is associated with a fitness cost, several studies support that resistance mutations may not be associated with a decrease in virulence and/or that certain compensatory mutations may allow multidrug resistance strains to recover their initial fitness. We discuss the interplay between resistance profiles and virulence from a microbiological perspective but also the clinical consequences in outcomes and the economic impact.
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Affiliation(s)
- Elena Sendra
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain
| | - Almudena Fernández-Muñoz
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
| | - Laura Zamorano
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
| | - Antonio Oliver
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Juan
- Research Unit, University Hospital Son Espases-Health Research Institute of the Balearic Islands (IdISBa), Microbiology Department, University Hospital Son Espases, Crtra. Valldemossa 79, 07010, Palma, Spain.
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | - Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Hospital del Mar Research Institute, Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Passeig Marítim 25-27, 08003, Barcelona, Spain.
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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Metersky ML, Kalil AC. Management of Ventilator-Associated Pneumonia: Guidelines. Infect Dis Clin North Am 2024; 38:87-101. [PMID: 38280768 DOI: 10.1016/j.idc.2023.12.004] [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] [Indexed: 01/29/2024]
Abstract
Two recent major guidelines on diagnosis and treatment of ventilator-associated pneumonia (VAP) recommend consideration of local antibiotic resistance patterns and individual patient risks for resistant pathogens when formulating an initial empiric antibiotic regimen. One recommends against invasive diagnostic techniques with quantitative cultures to determine the cause of VAP; the other recommends either invasive or noninvasive techniques. Both guidelines recommend short-course therapy be used for most patients with VAP. Although neither guideline recommends use of procalcitonin as an adjunct to clinical judgment when diagnosing VAP, they differ with respect to use of serial procalcitonin to shorten the length of antibiotic treatment.
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Affiliation(s)
- Mark L Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-1321, USA.
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA
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Thapa D, Chair SY, Chong MS, Poudel RR, Melesse TG, Choi KC, Tam HL. Effects of ventilatory bundles on patient outcomes among ICU patients: A systematic review and meta-analysis. Heart Lung 2024; 63:98-107. [PMID: 37839229 DOI: 10.1016/j.hrtlng.2023.10.002] [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: 07/01/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Ventilator bundles are suggested to prevent ventilator-associated pneumonia (VAP), but significant variations in the effects of the bundle on patient outcomes have been reported. OBJECTIVES To synthesize the evidence and evaluate the effects of the ventilator bundle on patient outcomes among critically ill adult patients. METHODS A broad search was performed in seven databases for relevant articles published from January 2002 to November 2022. Randomized controlled trials and quasi-experimental studies investigating the effects of implementing ventilator bundles in adult intensive care units (ICUs) were included. Two independent reviewers performed the study selection, data extraction, and risk of bias assessment. All data for meta-analysis were pooled using the random-effects model. RESULTS After screening, 19 studies were included in the meta-analysis. Evidence of low-to-moderate certainty showed that the ventilator bundle reduced the rate of VAP (risk ratio [RR] = 0.64; P = 0.003), length of ICU stay (mean difference [MD] = -2.57; P = 0.03), mechanical ventilation days (MD = -3.38; P < 0.001), and ICU mortality (RR = 0.76; P = 0.02). Ventilator bundle was associated with improved outcomes, except mortality. CONCLUSIONS The ventilator bundle, especially the IHI ventilator bundle, was effective in decreasing the incidence of VAP and improving most of the VAP-related outcomes. However, given the low-to-moderate certainty of evidence and high heterogeneity, these results should be interpreted with caution. A future study that adopts hybrid implementation trials with high methodological quality is needed to confirm the effects of the ventilator bundle on patient outcomes.
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Affiliation(s)
- Dejina Thapa
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Sek Ying Chair
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Mei Sin Chong
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Rishi Ram Poudel
- Department of Orthopedics, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Tenaw Gualu Melesse
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China
| | - Hon Lon Tam
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Room 704B, 7/F Esther Lee Building, Hong Kong SAR, PR China.
