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Freitas FTDM, da Costa MSC, da Costa KHR, Alves EG. Antimicrobial resistance and epidemic clustering of late-onset neonatal infections in a Brazilian intensive care unit. J Trop Pediatr 2023; 70:fmad045. [PMID: 38085999 DOI: 10.1093/tropej/fmad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Nosocomial infections in the neonatal intensive care unit (NICU) tend to cluster and multidrug-resistant (MDR) pathogens are rising in developing countries. We did a retrospective cohort study of neonates admitted to a NICU in Brazil with late-onset neonatal sepsis (LOS) confirmed by blood culture from October 2012 to December 2016 and from July 2018 to December 2021. We defined a cluster of infection when at least two cases of LOS occurred within two different time intervals: 15 and 30 days with the same pathogen in different patients. A random amplified polymorphic DNA (RAPD) was performed from samples from one of these clusters. A logistic regression model was applied having death as the outcome and the infection with an MDR pathogen as the exposure of interest. There were 987 blood cultures from 754 neonates, 621 (63%) were gram-positive cocci, 264 (30%) were gram-negative rods and 72 (7%) fungi. A third of Enterobacterales were resistant to cefepime and a third of non-fermenting glucose rods were resistant to carbapenems. There were 100 or 104 clusters of infection in the 15- or 30-day interval, respectively. A RAPD analysis from an outbreak of MDR Acinetobacter baumannii showed that all five samples belonged to a single clone. An infection with an MDR pathogen was associated with death (OR 1.82, 95% CI 1.03-3.21). In conclusion, clusters of infections in a Brazilian NICU are a frequent phenomenon as seen elsewhere. They suggest cross-transmission of pathogens with increasing antimicrobial resistance and should prompt intensified surveillance and infection control measures.
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Affiliation(s)
- Felipe Teixeira de Mello Freitas
- Hospital Materno Infantil de Brasilia, Brasilia 70203-900, Brazil
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa, Brasilia 70710-907, Brazil
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2
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Meinich Juhl S, Angeliki Krogfelt K, Kot W, Sandris Nielsen D, Krych L. Used Nasogastric Feeding Tubes from Neonates Contain Infant-Specific Bacterial Profiles. Microorganisms 2023; 11:1365. [PMID: 37374868 DOI: 10.3390/microorganisms11061365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Abstract
Nasogastric feeding tubes (NG-tubes) from neonates contain potentially pathogenic bacteria. Using culture-based techniques, we have previously determined that the usage duration of NG-tubes did not impact the colonization of the nasogastric tubes. In the present study, we performed 16S rRNA gene amplicon sequencing to evaluate the microbial profile of 94 used nasogastric tubes collected from a single neonatal intensive care unit. Using culture-based whole genome sequencing, we as-sessed whether the same strain persisted in NG-tubes collected from the same neonate across different time-points. We found that the most commonly occurring Gram-negative bacteria were Enterobacteriaceae, Klebsiella and Serratia, while the most common Gram-positive bacteria were staphylococci and streptococci. The microbiota of the NG-feeding tube was overall infant-specific, rather than dependent on the duration of use. Furthermore, we determined that reoccurring species from the individual infant represented the same strain and that several strains were common for more than one infant. Our findings indicate that bacterial profiles found in NG-tubes of neonates are host-specific, not dependent on the duration of use and strongly influenced by the environment.
