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Rech MA, Faine BA, Gross AE, Vakkalanka P, Brown CS, Harding SJ, Slocum G, Zimmerman D, Zepeski A, Rewitzer S, Howington GT, Campbell M, Dawson J, Treu CN, Nelson L, Jones M, Flack T, Porter B, Sarangarm P, Mattson AE, Bailey A, Kelly G, Talan DA. Empirical antimicrobial prescribing for pyelonephritis in patients discharged from 15 US Emergency Departments: an opportunity for improvement. J Antimicrob Chemother 2024; 79:1038-1044. [PMID: 38482607 DOI: 10.1093/jac/dkae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/27/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. OBJECTIVES To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics. METHODS We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy. RESULTS Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83). CONCLUSIONS In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.
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Affiliation(s)
- Megan A Rech
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare Edward Hines, Jr. VA Hospital, 5000 South 5th Ave, Hines, IL 60141, USA
- Department of Emergency Medicine, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, USA
| | - Brett A Faine
- Department of Emergency Medicine and Pharmacy, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Alan E Gross
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, 833 S Wood St, Chicago, IL 60612, USA
| | - Priyanka Vakkalanka
- Department of Emergency Medicine and Pharmacy, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Caitlin S Brown
- Department of Pharmacy and Emergency Medicine, Mayo Clinic School of Medicine and Science, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Stephanie J Harding
- Department of Pharmacy, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, USA
| | - Giles Slocum
- Department of Pharmacy and Emergency Medicine, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, USA
| | - David Zimmerman
- Department of Pharmacy Practice, Duquesne University School of Pharmacy, 600 Forbes Ave, Pittsburgh, PA 15282, USA
- University of Pittsburgh Medical Center- Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219, USA
| | - Anne Zepeski
- Department of Emergency Medicine and Pharmacy, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242, USA
| | - Stacey Rewitzer
- Department of Pharmacy, Methodist Hospital, St. Louis Park, MN 55426, USA
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S Limestone, Lexington, KY 40508, USA
- Department of Pharmacy, University of Kentucky HealthCare, 1000 S Limestone, Lexington, KY 40536, USA
| | - Matt Campbell
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Jordan Dawson
- Denver Health Medical Center, 777 Bannock St, Denver, CO 80204, USA
| | - Cierra N Treu
- Department of Pharmacy, New York-Presbyterian Brooklyn Methodist Hospital, 506 6th St, Brooklyn, NY 11215, USA
| | - Lucas Nelson
- Department of Pharmacy, Park Nicollet, Methodist Hospital, 6500 Excelsior Blvd, St Louis Park, MN 55426, USA
| | - Mandy Jones
- Department of Pharmacy, University of Kentucky HealthCare, 1000 S Limestone, Lexington, KY 40536, USA
| | - Tara Flack
- Department of Pharmacy, Indiana University Health Methodist Hospital, 1701 N Senate Ave, Indianapolis, IN 46202, USA
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, 111 Colchester, Burlington, VT 05401, USA
| | - Preeyaporn Sarangarm
- Department of Pharmacy, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM 87106, USA
| | - Alicia E Mattson
- Department of Pharmacy and Emergency Medicine, Mayo Clinic School of Medicine and Science, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Abby Bailey
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S Limestone, Lexington, KY 40508, USA
- Department of Pharmacy, University of Kentucky HealthCare, 1000 S Limestone, Lexington, KY 40536, USA
| | - Gregory Kelly
- Department of Pharmacy Practice and Administration, Rutgers Ernest Mario College of Pharmacy, 160 Frelinghuysen Rd, Piscataway, NJ 08854, USA
- Department of Pharmacy, Robert Wood Johnson University Hospital-New Brunswick, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901, USA
| | - David A Talan
- Department of Emergency Medicine and Division of Infectious Diseases, Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA 91342, USA
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Gerges B, Rosenblatt J, Truong YL, Jiang Y, Shelburne SA, Chaftari AM, Hachem R, Raad I. In vitro activity of cefepime/taniborbactam and comparator agents against Gram-negative bacterial bloodstream pathogens recovered from patients with cancer. JAC Antimicrob Resist 2024; 6:dlae060. [PMID: 38601790 PMCID: PMC11005172 DOI: 10.1093/jacamr/dlae060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/21/2024] [Indexed: 04/12/2024] Open