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Jeck J, Wingen-Heimann SM, Jakobs F, Franz J, Baltin CT, Kron A, Böll B, Kochanek M, Cornely OA, Kron F. Last Resort Antibiotics Costs and Reimbursement Analysis of Real-Life ICU Patients with Pneumonia Caused by Multidrug-Resistant Gram-Negative Bacteria in Germany. Healthcare (Basel) 2022; 10:healthcare10122546. [PMID: 36554068 PMCID: PMC9778355 DOI: 10.3390/healthcare10122546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Multidrug-resistant Gram-negative bacteria (MDR-GNB) cause serious infections and aggravate disease progression. Last resort antibiotics are effective against MDR-GNB and are reimbursed by flat rates based on German diagnosis-related groups (G-DRG). From a hospital management perspective, this analysis compared hospital reimbursement for last resort antibiotics with their acquisition costs to outline potential funding gaps. Retrospective analyses based on medical charts and real-life reimbursement data included patients with pneumonia due to MDR-GNB treated in intensive care units (ICU) of a German tertiary care hospital (University Hospital Cologne) between January 2017 and December 2020. Drug-associated hospital reimbursement of G-DRG was compared with drug acquisition costs based on preliminarily approved last resort antibiotics (cefiderocol, ceftazidime-avibactam, ceftolozane-tazobactam, and imipenem-cilastatin-relebactam) according to label. Funding gaps were determined for the treatment of Enterobacterales, Pseudomonas aeruginosa, Acinetobacter baumannii, and mixed infections, respectively. Most of the 31 patients were infected with Enterobacterales (n = 15; 48.4%) and P. aeruginosa (n = 13; 41.9%). Drug-associated G-DRG reimbursement varied from 44.50 EUR (mixed infection of P. aeruginosa and Enterobacterales) to 2265.27 EUR (P. aeruginosa; mixed infection of P. aeruginosa and Enterobacterales). Drug acquisition costs ranged from 3284.40 EUR in ceftazidime-avibactam (minimum duration) to 15,827.01 EUR for imipenem-cilastatin-relebactam (maximum duration). Underfunding was found for all MDR-GNB, reaching from 1019.13 EUR (P. aeruginosa; mixed infection of P. aeruginosa and Enterobacterales) to 14,591.24 EUR (Enterobacterales). This analysis revealed the underfunding of last resort antibiotics in German hospital treatment. Insufficient reimbursement implies less research in this field, leading to a more frequent use of inappropriate antibiotics. The cycle closes as this contributes to the development of multi-drug resistant bacteria.
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Affiliation(s)
- Julia Jeck
- VITIS Healthcare Group, Am Morsdorfer Hof 12, 50933 Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Sebastian M. Wingen-Heimann
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Herkulesstraße 32, 45127 Essen, Germany
| | - Florian Jakobs
- Department of Haematology and Stem Cell Transplantation, Faculty of Medicine and Essen University Hospital, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Jennifer Franz
- VITIS Healthcare Group, Am Morsdorfer Hof 12, 50933 Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Christoph T. Baltin
- VITIS Healthcare Group, Am Morsdorfer Hof 12, 50933 Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Herkulesstraße 32, 45127 Essen, Germany
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Anna Kron
- VITIS Healthcare Group, Am Morsdorfer Hof 12, 50933 Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- National Network Genomic Medicine Lung Cancer, University Hospital Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Boris Böll
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Oliver A. Cornely
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 269, 50935 Cologne, Germany
- Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Joseph-Stelzmann-Straße 26, 50931 Cologne, Germany
- Excellence Center for Medical Mycology (ECMM), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Florian Kron
- VITIS Healthcare Group, Am Morsdorfer Hof 12, 50933 Cologne, Germany
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Herkulesstraße 32, 45127 Essen, Germany
- Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-6200-3950
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Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”. Antibiotics (Basel) 2022; 11:antibiotics11030359. [PMID: 35326822 PMCID: PMC8944836 DOI: 10.3390/antibiotics11030359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/04/2022] [Accepted: 03/06/2022] [Indexed: 12/26/2022] Open
Abstract
Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.
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Pan D, Niederman MS. Risk Factors and Algorithms for the Empirical Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:183-190. [PMID: 35042262 DOI: 10.1055/s-0041-1740335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to be major concerns for morbidity and mortality, especially in patients treated in the intensive care unit. With the rise in multidrug-resistant organisms, HAP and VAP treatment is challenged by the need for early appropriate treatment, with broad-spectrum agents, while still being aware of the principles of antibiotic stewardship. The two major society guidelines proposed a series of risk factors in their most recent guidelines to help identify patients who can most benefit from narrow- or broad-spectrum initial empiric antibiotic therapy. The guidelines reveal differences in the proposed risk factors and treatment approaches, as well as major similarities.