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Affiliation(s)
- Sandra Meinich Juhl
- Department of Neonatology, Rigshospitalet-Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Karen Angeliki Krogfelt
- Department of Virus and Microbiological Special Diagnostics, Statens Serum Institut, 2300 Copenhagen, Denmark
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Witold Kot
- Department of Plant and Environmental Sciences, University of Copenhagen, 1871 Frederiksberg C, Denmark
| | - Dennis Sandris Nielsen
- Department of Food Science, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark
| | - Lukasz Krych
- Department of Food Science, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark
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3
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Schwartz DJ, Shalon N, Wardenburg K, DeVeaux A, Wallace MA, Hall-Moore C, Ndao IM, Sullivan JE, Radmacher P, Escobedo M, D. Burnham CA, Warner BB, Tarr PI, Dantas G. Gut pathogen colonization precedes bloodstream infection in the neonatal intensive care unit. Sci Transl Med 2023; 15:eadg5562. [PMID: 37134153 PMCID: PMC10259202 DOI: 10.1126/scitranslmed.adg5562] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023]
Abstract
Bacterial bloodstream infections (BSIs) resulting in late-onset sepsis affect up to half of extremely preterm infants and have substantial morbidity and mortality. Bacterial species associated with BSIs in neonatal intensive care units (NICUs) commonly colonize the preterm infant gut microbiome. Accordingly, we hypothesized that the gut microbiome is a reservoir of BSI-causing pathogenic strains that increase in abundance before BSI onset. We analyzed 550 previously published fecal metagenomes from 115 hospitalized neonates and found that recent ampicillin, gentamicin, or vancomycin exposure was associated with increased abundance of Enterobacteriaceae and Enterococcaceae in infant guts. We then performed shotgun metagenomic sequencing on 462 longitudinal fecal samples from 19 preterm infants (cases) with BSI and 37 non-BSI controls, along with whole-genome sequencing of the BSI isolates. Infants with BSI caused by Enterobacteriaceae were more likely than infants with BSI caused by other organisms to have had ampicillin, gentamicin, or vancomycin exposure in the 10 days before BSI. Relative to controls, gut microbiomes of cases had increased relative abundance of the BSI-causing species and clustered by Bray-Curtis dissimilarity according to BSI pathogen. We demonstrated that 11 of 19 (58%) of gut microbiomes before BSI, and 15 of 19 (79%) of gut microbiomes at any time, harbored the BSI isolate with fewer than 20 genomic substitutions. Last, BSI strains from the Enterobacteriaceae and Enterococcaceae families were detected in multiple infants, indicating BSI-strain transmission. Our findings support future studies to evaluate BSI risk prediction strategies based on gut microbiome abundance in hospitalized preterm infants.
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Affiliation(s)
- Drew J. Schwartz
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Center for Women’s Infectious Disease Research, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Nitan Shalon
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Kate Wardenburg
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Anna DeVeaux
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Meghan A. Wallace
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Carla Hall-Moore
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - I. Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Janice E. Sullivan
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, KY 40202, USA
| | - Paula Radmacher
- Department of Pediatrics, University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, KY 40202, USA
| | - Marilyn Escobedo
- Department of Pediatrics, University of Oklahoma, Oklahoma City, OK 73117, USA
| | - Carey-Ann D. Burnham
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Barbara B. Warner
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Phillip I. Tarr
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gautam Dantas
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
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4