Abstract
Background Taniborbactam is a β-lactamase inhibitor that, when combined with cefepime, may offer a potential treatment option for patients with serious and resistant Gram-negative bacterial (GNB) pathogens. Objectives This study evaluated in vitro activity of cefepime/taniborbactam and comparator agents against GNB pathogens isolated from patients with cancer at our institution. Methods A total of 270 GNB pathogens (2019-23) isolated from patients with cancer were tested against cefepime/taniborbactam and comparator agents commonly used for these patients. CLSI-approved broth microdilution methods were used. MIC50, MIC90, MIC range and percentage of susceptibility calculations were made using FDA breakpoints when available. Results Cefepime/taniborbactam showed highly potent activity against tested Enterobacterales, including isolates producing ESBLs and carbapenem-resistant Enterobacterales. At a provisional breakpoint of ≤16/4 mg/L, cefepime/taniborbactam inhibited most tested species of GNB pathogens, with overall 98.9% susceptibility, which was significantly (P < 0.0001) higher than the susceptibility of the GNB isolates to all other tested comparator agents, ranging from 39.6% for cefepime to 86.3% for ceftazidime/avibactam. Conclusions Our results showed that taniborbactam in combination with cefepime improved in vitro activity against GNB pathogens isolated from patients with cancer, including MDR Pseudomonas aeruginosa, carbapenem-resistant Enterobacterales, ESBL-producing Enterobacterales and Stenotrophomonas maltophilia isolates, with highest activity compared with all tested comparator agents, including other β-lactam/β-lactamase inhibitor combinations. Further studies are warranted to explore the efficacy of cefepime/taniborbactam for empirical initial treatment of GNB infections in cancer patients with high rates of febrile neutropenia requiring hospitalization.
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Affiliation(s)
- Bahgat Gerges
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Joel Rosenblatt
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Y-Lan Truong
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Samuel A Shelburne
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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García-Meniño I, García V, Lumbreras-Iglesias P, Fernández J, Mora A. Fluoroquinolone resistance in complicated urinary tract infections: association with the increased occurrence and diversity of Escherichia coli of clonal complex 131, together with ST1193. Front Cell Infect Microbiol 2024; 14:1351618. [PMID: 38510968 PMCID: PMC10953827 DOI: 10.3389/fcimb.2024.1351618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/02/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction Urinary tract infections (UTIs) are one of the leading causes of multidrug-resistance (MDR) spread and infection-related deaths. Escherichia coli is by far the main causative agent. We conducted a prospective study on complicated urinary tract infections (cUTIs) i) to monitor the high-risk clones that could be compromising the therapeutic management and ii) to compare the cUTI etiology with uncomplicated infections (uUTIs) occurring in the same period and health area. Methods 154 non-duplicated E. coli recovered from cUTIs in 2020 at the Hospital Universitario Central de Asturias (Spain) constituted the study collection. Results Most cUTI isolates belonged to phylogroup B2 (72.1%) and met the uropathogenic (UPEC) status (69.5%) (≥3 of chuA, fyuA, vat, and yfcV genes). MDR was exhibited by 35.7% of the isolates, similarly to data observed in the uUTI collection. A significant difference observed in cUTI was the higher level of fluoroquinolone resistance (FQR) (47.4%), where the pandemic clonal groups B2-CC131 and B2-ST1193 (CH14-64) comprised 28% of the 154 E. coli, representing 52.1% of the FQR isolates. Other prevalent FQR clones were D-ST69 (CH35-27), D-ST405 (CH37-27), and B2-ST429 (CH40-20) (three isolates each). We uncovered an increased genetic and genomic diversity of the CC131: 10 different virotypes, 8 clonotypes (CH), and 2 STs. The presence of bla CTX-M-15 was determined in 12 (7.8%) isolates (all CC131), which showed 10 different core genome (cg)STs and 2 fimH types (fimH30 and fimH602) but the same set of chromosomal mutations conferring FQR (gyrA p.S83L, gyrA p.D87N, parC p.S80I, parC p.E84V, and parE p.I529L). In addition, the plasmidome analysis revealed 10 different IncF formulae in CC131 genomes. Conclusion We proved here that non-lactose fermenting screening, together with the detection of O25b (rfbO25b), H4 (fliCH4), and H5 (fliCH5) genes, and phylogroup and clonotyping assignation, is a reasonable approach that can be easily implemented for the surveillance of emerging high-risk clones associated with FQR spread in cUTIs, such as the uncommonly reported O25b:H4-B2-ST9126-CC131 (CH1267-30). Since E. coli CC131 and ST1193 are also involved in the community uUTIs of this health area, interventions to eradicate these MDR clones, along with surveillance for other emerging ones, are essential for antibiotic use optimization programs.