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Affiliation(s)
- Di Pan
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Michael S Niederman
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
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Gennequin M, Bachelet D, Eloy P, Moyer JD, Roquilly A, Gauss T, Weiss E, Foucrier A. Empiric antimicrobial therapy for early-onset pneumonia in severe trauma patients. Eur J Trauma Emerg Surg 2022; 48:2763-2771. [PMID: 35001179 DOI: 10.1007/s00068-021-01870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/28/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The bacterial ecology involved in early pneumonia of severe trauma patients is mostly commensal and would allow wide use of narrow-spectrum antibiotics. We describe risk factors for treatment failure of severe trauma patients' pneumonia with the use of narrow-spectrum antimicrobial therapy in order to develop a score that could help clinicians to determine which patients might be treated with narrow-spectrum antibiotics. METHODS A retrospective, observational, monocentric cohort study was conducted of severe trauma patients requiring mechanical ventilation for > 48 h and developing a first episode of microbiologically confirmed pneumonia occurring within the first 10 days after admission. RESULTS Overall, 370 patients were included. The resistance rate against narrow-spectrum antibiotics (amoxicillin/clavulanic acid) was 22.7% (84 pneumonia). In a multivariate analysis, two independent risk factors were associated with this resistance: prior antimicrobial therapy ≥ 48 h (OR 4.00; 95 CI [2.39; 6.75]) and age ≥ 30y (OR 2.10; 95 CI [1.21; 3.78]). We created a prediction score that defined patient with one or two risk factors at high risk of resistance. This score presented a sensitivity of 0.92 [0.88; 0.94], a specificity of 0.33 [0.28; 0.38], a positive predictive value of 0.29 [0.24; 0.33] and a negative predictive value of 0.93 [0.90; 0.95]. CONCLUSION Simple risk factors may help clinicians to identify severe trauma patients at high risk of pneumonia treatment failure with the use of narrow-spectrum antimicrobial therapy and, thus, use better tailored empiric therapy and limit the use of unnecessary broad-spectrum antimicrobial therapy.
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Affiliation(s)
- Maël Gennequin
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Delphine Bachelet
- Département d'épidémiologie, Biostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, 75018, Paris, France
| | - Philippine Eloy
- Département d'épidémiologie, Biostatistiques et Recherche Clinique, Hôpital Bichat, AP-HP Nord, Université de Paris, 75018, Paris, France
| | - Jean-Denis Moyer
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Antoine Roquilly
- Intensive Care Unit, Anaesthesia and Critical Care Dept, Hôtel Dieu-HME, University Hospital of Nantes, Nantes, France
| | - Tobias Gauss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Arnaud Foucrier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
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Hocking L, Ali GC, d’Angelo C, Deshpande A, Stevenson C, Virdee M, Guthrie S. A rapid evidence assessment exploring whether antimicrobial resistance complicates non-infectious health conditions and healthcare services, 2010-20. JAC Antimicrob Resist 2021; 3:dlab171. [PMID: 34806009 PMCID: PMC8599069 DOI: 10.1093/jacamr/dlab171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Antimicrobial resistance (AMR) is one of the greatest public health threats at this time. While there is a good understanding of the impacts of AMR on infectious diseases, an area of less focus is the effects AMR may be having on non-communicable health conditions (such as cancer) and healthcare services (such as surgery). Therefore, this study aimed to explore what impact AMR is currently having on non-communicable health conditions, or areas of health services, where AMR could be a complicating factor impacting on the ability to treat the condition and/or health outcomes. To do this, a rapid evidence assessment of the literature was conducted, involving a systematic approach to searching and reviewing the evidence. In total, 101 studies were reviewed covering surgery, organ transplants, cancer, ICUs, diabetes, paediatric patients, immunodeficiency conditions, liver and kidney disease, and physical trauma. The results showed limited research in this area and studies often use a selective population, making the results difficult to generalize. However, the evidence showed that for all health conditions and healthcare service areas reviewed, at least one study demonstrated a higher risk of death for patients with resistant infections, compared with no or drug-susceptible infections. Poor health outcomes were also associated with resistant infections in some instances, such as severe sepsis and failure of treatments, as well as a greater need for invasive medical support. While there are gaps in the evidence base requiring further research, efforts are also needed within policy and practice to better understand and overcome these challenges.