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Coggins SA, Edwards EM, Flannery DD, Gerber JS, Horbar JD, Puopolo KM. Serratia Infection Epidemiology Among Very Preterm Infants in the Neonatal Intensive Care Unit. Pediatr Infect Dis J 2023; 42:152-158. [PMID: 36638403 PMCID: PMC9846441 DOI: 10.1097/inf.0000000000003736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Serratia spp. are opportunistic, multidrug resistant, Gram-negative pathogens, previously described among preterm infants in case reports or outbreaks of infection. We describe Serratia late-onset infection (LOI) in very preterm infants in a large, contemporary, nationally representative cohort. METHODS In this secondary analysis of prospectively collected data of preterm infants born 401-1500 grams and/or 22-29 weeks gestational age from 2018 to 2020 at 774 Vermont Oxford Network members, LOI was defined as culture-confirmed blood and/or cerebrospinal fluid infection > 3 days after birth. The primary outcome was incidence of Serratia LOI. Secondary outcomes compared rates of survival and discharge morbidities between infants with Serratia and non-Serratia LOI. RESULTS Among 119,565 infants, LOI occurred in 10,687 (8.9%). Serratia was isolated in 279 cases (2.6% of all LOI; 2.3 Serratia infections per 1000 infants). Of 774 hospitals, 161 (21%) reported at least one Serratia LOI; 170 of 271 (63%) cases occurred at hospitals reporting 1 or 2 Serratia infections, and 53 of 271 (20%) occurred at hospitals reporting ≥5 Serratia infections. Serratia LOI was associated with a lower rate of survival to discharge compared with those with non-Serratia LOI (adjusted relative risk 0.88, 95% CI: 0.82-0.95). Among survivors, infants with Serratia LOI had higher rates of tracheostomy, gastrostomy and home oxygen use compared with those with non-Serratia LOI. CONCLUSIONS The incidence of Serratia LOI was 2.3 infections per 1000 very preterm infants in this cohort. Lower survival and significant morbidity among Serratia LOI survivors highlight the need for recognition and targeted prevention strategies for this opportunistic nosocomial infection.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Erika M. Edwards
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Dustin D. Flannery
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S. Gerber
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey D. Horbar
- University of Vermont, Burlington, VT, USA
- Vermont-Oxford Network, Burlington, VT, USA
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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5
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Aghdassi SJS, Kohlmorgen B, Schröder C, Peña Diaz LA, Thoma N, Rohde AM, Piening B, Gastmeier P, Behnke M. Implementation of an automated cluster alert system into the routine work of infection control and hospital epidemiology: experiences from a tertiary care university hospital. BMC Infect Dis 2021; 21:1075. [PMID: 34663246 PMCID: PMC8522860 DOI: 10.1186/s12879-021-06771-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/07/2021] [Indexed: 12/04/2022] Open
Abstract
Background Early detection of clusters of pathogens is crucial for infection prevention and control (IPC) in hospitals. Conventional manual cluster detection is usually restricted to certain areas of the hospital and multidrug resistant organisms. Automation can increase the comprehensiveness of cluster surveillance without depleting human resources. We aimed to describe the application of an automated cluster alert system (CLAR) in the routine IPC work in a hospital. Additionally, we aimed to provide information on the clusters detected and their properties. Methods CLAR was continuously utilized during the year 2019 at Charité university hospital. CLAR analyzed microbiological and patient-related data to calculate a pathogen-baseline for every ward. Daily, this baseline was compared to data of the previous 14 days. If the baseline was exceeded, a cluster alert was generated and sent to the IPC team. From July 2019 onwards, alerts were systematically categorized as relevant or non-relevant at the discretion of the IPC physician in charge. Results In one year, CLAR detected 1,714 clusters. The median number of isolates per cluster was two. The most common cluster pathogens were Enterococcus faecium (n = 326, 19 %), Escherichia coli (n = 274, 16 %) and Enterococcus faecalis (n = 250, 15 %). The majority of clusters (n = 1,360, 79 %) comprised of susceptible organisms. For 906 alerts relevance assessment was performed, with 317 (35 %) alerts being classified as relevant. Conclusions CLAR demonstrated the capability of detecting small clusters and clusters of susceptible organisms. Future improvements must aim to reduce the number of non-relevant alerts without impeding detection of relevant clusters. Digital solutions to IPC represent a considerable potential for improved patient care. Systems such as CLAR could be adapted to other hospitals and healthcare settings, and thereby serve as a means to fulfill these potentials.
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Affiliation(s)
- Seven Johannes Sam Aghdassi
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany. .,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany.