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Affiliation(s)
- Isidro García-Meniño
- Laboratorio de Referencia de Escherichia coli (LREC), Dpto. de Microbioloxía e Parasitoloxía, Universidade de Santiago de Compostela (USC), Lugo, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Department for Biological Safety, German Federal Institute for Risk Assessment, Berlin, Germany
| | - Vanesa García
- Laboratorio de Referencia de Escherichia coli (LREC), Dpto. de Microbioloxía e Parasitoloxía, Universidade de Santiago de Compostela (USC), Lugo, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Pilar Lumbreras-Iglesias
- Servicio de Microbiología, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
- Grupo de Microbiología Traslacional, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Javier Fernández
- Servicio de Microbiología, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
- Grupo de Microbiología Traslacional, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Research and Innovation, Artificial Intelligence and Statistical Department, Pragmatech AI Solutions, Oviedo, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Departamento de Biología Funcional, Universidad de Oviedo, Oviedo, Spain
| | - Azucena Mora
- Laboratorio de Referencia de Escherichia coli (LREC), Dpto. de Microbioloxía e Parasitoloxía, Universidade de Santiago de Compostela (USC), Lugo, Spain
- Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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Dao TH, Echlin H, McKnight A, Marr ES, Junker J, Jia Q, Hayden R, van Opijnen T, Isberg RR, Cooper VS, Rosch JW. Streptococcus pneumoniae favors tolerance via metabolic adaptation over resistance to circumvent fluoroquinolones. mBio 2024; 15:e0282823. [PMID: 38193698 PMCID: PMC10865975 DOI: 10.1128/mbio.02828-23] [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: 10/17/2023] [Accepted: 12/01/2023] [Indexed: 01/10/2024] Open
Abstract
Streptococcus pneumoniae is a major human pathogen of global health concern and the rapid emergence of antibiotic resistance poses a serious public health problem worldwide. Fluoroquinolone resistance in S. pneumoniae is an intriguing case because the prevalence of fluoroquinolone resistance does not correlate with increasing usage and has remained rare. Our data indicate that deleterious fitness costs in the mammalian host constrain the emergence of fluoroquinolone resistance both by de novo mutation and recombination. S. pneumoniae was able to circumvent such deleterious fitness costs via the development of antibiotic tolerance through metabolic adaptation that reduced the production of reactive oxygen species, resulting in a fitness benefit during infection of mice treated with fluoroquinolones. These data suggest that the emergence of fluoroquinolone resistance is tightly constrained in S. pneumoniae by fitness tradeoffs and that mutational pathways involving metabolic networks to enable tolerance phenotypes are an important contributor to the evasion of antibiotic-mediated killing.IMPORTANCEThe increasing prevalence of antibiotic resistant bacteria is a major global health concern. While many species have the potential to develop antibiotic resistance, understanding the barriers to resistance emergence in the clinic remains poorly understood. A prime example of this is fluroquinolone resistance in Streptococcus pneumoniae, whereby, despite continued utilization, resistance to this class of antibiotic remains rare. In this study, we found that the predominant pathways for developing resistance to this antibiotic class severely compromised the infectious capacity of the pneumococcus, providing a key impediment for the emergence of resistance. Using in vivo models of experimental evolution, we found that S. pneumoniae responds to repeated fluoroquinolone exposure by modulating key metabolic pathways involved in the generation of redox molecules, which leads to antibiotic treatment failure in the absence of appreciable shifts in resistance levels. These data underscore the complex pathways available to pathogens to evade antibiotic mediating killing via antibiotic tolerance.