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Affiliation(s)
- Lucy Hocking
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
- Corresponding author. E-mail:
| | | | | | | | | | - Mann Virdee
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
| | - Susan Guthrie
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
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Abstract
PURPOSE OF REVIEW In the last 2 years, two major guidelines for the management of nosocomial pneumonia have been published: The International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Asociación Latinoamericana de Toráx guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) and the American guidelines for management of adults with HAP and VAP; both the guidelines made important clinical recommendations for the management of patients. RECENT FINDINGS With the increasing emergence of multidrug resistant (MDR) organisms, paired with a relative reduction in new antibiotic development, nosocomial infections have become one of the most significant issues affecting global healthcare today. Despite several stark differences between the European and American guidelines, they are in agreement about many aspects of nosocomial pneumonia management. SUMMARY American and European guidelines promote prompt and appropriate empiric treatment which is immediately guided by local microbiological data, followed by an adequate de-escalation protocol based on culture results with a 1-week course of treatment. Both also questioned the use of biomarkers in HAP/VAP, whether as part of the diagnosis or daily assessment of patients. On the contrary, they have conflicting views in regards to the optimum method of diagnosis, the risk factors used to stratify patients, the use of clinical scoring systems and the various antibiotic classes used. All were presented with varying levels of evidence to support these differences in opinion, indicating that further research into these areas is required before a consensus can be agreed upon.
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Raban MZ, Gasparini C, Li L, Baysari MT, Westbrook JI. Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis. BMJ Open 2020; 10:e028494. [PMID: 31924627 PMCID: PMC6955563 DOI: 10.1136/bmjopen-2018-028494] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES There are high levels of inappropriate antibiotic use in long-term care facilities (LTCFs). Our objective was to examine evidence of the effectiveness of interventions designed to reduce antibiotic use and/or inappropriate use in LTCFs. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase and CINAHL from 1997 until November 2018. ELIGIBILITY CRITERIA Controlled and uncontrolled studies in LTCFs measuring intervention effects on rates of overall antibiotic use and/or appropriateness of use were included. Secondary outcomes were intervention implementation barriers from process evaluations. DATA EXTRACTION AND SYNTHESIS Two reviewers independently applied the Cochrane Effective Practice and Organisation of Care group's resources to classify interventions and assess risk of bias. Meta-analyses used random effects models to pool results. RESULTS Of include studies (n=19), 10 had a control group and 17 had a high risk of bias. All interventions had multiple components. Eight studies (with high risk of bias) showed positive impacts on outcomes and included one of the following interventions: audit and feedback, introduction of care pathways or an infectious disease team. Meta-analyses on change in the percentage of residents on antibiotics (pooled relative risk (RR) (three studies, 6862 residents): 0.85, 95% CI: 0.61 to 1.18), appropriateness of decision to treat with antibiotics (pooled RR (three studies, 993 antibiotic orders): 1.10, 95% CI: 0.64 to 1.91) and appropriateness of antibiotic selection for respiratory tract infections (pooled RR (three studies, 292 orders): 1.15, 95% CI: 0.95 to 1.40), showed no significant intervention effects. However, meta-analyses only included results from intervention groups since most studies lacked a control group. Insufficient data prevented meta-analysis on other outcomes. Process evaluations (n=7) noted poor intervention adoption, low physician engagement and high staff turnover as barriers. CONCLUSIONS There is insufficient evidence that interventions employed to date are effective at improving antibiotic use in LTCFs. Future studies should use rigorous study designs and tailor intervention implementation to the setting.
