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Hu JN, Hu SQ, Li ZL, Bao C, Liu Q, Liu C, Xu SY. Risk factors of multidrug-resistant bacteria infection in patients with ventilator-associated pneumonia: A systematic review and meta-analysis. J Infect Chemother 2023; 29:942-947. [PMID: 37321291 DOI: 10.1016/j.jiac.2023.06.008] [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: 11/21/2022] [Revised: 02/03/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Multidrug-resistant (MDR) bacteria-induced VAP often has high lethality. We present this systematic review and meta-analysis to assess the risk factors for MDR bacterial infection in patients with VAP. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library were searched for studies regarding MDR bacterial infection in VAP patients, from Jan 1996 to Aug 2022. Study selection, data extraction, and quality assessment of included studies were conducted by two reviewers independently, and potential risk factors for MDR bacterial infection were identified. RESULTS Meta-analysis showed that the score of the Acute Physiology and Chronic Health Evaluation II (APACHE-II) [OR = 1.009, 95% (CI 0.732, 1.287)], Simplified Acute Physiology Score II (SAPS-II) [OR = 2.805, 95%CI (0.854, 4.755)], length of hospital-stay before VAP onset (days) [OR = 2.639, 95%CI (0.387, 4.892)], in-ICU duration [OR = 3.958, 95%CI (0.894, 7.021)], Charlson index [OR = 1.000, 95%CI (0.889, 1.111)], overall hospital-stay [OR = 20.742, 95%CI (18.894, 22.591)], Medication of Quinolones [OR = 2.017, 95%CI (1.339, 3.038)], medication of carbapenems [OR = 3.527, 95%CI (2.476, 5.024)], combination of more than 2 prior antibiotics [OR = 3.181, 95%CI (2.102, 4.812)], and prior use of antibiotics [OR 2.971, 95%CI (2.001, 4.412)] were independent risk factors of MDR bacterial infection in VAP patients. Diabetes and mechanical ventilation duration before VAP onset showed no association with risk for MDR bacterial infection. CONCLUSIONS This study has identified 10 risk factors associated with MDR bacterial infection in VAP patients. Identification of these factors would be able to facilitate the treatment and prevention of MDR bacterial infection in clinical practice.
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Affiliation(s)
- Jian-Nan Hu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Sheng-Qi Hu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan, 430030, Hubei Province, PR China.
| | - Zi-Ling Li
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Chen Bao
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Qian Liu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Chao Liu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Shu-Yun Xu
- Department of Respiratory and Critical Care Medicine, Key Laboratory of Pulmonary Diseases of Health Ministry, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Mora-Guzmán I, Rubio-Perez I, Domingo-Garcia D, Martin-Perez E. Risk Factors for Intra-Abdominal Infections Caused by Carbapenemase-Producing Enterobacteriaceae in a Surgical Setting. Surg Infect (Larchmt) 2021; 22:864-870. [PMID: 33857380 DOI: 10.1089/sur.2020.472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The aim of this study was to identify risk factors for acquisition of intra-abdominal infections (IAI) caused by carbapenemase-producing Enterobacteriaceae (CPE) in surgical patients. Methods: A matched case-control study was performed. We included all cases with CPE-related IAI acquired during admission to a general surgery department from January 2013 to December 2018, and they were matched with control subjects with IAI caused by non-resistant bacteria (ratio 1:3). Independent risk factors were obtained by logistic regression. Results: Forty patients with IAI-CPE were matched with 120 control subjects. Independent risk factors for acquisition of IAI-CPE were previous hospitalization (odds ratio [OR] 2.56; 95% confidence interval [CI] l 1.01-6.49; p = 0.047), digestive endoscopy (OR 4.11; 95% CI 1.40-12.07; p = 0.010), carbapenem therapy (OR 9.54; 95% CI 3.33-27.30; p < 0.001), and aminoglycoside use (OR 45.41; 95% CI 7.90-261.06; p < 0.001). Conclusions: Four clinical factors can identify patients at high-risk of IAI-CPE.