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Affiliation(s)
- Tina H. Dao
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Haley Echlin
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Abigail McKnight
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Enolia S. Marr
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Julia Junker
- Nationales Referenzzentrum für Streptokokken Abteilung Medizinische Mikrobiologie, Universitätsklinikum RWTH Aachen, Aachen, Germany
| | - Qidong Jia
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Randall Hayden
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Tim van Opijnen
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Ralph R. Isberg
- Deptartment of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Vaughn S. Cooper
- Center for Evolutionary Biology and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason W. Rosch
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Thompson D, Xu J, Ischia J, Bolton D. Fluoroquinolone resistance in urinary tract infections: Epidemiology, mechanisms of action and management strategies. BJUI COMPASS 2024; 5:5-11. [PMID: 38179021 PMCID: PMC10764174 DOI: 10.1002/bco2.286] [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: 07/15/2023] [Revised: 08/06/2023] [Accepted: 08/12/2023] [Indexed: 01/06/2024] Open
Abstract
Background Fluoroquinolone resistance is an issue of concern amongst physicians worldwide. In urology, fluoroquinolones are often used in the treatment of acute pyelonephritis and prostatitis, as well as infections caused by multidrug-resistant pathogens. Aims We aim to highlight the importance of antimicrobial stewardship and the need for ongoing biomedical research to discover novel agents in our losing battle against resistant pathogens. Materials and methods In this review, we survey the literature and summarise fluoroquinolone resistance as it pertains to pyelonephritis and prostatitis, as well as alternative treatment strategies and prevention of multidrug resistance. Results The rise of fluoroquinolone resistance in bacteria has reduced the available treatment options, often necessitating hospital admission for intravenous antibiotics, which places an additional burden on both patients and the healthcare system. Many countries such as Australia have attempted to limit fluoroquinolone resistance by imposing strict prescribing criteria, though these efforts have not been entirely successful. Solutions to overcome resistance include prevention, combination therapy and the development of novel antimicrobial agents. Conclusions Prevention of the proliferation of resistant organisms by antimicrobial stewardship is paramount, and urologists are obliged to be aware of responsible prescribing practices such as referring to local guidelines when prescribing. By reserving fluoroquinolones for infections in which they are truly indicated and by prescribing based on both patient and local environmental factors, we can preserve this effective resource for future use.