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Affiliation(s)
- Magdalena Z Raban
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Claudia Gasparini
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Horcajada JP, Montero M, Oliver A, Sorlí L, Luque S, Gómez-Zorrilla S, Benito N, Grau S. Epidemiology and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Pseudomonas aeruginosa Infections. Clin Microbiol Rev 2019; 32:32/4/e00031-19. [PMID: 31462403 PMCID: PMC6730496 DOI: 10.1128/cmr.00031-19] [Citation(s) in RCA: 439] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In recent years, the worldwide spread of the so-called high-risk clones of multidrug-resistant or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa has become a public health threat. This article reviews their mechanisms of resistance, epidemiology, and clinical impact and current and upcoming therapeutic options. In vitro and in vivo treatment studies and pharmacokinetic and pharmacodynamic (PK/PD) models are discussed. Polymyxins are reviewed as an important therapeutic option, outlining dosage, pharmacokinetics and pharmacodynamics, and their clinical efficacy against MDR/XDR P. aeruginosa infections. Their narrow therapeutic window and potential for combination therapy are also discussed. Other "old" antimicrobials, such as certain β-lactams, aminoglycosides, and fosfomycin, are reviewed here. New antipseudomonals, as well as those in the pipeline, are also reviewed. Ceftolozane-tazobactam has clinical activity against a significant percentage of MDR/XDR P. aeruginosa strains, and its microbiological and clinical data, as well as recommendations for improving its use against these bacteria, are described, as are those for ceftazidime-avibactam, which has better activity against MDR/XDR P. aeruginosa, especially strains with certain specific mechanisms of resistance. A section is devoted to reviewing upcoming active drugs such as imipenem-relebactam, cefepime-zidebactam, cefiderocol, and murepavadin. Finally, other therapeutic strategies, such as use of vaccines, antibodies, bacteriocins, anti-quorum sensing, and bacteriophages, are described as future options.
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Affiliation(s)
- Juan P Horcajada
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Milagro Montero
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Antonio Oliver
- Service of Microbiology, Hospital Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Luisa Sorlí
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Sònia Luque
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Gómez-Zorrilla
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
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Risk stratification and treatment of ICU-acquired pneumonia caused by multidrug- resistant/extensively drug-resistant/pandrug-resistant bacteria. Curr Opin Crit Care 2019; 24:385-393. [PMID: 30156569 DOI: 10.1097/mcc.0000000000000534] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Describe the risk factors and discuss the management of multidrug-resistant (MDR) bacteria responsible for pneumonia among critically ill patients, including methicillin-resistant Staphylococcus aureus, extended spectrum beta-lactamase-producing Enterobactericeae, carbapenem-resistant Enterobactericeae, multidrug resistant Pseudomonas aeruginosa, and Acinetobacter baumannii. RECENT FINDINGS Multiple factors have been associated with infections because of MDR bacteria, including prolonged hospital stay, presence of invasive devices, mechanical ventilation, colonization with resistant pathogens, and use of broad-spectrum antibiotics. Management of these infections includes the prompt use of appropriate antimicrobial therapy, implementation of antimicrobial stewardship protocols, and targeted active microbiology surveillance. Combination therapy and novel molecules have been used for the treatment of severe infections caused by resistant bacteria. SUMMARY The exponential increase of antimicrobial resistance among virulent pathogens currently represents one of the main challenges for clinicians in the intensive care unit. Knowledge of the local epidemiology, patient risk stratification, and infection-control policies remain key elements for the management of MDR infections. Results from clinical trials on new molecules are largely awaited.
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Abstract
Two recent major guidelines on diagnosis and treatment of ventilator-associated pneumonia (VAP) recommend consideration of local antibiotic resistance patterns and individual patient risks for resistant pathogens when formulating an initial empiric antibiotic regimen. One recommends against invasive diagnostic techniques with quantitative cultures to determine the cause of VAP; the other recommends either invasive or noninvasive techniques. Both guidelines recommend short-course therapy be used for most patients with VAP. Although neither guideline recommends use of procalcitonin as an adjunct to clinical judgment when diagnosing VAP, they differ with respect to use of serial procalcitonin to shorten the length of antibiotic treatment.
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Affiliation(s)
- Mark L Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-1321, USA.
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA
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Bickenbach J, Schöneis D, Marx G, Marx N, Lemmen S, Dreher M. Impact of multidrug-resistant bacteria on outcome in patients with prolonged weaning. BMC Pulm Med 2018; 18:141. [PMID: 30126392 PMCID: PMC6102812 DOI: 10.1186/s12890-018-0708-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 08/09/2018] [Indexed: 12/05/2022] Open
Abstract
Background Pneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown. Methods Patients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation. Results Of 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p < 0.05). Mortality rate on the weaning unit was 12.4% with no difference between the two patient groups. There were no significant differences between patient groups in secondary infections and ventilator-free days. Conclusions In patients with pneumonia or septic pneumonic shock undergoing prolonged weaning, infection with MDR bacteria may influence the weaning success rate but does not appear to impact on patient survival.