| | - Britta Kohlmorgen
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Christin Schröder
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Luis Alberto Peña Diaz
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Norbert Thoma
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Anna Maria Rohde
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Brar Piening
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Michael Behnke
- Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Universität zu Berlin, Hindenburgdamm 27, 12203, Berlin, Germany.,National Reference Centre for Surveillance of Nosocomial Infections, Hindenburgdamm 27, 12203, Berlin, Germany
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6
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Härtel C, Faust K, Fortmann I, Humberg A, Pagel J, Haug C, Kühl R, Bohnhorst B, Pirr S, Viemann D, Simon A, Zemlin M, Poralla S, Müller A, Köstlin-Gille N, Gille C, Heckmann M, Rupp J, Herting E, Göpel W. Sepsis related mortality of extremely low gestational age newborns after the introduction of colonization screening for multi-drug resistant organisms. Antimicrob Resist Infect Control 2020; 9:144. [PMID: 32843080 PMCID: PMC7449086 DOI: 10.1186/s13756-020-00804-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/12/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In 2013 German infection surveillance guidelines recommended weekly colonization screening for multidrug-resistant (MDRO) or highly epidemic organisms for neonatal intensive care units (NICUs) and extended hygiene measures based on screening results. It remains a matter of debate whether screening is worth the effort. We therefore aimed to evaluate sepsis related outcomes before and after the guideline update. METHODS The German Neonatal Network (GNN) is a prospective cohort study including data from extremely preterm infants between 22 + 0 and 28 + 6 gestational weeks born in 62 German level III NICUs. RESULTS Infants treated after guideline update (n = 8.903) had a lower mortality (12.5% vs. 13.8%, p = 0.036), reduced rates for clinical sepsis (31.4 vs. 42.8%, p < 0.001) and culture-proven sepsis (14.4% vs. 16.5%, p = 0.003) as compared to infants treated before update (n = 3.920). In a multivariate logistic regression analysis, nine pathogens of culture-proven sepsis were associated with sepsis-related death, e.g. Pseudomonas aeruginosa [OR 59 (19-180), p < 0.001)]. However, the guideline update had no significant effect on pathogen-specific case fatality, total sepsis-related mortality and culture-proven sepsis rates with MDRO. While the exposure of GNN infants to cefotaxime declined over time (31.1 vs. 40.1%, p < 0.001), the treatment rate with meropenem was increased (31.6 vs. 26.3%, p < 0.001). CONCLUSIONS The introduction of weekly screening and extended hygiene measures is associated with reduced sepsis rates, but has no effects on sepsis-related mortality and sepsis with screening-relevant pathogens. The high exposure rate to meropenem should be a target of antibiotic stewardship programs.
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Affiliation(s)
- Christoph Härtel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany. .,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany. .,German Neonatal Network (GNN), Lübeck, Germany. .,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany. .,Department of Pediatrics, University of Würzburg, Josef-Schneider-Strasse 2, D-97080, Würzburg, Germany.
| | - Kirstin Faust
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Ingmar Fortmann
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Alexander Humberg
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Julia Pagel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Clara Haug
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Reinhard Kühl
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, Diakonissenkrankenhaus, Flensburg, Germany
| | - Bettina Bohnhorst
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Sabine Pirr
- Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Dorothee Viemann
- Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Arne Simon
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, Saar University Homburg, Homburg, Germany
| | - Michael Zemlin
- German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Pediatrics, Saar University Homburg, Homburg, Germany
| | - Silvia Poralla
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, University of Bonn, Bonn, Germany
| | - Andreas Müller
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, University of Bonn, Bonn, Germany
| | | | - Christian Gille
- German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Tuebingen University Children's Hospital, Tuebingen, Germany
| | - Matthias Heckmann
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Neonatology and Pediatric Intensive Care, University of Greifswald, Greifswald, Germany
| | - Jan Rupp
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany.,Department of Infectious Diseases and Medical Microbiology, University of Lübeck, Lübeck, Germany
| | - Egbert Herting
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany
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7
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Slingerland BCGC, Vos MC, Bras W, Kornelisse RF, De Coninck D, van Belkum A, Reiss IKM, Goessens WHF, Klaassen CHW, Verkaik NJ. Whole-genome sequencing to explore nosocomial transmission and virulence in neonatal methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Resist Infect Control 2020; 9:39. [PMID: 32087747 PMCID: PMC7036242 DOI: 10.1186/s13756-020-0699-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/10/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Neonatal Staphylococcus aureus (S. aureus) bacteremia is an important cause of morbidity and mortality. In this study, we examined whether methicillin-susceptible S. aureus (MSSA) transmission and genetic makeup contribute to the occurrence of neonatal S. aureus bacteremia. METHODS A retrospective, single-centre study was performed. All patients were included who suffered from S. aureus bacteremia in the neonatal intensive care unit (NICU), Erasmus MC-Sophia, Rotterdam, the Netherlands, between January 2011 and November 2017. Whole-genome sequencing (WGS) was used to characterize the S. aureus isolates, as was also done in comparison to reference genomes. Transmission was considered likely in case of genetically indistinguishable S. aureus isolates. RESULTS Excluding coagulase-negative staphylococci (CoNS), S. aureus was the most common cause of neonatal bacteremia. Twelve percent (n = 112) of all 926 positive blood cultures from neonates grew S. aureus. Based on core genome multilocus sequence typing (cgMLST), 12 clusters of genetically indistinguishable MSSA isolates were found, containing 33 isolates in total (2-4 isolates per cluster). In seven of these clusters, at least two of the identified MSSA isolates were collected within a time period of one month. Six virulence genes were present in 98-100% of all MSSA isolates. In comparison to S. aureus reference genomes, toxin genes encoding staphylococcal enterotoxin A (sea) and toxic shock syndrome toxin 1 (tsst-1) were present more often in the genomes of bacteremia isolates. CONCLUSION Transmission of MSSA is a contributing factor to the occurrence of S. aureus bacteremia in neonates. Sea and tsst-1 might play a role in neonatal S. aureus bacteremia.