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Affiliation(s)
- Daryl Thompson
- Department of SurgeryThe University of Melbourne, Austin HealthHeidelbergVictoriaAustralia
| | - Jennifer Xu
- Department of SurgeryThe University of Melbourne, Austin HealthHeidelbergVictoriaAustralia
| | - Joseph Ischia
- Department of SurgeryThe University of Melbourne, Austin HealthHeidelbergVictoriaAustralia
| | - Damien Bolton
- Department of SurgeryThe University of Melbourne, Austin HealthHeidelbergVictoriaAustralia
- Olivia Newton‐John Cancer Research Institute Austin HealthMelbourneVictoriaAustralia
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Zhang HL, Perez R, Krishnan J, Lautenbach E, Anderson DJ. Risk Factors for Recurrence of Community-Onset Urinary Tract Infections Caused by Extended-Spectrum Cephalosporin-Resistant Enterobacterales. Open Forum Infect Dis 2023; 10:ofad561. [PMID: 38130594 PMCID: PMC10733196 DOI: 10.1093/ofid/ofad561] [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: 08/30/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
Background Extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) are an increasingly important cause of community-onset urinary tract infections (UTIs), including recurrent infections. We evaluated risk factors for recurrence among patients with community-onset ESCrE UTI. Methods This retrospective cohort study included adults with community-onset ESCrE UTI in the Duke University Health System from April 2018 through December 2021. ESCrE UTI recurrence by the same species was assessed 14-180 days (ie, 6 months) after completion of antibiotic treatment. We evaluated the relationships between candidate risk factors and time to recurrence using Cox proportional hazards regression models. Results Among 1347 patients with community-onset ESCrE UTI, 202 (15.0%) experienced recurrent infection during the 6-month follow-up period. Independent risk factors for recurrence included neurogenic bladder (adjusted hazard ratio [aHR], 1.8 [95% confidence interval {CI}, 1.2-2.6]; P = .005), prior history of UTI (aHR, 2.4 [95% CI, 1.7-3.3]; P < .001), and fluoroquinolone nonsusceptibility of the index UTI (aHR, 1.5 [95% CI, 1.1-2.1]; P = .02). Klebsiella pneumoniae infection was associated with recurrence in univariate analysis (HR, 1.6 [95% CI, 1.1-2.1]; P = .007) but not multivariate analysis (aHR, 1.4 [95% CI, 1.0-1.9]; P = .06). Inappropriate initial or definitive antibiotic therapy was not predictive of ESCrE UTI recurrence. Conclusions Recurrence of community-onset ESCrE UTI was common and associated with several patient and pathogen-level risk factors. Future studies should evaluate microbial risk factors for recurrence and improve the management of ESCrE UTI.
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Affiliation(s)
- Helen L Zhang
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Reinaldo Perez
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Jay Krishnan
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Ebbing Lautenbach
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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7
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Pizzuti M, Tsai YV, Winders HR, Bookstaver PB, Al-Hasan MN. Application of Precision Medicine Concepts in Ambulatory Antibiotic Management of Acute Pyelonephritis. PHARMACY 2023; 11:169. [PMID: 37987379 PMCID: PMC10661281 DOI: 10.3390/pharmacy11060169] [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: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 11/22/2023] Open
Abstract
Acute pyelonephritis (APN) is a relatively common community-acquired infection, particularly in women. The early appropriate antibiotic treatment of this potentially life-threatening infection is associated with improved outcomes. The international management guidelines for complicated urinary tract infections and APN recommend using oral antibiotics with <10% resistance among urinary pathogens. However, increasing antibiotic resistance rates among Escherichia coli and other Enterobacterales to fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMX), and beta-lactams has left patients without reliable oral antibiotic treatment options for APN. This narrative review proposes using precision medicine concepts to improve empirical antibiotic therapy for APN in ambulatory settings. Whereas resistance rates to a particular antibiotic class may exceed 10% at the population-based level, the predicted antibiotic resistance rates based on patient-specific risk factors fall under 10% in many patients with APN on the individual level. The utilization of clinical tools for the prediction of fluoroquinolones, TMP-SMX, and third-generation cephalosporin resistance improves the ambulatory antibiotic management of APN. It may also reduce the need to switch antibiotic therapy later based on the in vitro antibiotic susceptibility testing results of bacterial isolates in urinary cultures. This approach may mitigate the burden of increasing antibiotic resistance in the community by ensuring that the initial antibiotic prescribed has the highest likelihood of treating APN appropriately.