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Affiliation(s)
- Johannes Bickenbach
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany.
| | - Daniel Schöneis
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr. 30, D-52074, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sebastian Lemmen
- Department of Infection Control and Infectious Diseases, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Michael Dreher
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, Kollef M, Li Bassi G, Luna CM, Martin-Loeches I, Paiva JA, Read RC, Rigau D, François Timsit J, Welte T, Wunderink R. Summary of the international clinical guidelines for the management of hospital-acquired and ventilator-acquired pneumonia. ERJ Open Res 2018; 4:00028-2018. [PMID: 29977898 PMCID: PMC6018155 DOI: 10.1183/23120541.00028-2018] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/22/2018] [Indexed: 11/05/2022] Open
Abstract
A summary of the evidence and recommendations made in the ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia http://ow.ly/S3zA30iZfLa.
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Affiliation(s)
- Antoni Torres
- Dept of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, CIBERES Barcelona, Barcelona, Spain
| | - Michael S. Niederman
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Jean Chastre
- Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, Herne und Bochum, Germany
| | | | - Hakan Hanberger
- Dept of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Marin Kollef
- Pulmonary and Critical Care Division, Washington University School of Medicine, St Louis, MO, USA
| | - Gianluigi Li Bassi
- Dept of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, CIBERES Barcelona, Barcelona, Spain
| | - Carlos M. Luna
- Dept of Medicine, Pulmonary Diseases Division, Hospital de Clínicas “José de San Martin”, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Martin-Loeches
- Dept of Clinical Medicine, Wellcome Trust – HRB Clinical Research Facility, St. James's Hospital, Trinity College, Dublin, Ireland. CIBER de Enfermedades Respiratorias (CIBERES)
| | - J. Artur Paiva
- Emergency and Intensive Care Dept, Centro Hospitalar São João EPE, Porto, Portugal
- Dept of Medicine, University of Porto Medical School, Porto, Portugal
| | - Robert C. Read
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Jean François Timsit
- IAME, INSERM UMR 1137, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France
| | - Tobias Welte
- CAPNETZ STIFTUNG, Hannover, Germany
- Dept of Respiratory Medicine, Medizinische Hoschschule Hannover and German Center of Lung Research (DZL), Germany
| | - Richard Wunderink
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Arvanitis M, Mylonakis E. Characteristics, Clinical Relevance, and the Role of Echinocandins in Fungal-Bacterial Interactions. Clin Infect Dis 2016; 61 Suppl 6:S630-4. [PMID: 26567281 DOI: 10.1093/cid/civ816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Fungal-bacterial interactions are common in the environment. The interactions between invasive fungi (eg, Candida species and Aspergillus species) and pathogenic bacteria can be particularly significant in the outcome of human infections. Study of these interactions in vivo using murine or invertebrate models, such as Caenorhabditis elegans or Galleria mellonella, has been very helpful in increasing our understanding of the pathogenesis of mixed infections and in identifying ways to use this between-kingdom interplay to our advantage. Based on their effect against fungal biofilms and their immunomodulatory properties, the newer class of antifungal agents, known as echinocandins, has the potential to be useful in polymicrobial infections and in high-risk complex infections such as ventilator-associated pneumonia or sepsis where colonization by fungi can lead to worse outcomes.