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Affiliation(s)
- Ismael Mora-Guzmán
- Department of General Surgery. Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Inés Rubio-Perez
- Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Diego Domingo-Garcia
- Department of Clinical Microbiology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Elena Martin-Perez
- Department of General Surgery, Hospital Universitario de La Princesa, Madrid, Spain
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Guerci P, Bellut H, Mokhtari M, Gaudefroy J, Mongardon N, Charpentier C, Louis G, Tashk P, Dubost C, Ledochowski S, Kimmoun A, Godet T, Pottecher J, Lalot JM, Novy E, Hajage D, Bouglé A. Outcomes of Stenotrophomonas maltophilia hospital-acquired pneumonia in intensive care unit: a nationwide retrospective study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:371. [PMID: 31752976 PMCID: PMC6873544 DOI: 10.1186/s13054-019-2649-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022]
Abstract
Background There is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy. Methods This nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy. Results Of the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5–18] days. The Simplified Acute Physiology Score II was 47 [36–63], and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively). Conclusions S. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival. Trial registration clinicaltrials.gov, NCT03506191
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Affiliation(s)
- Philippe Guerci
- Department of Anaesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy-Brabois, Vandoeuvre-Lès-Nancy, France.,INSERM U1116, Groupe Choc, University of Lorraine, Nancy, France
| | - Hugo Bellut
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Mokhtar Mokhtari
- Department of Anaesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy-Brabois, Vandoeuvre-Lès-Nancy, France
| | - Julie Gaudefroy
- Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor, DMU CARE, Assistance Publique - Hôpitaux de Paris (AP-HP), Inserm U955 équipe 3, Université Paris-Est Créteil, Créteil, France
| | - Claire Charpentier
- Réanimation Chirurgicale Polyvalente, Hôpital Central, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Guillaume Louis
- Réanimation polyvalente, Hôpital de Mercy, CHR Metz-Thionville, Metz, France
| | - Parvine Tashk
- Service d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Clément Dubost
- Réanimation polyvalente, Hôpital d'Instruction des Armées (HIA) Bégin, Saint-Mandé, France
| | - Stanislas Ledochowski
- Service de Réanimation Polyvalente, Groupement Hospitalier Nord Dauphiné- Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Antoine Kimmoun
- Réanimation Médicale, Institut Lorrain du Cœur et des Vaisseaux, CHU Nancy-Brabois, Vandoeuvre-Lès-Nancy, France
| | - Thomas Godet
- Réanimation Adultes et Soins Continus, Pôle de Médecine Péri-opératoire, Hôpital Estaing, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Julien Pottecher
- Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Faculté de Médecine, Institut de Physiologie, EA3072, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Jean-Marc Lalot
- Service d'Anesthésie-Réanimation, Réanimation polyvalente, Centre Hospitalier Emile Durkheim, Epinal, France
| | - Emmanuel Novy
- Department of Anaesthesiology and Critical Care Medicine, Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy-Brabois, Vandoeuvre-Lès-Nancy, France
| | - David Hajage
- Département Biostatistique Santé Publique Et Information Médicale, Unité de Recherche Clinique PSL-CFX, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, INSERM, Institut Pierre Louis de Santé Publique, Equipe Pharmacoépidémiologie et évaluation des soins, AP-HP, Hôpital Pitié-Salpêtrière, CIC-1421, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
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Ibn Saied W, Merceron S, Schwebel C, Le Monnier A, Oziel J, Garrouste-Orgeas M, Marcotte G, Ruckly S, Souweine B, Darmon M, Bouadma L, de Montmollin E, Mourvillier B, Reignier J, Papazian L, Siami S, Azoulay E, Bédos JP, Timsit JF. Ventilator-associated pneumonia due to Stenotrophomonas maltophilia: Risk factors and outcome. J Infect 2019; 80:279-285. [PMID: 31682878 DOI: 10.1016/j.jinf.2019.10.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Stenotrophomonas maltophilia (SM) is increasingly identified in intensive care unit (ICU). This study aim to identify risk factors for SM ventilator-associated pneumonia (VAP) and whether it affects ICU mortality METHODS: Two nested matched case-control studies were performed based in OUTCOMEREA database. The first episodes of SM-VAP patients were matched with two different control groups: VAP due to other micro-organisms (VAP-other) and Pseudomonas aeruginosa VAP (Pyo-VAP). Matching criteria were the hospital, the SAPS II, and the previous duration of mechanical ventilation (MV). RESULTS Of the 102 SM-VAP patients (6.2% of all VAP patients), 92 were matched with 375 controls for the SM-VAP/other-VAP matching and 84 with 237 controls for the SM-VAP/Pyo-VAP matching. SM-VAP risk factors were an exposition to ureido/carboxypenicillin or carbapenem during the week before VAP, and respiratory and coagulation components of SOFA score upper to 2 before VAP. SM-VAP received early adequate therapy in 70 cases (68.6%). Risk factors for Day-30 were age (OR = 1.03; p < 0.01) and Chronic heart failure (OR = 3.15; p < 0.01). Adequate treatment, either monotherapy or combination of antimicrobials, did not modify mortality. There was no difference in 30-day mortality, but 60-day mortality was higher in patients with SM-VAP compared to Other-VAP (P = 0.056). CONCLUSIONS In a large series, independent risk factors for the SM-VAP were ureido/carboxypenicillin or carbapenem exposure the week before VAP, and respiratory and coagulation components of the SOFA score > 2 before VAP. Mortality risk factors of SM-VAP were age and chronic heart failure. Adequate treatment did not improve SM-VAP prognosis.