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Affiliation(s)
- Morgan Pizzuti
- Department of Pharmacy, Prisma Health-Midlands, Columbia, SC 29203, USA; (H.R.W.); (P.B.B.)
| | | | - Hana R. Winders
- Department of Pharmacy, Prisma Health-Midlands, Columbia, SC 29203, USA; (H.R.W.); (P.B.B.)
| | - Paul Brandon Bookstaver
- Department of Pharmacy, Prisma Health-Midlands, Columbia, SC 29203, USA; (H.R.W.); (P.B.B.)
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA
| | - Majdi N. Al-Hasan
- Department of Internal Medicine, Division of Infectious Diseases, Prisma Health-Midlands, Columbia, SC 29203, USA;
- Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC 29209, USA
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Ruiz-Ramos J, Escolà-Vergé L, Monje-López ÁE, Herrera-Mateo S, Rivera A. The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department. Antibiotics (Basel) 2023; 12:1522. [PMID: 37887223 PMCID: PMC10604141 DOI: 10.3390/antibiotics12101522] [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: 09/10/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.
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Affiliation(s)
- Jesus Ruiz-Ramos
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Laura Escolà-Vergé
- Infectious Diseases Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- CIBERINFEC, ISCIII—CIBER, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Álvaro Eloy Monje-López
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Sergio Herrera-Mateo
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Emergency Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Alba Rivera
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Microbiology Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
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Chung HS, Namgung M, Lee DH, Choi Y, Choi YH, Choi JY, Bae SJ. Comparison of antibiotic resistance rates and outcomes among older adult patients with urinary tract infections living in long- term care hospitals and the community. Geriatr Nurs 2023; 53:6-11. [PMID: 37399614 DOI: 10.1016/j.gerinurse.2023.06.012] [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: 04/06/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE In this study, we compared the proportion of antibiotic resistance between patients who visited the emergency department (ED) with urinary tract infection (UTI) from long-term care hospitals (LTCH), which is a type of long-term care facilities (LTCF) and the community. We assessed the resulting difference in prognosis. METHOD Older adults who visited the ED between January and December 2019 and were diagnosed with UTI were divided into community residents and LTCH residents. We investigated the antibiotics sensitivity rates, end of therapy (EOT), and the patient's outcomes were evaluated. RESULTS The antibiotic resistance rate was higher in LTCH residents. LTCH residents had a higher in hospital mortality rate compared to community residents. EOT was found to be longer, and admission rate and in-hospital mortality rate were also higher in LTCH residents. CONCLUSION LTCF residents had a higher rate of antibiotic resistance and a poor prognosis.
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Affiliation(s)
- Ho Sub Chung
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Myeong Namgung
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, Republic of Korea
| | - Yunhyung Choi
- Ewha Womans University Mokdong Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, Republic of Korea
| | - Yoon Hee Choi
- Ewha Womans University Mokdong Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, Republic of Korea
| | - Jae Young Choi
- Department of Urology, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-gu, Daegu, Republic of Korea
| | - Sung Jin Bae
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, Republic of Korea.