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Affiliation(s)
- Marios Arvanitis
- Infectious Diseases Division, Rhode Island Hospital Warren Alpert Medical School of Brown University, Providence, Rhode Island Internal Medicine Department, Boston Medical Center, Massachusetts
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Arvanitis M, Li G, Li DD, Cotnoir D, Ganley-Leal L, Carney DW, Sello JK, Mylonakis E. A Conformationally Constrained Cyclic Acyldepsipeptide Is Highly Effective in Mice Infected with Methicillin-Susceptible and -Resistant Staphylococcus aureus. PLoS One 2016; 11:e0153912. [PMID: 27101010 PMCID: PMC4839560 DOI: 10.1371/journal.pone.0153912] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 04/06/2016] [Indexed: 01/21/2023] Open
Abstract
Background Cyclic acyldepsipeptides (ADEPs) are a novel class of antibacterial agents, some of which (e.g., ADEP 4) are highly active against Gram-positive bacteria. The focus of these in vivo studies is ADEP B315, a rationally designed compound that has the most potent in vitro activity of any ADEP analog reported to date. Methods In vivo efficacy experiments were performed using lethal intraperitoneal mice infection models with a methicillin-sensitive S. aureus (MSSA) and a methicillin-resistant (MRSA) strain. The infected mice were treated with ADEP B315, a des-methyl analog of ADEP 4, vancomycin, or the vehicle used for the ADEPs and their survival was assessed daily. A subset of MSSA-infected mice was sacrificed soon after inoculation and the bacterial burden was measured in their livers and spleens. The toxicity of ADEP B315 was assessed in viability assays using human whole blood cultures. Results In the MSSA experiments, all mice treated with the vehicle succumbed to the infection within 24 hours. All tested compounds were effective in prolonging survival of infected mice (p<0.001). Mice treated with ADEP B315 had a 39% survival rate by 10 days compared to 7% survival in mice treated with a des-methyl ADEP 4 analog (p = 0.017). Survival of the infected mice treated with ADEP B315 was comparable to those treated with vanocmycin (p = 0.12) at the same dose. Further, bacterial burden in the liver and spleen was significantly lower in mice treated with ADEP B315 compared to controls. In the MRSA experiments, ADEP B315 was able to significantly prolong survival compared to mice treated with either the vehicle (p = 0.001) or vancomycin (p = 0.007). ADEP B315 exhibited no significant toxicity in human whole blood cultures at concentrations up to 25 μg/ml. Conclusions ADEP B315 is safe and can cure mice that have lethal infections of methicillin-sensitive and -resistant strains of S. aureus.
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Affiliation(s)
- Marios Arvanitis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States of America
- Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Gang Li
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States of America
- Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - De-Dong Li
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States of America
- Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Daniel Cotnoir
- Department of Pediatrics, Hasbro Children's Hospital, Brown University Alpert Medical School, Providence, RI, United States of America
| | - Lisa Ganley-Leal
- Department of Pediatrics, Hasbro Children's Hospital, Brown University Alpert Medical School, Providence, RI, United States of America
| | - Daniel W. Carney
- Department of Chemistry, Brown University, 324 Brook Street, Providence, RI, United States of America
| | - Jason K. Sello
- Department of Chemistry, Brown University, 324 Brook Street, Providence, RI, United States of America
- * E-mail: (EM); (JKS)
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States of America
- Warren Alpert Medical School of Brown University, Providence, RI, United States of America
- * E-mail: (EM); (JKS)
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Nasiriani K, Torki F, Jarahzadeh MH, Rashidi Maybodi F. The Effect of Brushing with a Soft Toothbrush and Distilled Water on the Incidence of Ventilator-Associated Pneumonia in the Intensive Care Unit. TANAFFOS 2016; 15:101-107. [PMID: 27904542 PMCID: PMC5127611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a common nosocomial infection, which results in longer hospitalization, increased treatment costs, and higher mortality rates. One major cause of VAP is colonization and microaspiration of oropharyngeal secretions following the formation of dental plaque, which is due to poor oral hygiene and failure to mechanically remove these microorganisms from the teeth. This study was conducted to determine the effect of brushing teeth with distilled water on the incidence of VAP in patients admitted to intensive care unit (ICU). MATERIALS AND METHODS In this randomized clinical trial, 168 intubated patients, who had at least 20 teeth were randomly assigned to two groups. In the experimental group, the patients' teeth were brushed twice a day with a children's toothbrush and distilled water in addition to the routine oral care. The clinical pulmonary infection score (CPIS) was used to diagnose VAP. The data were analyzed using SPSS version 16 software. RESULTS A total of 38.6% of the patients in each group developed VAP. There was a significant difference in incidence of VAP on day five between the two groups (P<0.05). The incidence of VAP had a significant relationship with smoking (P<0.001), underlying diseases (P<0.001), duration of hospitalization (P=0.002), and age (P<0.001). Enterobacter was the most common microorganism identified in both groups. CONCLUSION According to our results, tooth brushing twice daily with distilled water reduced the incidence of VAP in patients admitted to the ICU. Therefore, it is recommended that nurses caring for ventilator-dependent patients brush the patients' teeth with distilled water as a part of their routine oral care.