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Affiliation(s)
| | | | - Carole Schwebel
- Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, La Tronche, France
| | - Alban Le Monnier
- Microbiology Laboratory, Saint Joseph Hospital Network, Paris, France
| | - Johana Oziel
- Medical Surgical ICU, Avicenne Hospital, Bobigny, France
| | - Maité Garrouste-Orgeas
- Intensive Care Unit Hospital A Mignot, Versailles, France; Intensive Care Unit, Saint Joseph Hospital Network, Paris, France; Outcomerea Research Network, Aulnay sous Bois, France
| | | | | | - Bertrand Souweine
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Michael Darmon
- Saint Etienne University Hospital, Medical Intensive Care Unit, Saint-Etienne, France; Intensive Care Unit, Saint Louis Hospital, Paris, France
| | - Lila Bouadma
- UMR 1137, IAME, Université Paris Diderot, Paris, France; Medical and Infectious diseases ICU (MI2), APHP, Bichat Hospital, Paris, France
| | | | - Bruno Mourvillier
- Intensive Care Medicine, University Hospital, Reims, France; Medical and Infectious diseases ICU (MI2), APHP, Bichat Hospital, Paris, France
| | - Jean Reignier
- Medical Intensive Care Unit and University Hospital Centre, Nantes, France
| | - Laurent Papazian
- Respiratory and Infectious Diseases ICU, APHM Hôpital Nord, Aix Marseille University, Marseille, France
| | - Shidasp Siami
- Critical Care Medicine Unit CH Etampes-Dourdan, Etampes, France
| | - Elie Azoulay
- Intensive Care Unit, Saint Louis Hospital, Paris, France
| | | | - Jean-Francois Timsit
- UMR 1137, IAME, Université Paris Diderot, Paris, France; Outcomerea Research Network, Aulnay sous Bois, France; Medical and Infectious diseases ICU (MI2), APHP, Bichat Hospital, Paris, France.
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Burillo A, Marín M, Cercenado E, Ruiz-Carrascoso G, Pérez-Granda MJ, Oteo J, Bouza E. Evaluation of the Xpert Carba-R (Cepheid) Assay Using Contrived Bronchial Specimens from Patients with Suspicion of Ventilator-Associated Pneumonia for the Detection of Prevalent Carbapenemases. PLoS One 2016; 11:e0168473. [PMID: 27992521 PMCID: PMC5161504 DOI: 10.1371/journal.pone.0168473] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 12/01/2016] [Indexed: 12/16/2022] Open
Abstract
There is a critical need for rapid diagnostic methods for multidrug-resistant (MDR) pathogens in patients with a suspicion of ventilator-associated pneumonia (VAP). The Xpert Carba-R detects 5 targets for carbapenemase-producing organisms (blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP-1). Our objective was to evaluate the performance of this assay directly on bronchial aspirates and to correlate the cycle number for a positive result (Ct) with the bacterial count. Bronchial aspirates from patients with a suspicion of VAP were spiked with a dilution of 1 of 4 MDR organisms carrying the resistance genes detected by the test prepared to a final concentration of 102−105 cfu/mL. We used a ROC curve and provided areas under the curve (AUC) with their 95% confidence intervals (CI). A point of maximum sensitivity (Se) and specificity (Sp) was derived and validity indices were calculated. One hundred contrived tests were performed. Se and Sp were 100% for all bacterial counts. A positive sample with a Ct ≤24.7 corresponded to a count ≥105 cfu/mL; if the Ct was within the range >24.7-≤26.9, this corresponded to a count ≥104 cfu/mL. When the Ct was >26.9, this corresponded to a count <104 cfu/mL. The Xpert Carba-R detects carbapenemase-producing organisms directly in contrived bronchial aspirates. Still, an important issue to consider is that the number of gene copies may vary according to many factors in vivo. If confirmed in further studies, the strong correlation observed between Ct values and the results of semiquantitative cultures suggests this test could serve to differentiate between infection and colonization in routine clinical practice.