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Affiliation(s)
- Bibi C G C Slingerland
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Willeke Bras
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - René F Kornelisse
- Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dieter De Coninck
- BioMérieux SA, Data Analytics, Clinical Unit, Sint-Martens-Latem, Belgium
| | - Alex van Belkum
- BioMérieux SA, Clinical Unit, 38390, La Balme-les-Grottes, France
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wil H F Goessens
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Corné H W Klaassen
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Nelianne J Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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8
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Lai MY, Hsu JF, Chu SM, Wu IH, Huang HR, Chiang MC, Fu RH, Tsai MH. Risk Factors and Outcomes of Recurrent Candidemia in Children: Relapse or Re-Infection? J Clin Med 2019; 8:jcm8010099. [PMID: 30654524 PMCID: PMC6352033 DOI: 10.3390/jcm8010099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/07/2019] [Accepted: 01/11/2019] [Indexed: 12/30/2022] Open
Abstract
In this paper, our aim was to investigate the incidence, clinical characteristics, risk factors, and outcomes of recurrent candidemia in children. We retrospectively reviewed all children with candidemia from a medical center in Taiwan between 2004 and 2015. Two episodes of candidemia ≥30 days apart with clinical and microbiological resolution in the interim were defined as "late recurrence", and those that had 8⁻29 days apart from previous episodes were defined as "early recurrence". 45 patients (17.2%) had 57 episodes of recurrent candidemia, and 24 had 28 episodes of late recurrent candidemia. The median time between recurrences was 1.8 months (range: <1 month to 13 months). Of those, 29 had relapsed candidemia and 28 were re-infected by different Candida species (n = 24) or by different strains (n = 4). Recurrent candidemia patients were more likely to require echinocandins treatment, had a longer duration of candidemia, and higher rate of treatment failure (p = 0.001, 0.014, and 0.012, respectively). Underlying gastrointestinal diseases (Odds ratio (OR) 3.84; 95% Confidence interval (CI) 1.81⁻8.12) and neurological sequelae (OR 2.32; 95% CI 1.15⁻4.69) were independently associated with the development of recurrent candidemia. 17.2% of pediatric patients with candidemia developed recurrent candidemia, and approximately half were re-infected. Underlying gastrointestinal diseases and neurological sequelae were the independent risk factors for recurrent candidemia.
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Affiliation(s)
- Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - I-Hsyuan Wu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Ming-Horng Tsai
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 333, Taiwan.
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9
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Litz JE, Goedicke-Fritz S, Härtel C, Zemlin M, Simon A. Management of early- and late-onset sepsis: results from a survey in 80 German NICUs. Infection 2019; 47:557-564. [DOI: 10.1007/s15010-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
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Factors and outcomes associated with candidemia caused by non-albicans Candida spp versus Candida albicans in children. Am J Infect Control 2018; 46:1387-1393. [PMID: 30100260 DOI: 10.1016/j.ajic.2018.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/18/2018] [Accepted: 05/20/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Candidemia in children caused by non-albicans Candida (NAC) spp is increasing in prevalence, but the relevant information is limited. METHODS All isolates of pediatric candidemia from a medical center in Taiwan between 2003 and 2015 were enrolled. The characteristics of patients with NAC and Candida albicans candidemia (CAC) were compared. RESULTS Among the 319 episodes of candidemia occurring in 262 patients, C albicans accounted for 46.4%. The NAC and CAC groups had no significant differences in demographics, underlying diseases, most risk factors, and clinical characteristics. Patients in the NAC group were significantly more likely to have fluconazole exposure (14.0% vs 6.8%, respectively; P = .045), and NAC species accounted for 70.2% of all recurrent episodes. NAC candidemia had a longer duration of candidemia (median, 3.0 vs 1.0 days after effective antifungal treatment, respectively; P = .001), slower responses to antifungal treatment, and a higher rate of treatment failure than CAC. However, the 2 groups had similar 30-day candidemia-attributable mortality rates. After multivariate logistic regression, longer duration of central venous catheter was the independent risk factor for NAC candidemia in children (odds ratio, 1.21; 95% confidence interval, 1.08-1.35 for every 10-day increment). CONCLUSIONS NAC species collectively have emerged as the predominant pathogens of candidemia in children. Prolonged use of a central venous catheter is associated with an increased risk of candidemia caused by NAC species.