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Affiliation(s)
- Khadijeh Nasiriani
- Nursing Department, Nursing - Midwifery School, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd-Iran
| | - Fakhri Torki
- Nursing Department, Nursing - Midwifery School, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd-Iran,,Correspondence to: Torki F Address: Nursing Department, Nursing - Midwifery School, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd-Iran Email address:
| | - Mohammad Hossein Jarahzadeh
- Anesthesiology and Critical Care Department, Medical School, Shahid Sadooghi University of Medical Sciences and Health Services, Yazd, Iran
| | - Fahimeh Rashidi Maybodi
- Periodontology Department, Dental School, Shahid Sadoughi University Of Medical Sciences School, Yazd, Iran
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Arvanitis M, Mylonakis E. Fungal-bacterial interactions and their relevance in health. Cell Microbiol 2015; 17:1442-6. [PMID: 26243723 DOI: 10.1111/cmi.12493] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/17/2015] [Accepted: 07/21/2015] [Indexed: 01/09/2023]
Abstract
Cross-kingdom interactions between bacteria and fungi are a common occurrence in the environment. Recent studies have identified various types of interactions that either can take the form of a synergistic relationship or can result in an antagonistic interplay with the subsequent destruction or inhibition of growth of bacteria, fungi or both. This cross-kingdom communication is of particular significance in human health and disease, as bacteria and fungi commonly colonize various human surfaces and their interactions can at times alter the outcome of invasive infections. Moreover, mixed infections from both bacteria and fungi are relatively common among critically ill patients and individuals with weak immune responses. The purpose of this review is to summarize our knowledge on the type of interactions between bacteria and fungi and their relevance in human infections.
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Affiliation(s)
- Marios Arvanitis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA.,Internal Medicine Department, Boston Medical Center, Boston, MA, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
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Inchai J, Liwsrisakun C, Theerakittikul T, Chaiwarith R, Khositsakulchai W, Pothirat C. Risk factors of multidrug-resistant, extensively drug-resistant and pandrug-resistant Acinetobacter baumannii ventilator-associated pneumonia in a Medical Intensive Care Unit of University Hospital in Thailand. J Infect Chemother 2015; 21:570-4. [PMID: 26026660 DOI: 10.1016/j.jiac.2015.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 12/23/2022]
Abstract
Ventilator-associated pneumonia (VAP) caused by Acinetobacter baumannii remains a significant cause of morbidity and mortality. Increasing antimicrobial resistance influences the selection of antibiotic treatment especially pandrug-resistant A. baumannii. A retrospective cohort study was conducted in the Medical Intensive Care Unit to identify the risk factors of VAP caused by multidrug-resistant A. baumannii (MDR-AB), extensively drug-resistant A. baumannii (XDR-AB) and pandrug-resistant A. baumannii (PDR-AB). All 337 adult patients with confirmed A. baumannii VAP were included. The incidence of MDR-AB, XDR-AB and PDR-AB were 72 (21.4%), 220 (65.3%) and 12 (3.6%), respectively. The risk factor for MDR-AB was prior use of carbapenems (OR 5.20; 95% CI 1.41-19.17). Risk factors for XDR-AB were the prior use of carbapenems (OR, 6.30; 95% CI, 1.80-21.97) and a high Sequential Organ Failure Assessment (SOFA) score (OR 1.35; 95% CI 1.07-1.71). In PDR-AB, the risk factors were the prior use of colistin (OR, 155.95; 95% CI, 8.00-3041.98), carbapenems (OR, 12.84; 95% CI, 1.60-103.20) and a high Simplified Acute Physiology Score (SAPS II) (OR 1.10; 95% CI 1.01-1.22). In conclusion, previous exposure to antibiotics and severity of VAP were risk factors of drug-resistant A. baumannii. Judicious use of carbapenems and colistin is recommended to prevent the antimicrobial-resistant strains of this organism.
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Affiliation(s)
- Juthamas Inchai
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chalerm Liwsrisakun
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Theerakorn Theerakittikul
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Romanee Chaiwarith
- Division of Infectious Disease, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Chaicharn Pothirat
- Division of Pulmonary, Critical Care and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Chahoud J, Semaan A, Almoosa KF. Ventilator-associated events prevention, learning lessons from the past: A systematic review. Heart Lung 2015; 44:251-9. [PMID: 25686517 DOI: 10.1016/j.hrtlng.2015.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/16/2015] [Accepted: 01/20/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated. OBJECTIVE This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods. METHODS We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations. CONCLUSION VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles.
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Affiliation(s)
| | - Adele Semaan
- Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Khalid F Almoosa
- Department of Internal Medicine, School of Medicine, University of Texas Health Science Center, Houston, TX, USA; Transplant Surgery ICU, Memorial Hermann Hospital TMC, Houston, TX, USA.
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