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Affiliation(s)
- Almudena Burillo
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- * E-mail:
| | - Mercedes Marín
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | - Emilia Cercenado
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
| | | | - María Jesús Pérez-Granda
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
- Department of Anesthesiology, Cardiac Surgery Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jesús Oteo
- Antibiotic Laboratory, Bacteriology Department, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain
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Ruppé É, Woerther PL, Barbier F. Mechanisms of antimicrobial resistance in Gram-negative bacilli. Ann Intensive Care 2015; 5:61. [PMID: 26261001 PMCID: PMC4531117 DOI: 10.1186/s13613-015-0061-0] [Citation(s) in RCA: 251] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/23/2015] [Indexed: 02/07/2023] Open
Abstract
The burden of multidrug resistance in Gram-negative bacilli (GNB) now represents a daily issue for the management of antimicrobial therapy in intensive care unit (ICU) patients. In Enterobacteriaceae, the dramatic increase in the rates of resistance to third-generation cephalosporins mainly results from the spread of plasmid-borne extended-spectrum beta-lactamase (ESBL), especially those belonging to the CTX-M family. The efficacy of beta-lactam/beta-lactamase inhibitor associations for severe infections due to ESBL-producing Enterobacteriaceae has not been adequately evaluated in critically ill patients, and carbapenems still stands as the first-line choice in this situation. However, carbapenemase-producing strains have emerged worldwide over the past decade. VIM- and NDM-type metallo-beta-lactamases, OXA-48 and KPC appear as the most successful enzymes and may threaten the efficacy of carbapenems in the near future. ESBL- and carbapenemase-encoding plasmids frequently bear resistance determinants for other antimicrobial classes, including aminoglycosides (aminoglycoside-modifying enzymes or 16S rRNA methylases) and fluoroquinolones (Qnr, AAC(6′)-Ib-cr or efflux pumps), a key feature that fosters the spread of multidrug resistance in Enterobacteriaceae. In non-fermenting GNB such as Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia, multidrug resistance may emerge following the sole occurrence of sequential chromosomal mutations, which may lead to the overproduction of intrinsic beta-lactamases, hyper-expression of efflux pumps, target modifications and permeability alterations. P. aeruginosa and A. baumannii also have the ability to acquire mobile genetic elements encoding resistance determinants, including carbapenemases. Available options for the treatment of ICU-acquired infections due to carbapenem-resistant GNB are currently scarce, and recent reports emphasizing the spread of colistin resistance in environments with high volume of polymyxins use elicit major concern.
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Affiliation(s)
- Étienne Ruppé
- Department of Infectious Diseases, Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland,
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Abstract
Increasing incidence of resistance of gram-negative bacteria against even newer antibiotic including carbapenem has generated interest in the old antibiotic colistin, which are being used as salvage therapy in the treatment of multidrug resistant infection. Colistin has excellent bactericidal activity against most gram-negative bacilli. It has shown persist level in the liver, kidney, heart, and muscle; while it is poorly distributed to the bones, cerebrospinal fluid, lung parenchyma, and pleural cavity. Being an old drug, colistin was never gone through the drug development process needed for compliance with competent regulatory authorities that resulted in very much limited understanding of pharmacokinetic (PK) and pharmacodynamic (PD) parameters, such as Cmax/MIC ratio, AUC/MIC and T > MIC that could predict the efficacy of colistin. In available PK/PD studies of colistin, mean maximum serum concentration (Cmax) of colistin were found just above the MIC breakpoint at steady states that would most probably lead to suboptimal for killing the bacteria, even at dosages of 3.0 million international units (MIU) i.e., 240 mg of colistimethate sodium (CMS) intravenously every 8 h. These finding stresses to use high loading as well as high maintenance dose of intravenous colistin. It is not only suboptimal plasma concentration of colistin but also poor lung tissue concentration, which has been demonstrated in recent studies, poses major concern in using intravenous colistin. Combination therapy mainly with carbapenems shows synergistic effect. In recent studies, inhaled colistin has been found promising in treatment of lung infection due to MDR gram-negative bacteria. New evidence shows less toxicity than previously reported.
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Affiliation(s)
- Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, UP India
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