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Hsu JF, Lai MY, Lee CW, Chu SM, Wu IH, Huang HR, Lee IT, Chiang MC, Fu RH, Tsai MH. Comparison of the incidence, clinical features and outcomes of invasive candidiasis in children and neonates. BMC Infect Dis 2018; 18:194. [PMID: 29699503 PMCID: PMC5921543 DOI: 10.1186/s12879-018-3100-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 04/17/2018] [Indexed: 12/16/2022] Open
Abstract
Background Invasive candidiasis differs greatly between children and neonates. We aimed to investigate the different therapeutic approaches and their effects on treatment outcomes of these two groups. Methods Episodes of neonatal invasive candidiasis were compared with non-neonatal pediatric episodes during a 12-year cohort study. Clinical isolates were documented by matrix-assisted laser desorption/ionization-time of flight mass spectrometry and DNA sequencing, and antifungal susceptibility testing was performed. Results A total of 342 episodes of invasive candidiasis (113 neonatal and 229 non-neonatal pediatric episodes) in 281 pediatric patients (96 neonates and 185 children) were identified. Candida albicans was the most common pathogen causing invasive candidiasis in neonates and children (47.8% vs. 44.1%). The antifungal susceptibility profiles were not significantly different between neonates and children. More neonates received amphotericin B as therapy, whereas more children received fluconazole or caspofungin. Compared with children, neonates had a significantly longer duration of fungemia, higher rates of septic shock (34.5% vs. 21.8%; P = 0.013), sepsis-attributable mortality (28.3% vs. 17.5%; P = 0.024) and in-hospital mortality (42.7% vs. 25.4%; P = 0.004) than children. Independent risk factors for treatment failure of invasive candidiasis were septic shock (odds ration [OR] 16.01; 95% confidence interval [CI] 7.64–33.56; P < 0.001), delayed removal of intravenous catheter (OR 6.78; 95% CI 2.80–17.41; P < 0.001), renal failure (OR 5.38; 95% CI 1.99–14.57; P = 0.001), and breakthrough invasive candidiasis (OR 2.99; 95% CI 1.04–8.67; P = 0.043). Conclusions Neonatal invasive candidiasis has worse outcomes than non-neonatal pediatric candidiasis. Neonatologists and pediatricians must consider age-specific differences when developing treatment and prevention guidelines, or when interpreting studies of other age groups.
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Affiliation(s)
- Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiang-Wen Lee
- Department of Nursing, Division of Basic Medical Sciences and Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Hsyuan Wu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Ta Lee
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, No.707, Gongye Rd., Sansheng, Mailiao Township, Yunlin, Taiwan, Republic of China. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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12
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Abstract
PURPOSE OF REVIEW Neonates in the neonatal ICU (NICU) are uniquely vulnerable to colonization and infection with pathogens such as multidrug resistant Gram-negative bacteria, which in turn are associated with increased infection-related morbidities and higher case-fatality rates. We reviewed the English, French, and German language literature published between 2015 and 2017, for reports of NICU outbreaks. RECENT FINDINGS A total of 39 outbreaks in NICUs were reported with Gram-negative bacteria (n = 21; 54%) causing most, and extended spectrum beta-lactamase-producing organisms being the most frequent resistance mechanism reported (n = 5). Five viral outbreaks were reported (respiratory syncytial virus = 3). A significant proportion of outbreaks (33%) did not identify a source. Whole genome sequencing was used more (n = 6 reports). The most common described infection prevention and control interventions included staff and parent education on hand hygiene, patient isolation, additional contact precautions, including discontinuation of 'kangaroo care', and cohorting. Reporting and publication bias are likely common. SUMMARY NICUs must be vigilant in identifying outbreaks, conduct comprehensive investigations, and implement targeted infection prevention and control strategies. Molecular epidemiology capacities are an essential element in outbreak investigation. More studies are needed to determine the added value of active colonization screening and their impact on outbreak development.