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10
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Colletti A, Pellizzato M, Cicero AF. The Possible Role of Probiotic Supplementation in Inflammation: A Narrative Review. Microorganisms 2023; 11:2160. [PMID: 37764004 PMCID: PMC10535592 DOI: 10.3390/microorganisms11092160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 09/29/2023] Open
Abstract
The fine balance between symbiotic and potentially opportunistic and/or pathogenic microorganisms can undergo quantitative alterations, which, when associated with low intestinal biodiversity, could be responsible for the development of gut inflammation and the so-called "intestinal dysbiosis". This condition is characterized by the disbalance of a fine synergistic mechanism involving the mucosal barrier, the intestinal neuroendocrine system, and the immune system that results in an acute inflammatory response induced by different causes, including viral or bacterial infections of the digestive tract. More frequently, however, dysbiosis is induced slowly and subtly by subliminal causal factors, resulting in a chronic condition related to different diseases affecting the digestive tract and other organs and apparatuses. Studies on animal models, together with studies on humans, highlight the significant role of the gut microbiota and microbiome in the occurrence of inflammatory conditions such as metabolic syndrome and cardiovascular diseases (CVDs); neurodegenerative, urologic, skin, liver, and kidney pathologies; and premature aging. The blood translocation of bacterial fragments has been found to be one of the processes linked to gut dysbiosis and responsible for the possible occurrence of "metabolic endotoxemia" and systemic inflammation, associated with an increased risk of oxidative stress and related diseases. In this context, supplementation with different probiotic strains has been shown to restore gut eubiosis, especially if administered in long-term treatments. The aim of this review is to describe the anti-inflammatory effects of specific probiotic strains observed in clinical trials and the respective indications, highlighting the differences in efficacy depending on strain, formulation, time and duration of treatment, and dosage used.
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Affiliation(s)
- Alessandro Colletti
- Department of Science and Drug Technology, University of Turin, 10124 Turin, Italy
- Italian Society of Nutraceutical Formulators (SIFNut), 31033 Treviso, Italy
| | - Marzia Pellizzato
- Italian Society of Nutraceutical Formulators (SIFNut), 31033 Treviso, Italy
| | - Arrigo Francesco Cicero
- Medical and Surgical Sciences Department, University of Bologna, 40126 Bologna, Italy;
- IRCCS AOUBO, 40138 Bologna, Italy
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11
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Andrade J, Truong J, Ciaramella C. Expansion of a Pharmacist-Led Culture Follow-Up Program to Real-Time Notification of Multidrug-Resistant Microbiology Results in the Emergency Department. Hosp Pharm 2023; 58:368-375. [PMID: 37360205 PMCID: PMC10288464 DOI: 10.1177/00185787231155833] [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] [Indexed: 09/20/2023]
Abstract
Introduction: There are currently limited published data for a pharmacist-led multidrug-resistant (MDR) culture follow-up program through a collaborative drug therapy management (CDTM) agreement in the emergency department (ED). Objective: The objective of this study was to assess the impact of a pharmacist-led culture follow-up program for MDR microbiology results on ED revisit rate. Methods: A single-center quasi-experimental retrospective study was conducted comparing the outcomes before (December 2017 to March 2019) and after (April 2019 to July 2020) implementation of the ED MDR Culture program. Patients 18 years of age or older; with confirmed positive microbiology culture of extended-spectrum beta-lactamases (ESBL), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) at any site; and discharged from the ED were included. The primary outcome was to evaluate ED revisit within 30 days due to antimicrobial treatment failure, defined as lack of resolution or worsening of infection. A statistical analysis was performed for categorical data using Fisher's exact test, and for continuous data using unpaired t test or Mann-Whitney U Test, when applicable. Results: A total of 130 patients were included in the analysis. Patients in the post-implementation group (n = 70) had a significant reduction in ED revisits compared to the pre-implementation group (n = 60); 9 [12.9%] versus 17 [28.3%], respectively; P = .046. Conclusion: Implementation of an ED MDR culture program was associated with significantly less ED revisits within 30 days due to antimicrobial treatment failure, thus demonstrating the expanded role of ED pharmacists in antimicrobial stewardship in the outpatient setting.