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Tsai MH, Hsu JF, Chu SM, Chang PJ, Lai MY, Wu IH, Huang HR, Chiang MC, Fu RH, Lu JJ. Clinical and microbiological characteristics, and impact of therapeutic strategies on the outcomes of children with candidemia. Sci Rep 2017; 7:1083. [PMID: 28439070 PMCID: PMC5430948 DOI: 10.1038/s41598-017-01123-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/22/2017] [Indexed: 01/17/2023] Open
Abstract
We aimed to determine the clinical and microbiological characteristics of Candida bloodstream infections in children and the impact of therapeutic strategies on outcomes. All pediatric patients with candidemia from a medical center in Taiwan over a 13-year period (2003-2015) were included and a total of 262 patients with 319 episodes of candidemia were analyzed. Overall susceptibility to fluconazole was 86.1%. Cumulative mortality at 7 and 30 days after the first episode of candidemia was 13.4% and 25.2%, respectively. The overall in-hospital mortality rate was 35.1%. The treatment outcomes did not change over the study period. Multivariate analysis showed that delayed catheter removal (odds ratio [OR], 5.52; 95% confidence interval [CI]: 2.97-10.25), septic shock (OR, 5.49; 95% CI: 2.85-10.57), and breakthrough candidemia (OR, 3.66; 95% CI: 1.43-9.35) were independently associated with clinical treatment failure. In children with candidemia, underlying renal insufficiency and hematological/oncological malignancy, delayed catheter removal, and septic shock at onset were independently associated final in-hospital mortality. Analyzing the subgroup of non-neonatal children did not change the findings. We concluded overall mortality of pediatric candidemia remains high during the past decade. Prompt early catheter removal and aggressive treatment strategy in patients with septic shock would be critical to improve outcomes.
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Affiliation(s)
- Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medicine, Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pey-Jium Chang
- Department of Medicine, Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Hsyuan Wu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan. .,Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan.
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Lai MY, Hsu JF, Chu SM, Wu IH, Huang HR, Lin CC, Lee IT, Chiang MC, Fu RH, Tsai MH. Breakthrough candidemia in children: clinical and microbiological characteristics, therapeutic strategies and impact on outcomes. Future Microbiol 2017; 12:695-705. [PMID: 28326813 DOI: 10.2217/fmb-2016-0223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess the characteristics, treatments, risk factors and outcomes of breakthrough candidemia in children. MATERIALS & METHODS Episodes of breakthrough candidemia in children were compared with the remaining episodes in a 13-year cohort study. RESULTS Out of 319 episodes, 45 (14.1%) were breakthrough candidemia. Breakthrough candidemia occurred in patients with more acutely ill conditions, and the majority was caused by non-albicans Candida species (73.3%; 33 episodes). A total of 79.1% of breakthrough candidemia were caused by antifungal-susceptible Candida isolates and emergence of resistance was the mechanism in five cases of patients receiving fluconazole. Episodes of breakthrough candidemia had significantly higher illness severity and higher rates of fungemia-attributable mortality. CONCLUSION Breakthrough candidemia independently contributed to unfavorable outcomes, and more aggressive treatment strategies are warranted when breakthrough candidemia is encountered.
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Affiliation(s)
- Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Hsyuan Wu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Chih Lin
- Department of Nursing, Division of Basic Medical Sciences & Research Center for Industry of Human Ecology, Chang Gung University of Science & Technology, Chiayi, Taiwan
| | - I-Ta Lee
- Department of Anatomy, College of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology & Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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