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Parzen-Johnson S, Sun S, Scardina T, Patel SJ. Fluoroquinolone Use Among Hospitalized Children: Diagnosis-Based Stratification to Identify Stewardship Targets. Open Forum Infect Dis 2023; 10:ofad297. [PMID: 37323425 PMCID: PMC10264067 DOI: 10.1093/ofid/ofad297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
Background As FQ (fluoroquinolone) use has shifted in pediatric populations, better metrics are needed to guide targeted antibiotic stewardship interventions and limit development of adverse events and resistance, particularly in medically complex children. In this study, we identify high-utilization groups based on underlying medical conditions and describe their relative FQ use over time. Methods This study is a retrospective analysis of data from the Pediatric Health Information System database from 2016 to 2020. We identify high-utilization groups based on underlying medical conditions using International Classification of Diseases, Ninth or Tenth Revision codes. We delineate overall trends in the use of FQs in the inpatient setting, including rate and proportional use by each patient group. Results Patients with an oncology diagnosis represent a large (25%-44%) and rising proportion (+4.8%/year, P = .001) of national FQ use over the study period. Patients with intra-abdominal infections, including appendicitis, have had a significant increase in both their relative proportional use of FQs (+0.6%/year, P = .037) and proportion of FQ use per admission encounter over the study period (+0.6%/year, P = .008). Patients with cystic fibrosis represent a decreasing proportion of overall use (-2.1%/year, P = .011) and have decreasing FQ use per inpatient encounter (-0.8%/year, P = .001). Conclusions Patients with an oncology diagnosis and patients with an intra-abdominal infection appear to be targets for FQ stewardship. Patients with cystic fibrosis have decreasing inpatient FQ use. Key Points: This study describes fluoroquinolone use among hospitalized children from 2016 to 2020, stratified by underlying diagnoses. These trends are used to identify high-yield antibiotic stewardship targets.
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Affiliation(s)
- Simon Parzen-Johnson
- Correspondence: Simon Parzen-Johnson, MD, Division of Infectious Diseases, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611 ()
| | - Shan Sun
- Division of Infectious Diseases, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tonya Scardina
- Department of Pharmacy, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers. Eur J Clin Microbiol Infect Dis 2023; 42:229-254. [PMID: 36680641 PMCID: PMC9899200 DOI: 10.1007/s10096-023-04548-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
The clinical impact of infections due to extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacterales (Ent) has reached dramatic levels worldwide. Infections due to these multidrug-resistant (MDR) pathogens-especially Escherichia coli and Klebsiella pneumoniae-may originate from a prior asymptomatic intestinal colonization that could also favor transmission to other subjects. It is therefore desirable that gut carriers are rapidly identified to try preventing both the occurrence of serious endogenous infections and potential transmission. Together with the infection prevention and control countermeasures, any strategy capable of effectively eradicating the MDR-Ent from the intestinal tract would be desirable. In this narrative review, we present a summary of the different aspects linked to the intestinal colonization due to MDR-Ent. In particular, culture- and molecular-based screening techniques to identify carriers, data on prevalence and risk factors in different populations, clinical impact, length of colonization, and contribution to transmission in various settings will be overviewed. We will also discuss the standard strategies (selective digestive decontamination, fecal microbiota transplant) and those still in development (bacteriophages, probiotics, microcins, and CRISPR-Cas-based) that might be used to decolonize MDR-Ent carriers.
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14
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Smith AD, Nikolaidis P, Khatri G, Chong ST, De Leon AD, Ganeshan D, Gore JL, Gupta RT, Kwun R, Lyshchik A, Nicola R, Purysko AS, Savage SJ, Taffel MT, Yoo DC, Delaney EW, Lockhart ME. ACR Appropriateness Criteria® Acute Pyelonephritis: 2022 Update. J Am Coll Radiol 2022; 19:S224-S239. [PMID: 36436954 DOI: 10.1016/j.jacr.2022.09.017] [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: 08/27/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Acute pyelonephritis (APN) is a severe urinary tract infection (UTI) that has the potential to cause sepsis, shock, and death. In the majority of patients, uncomplicated APN is diagnosed clinically and is responsive to treatment with appropriate antibiotics. In patients who are high risk or when treatment is delayed, microabscesses may coalesce to form an acute renal abscess. High-risk patients include those with a prior history of pyelonephritis, lack of response to therapy for lower UTI or for APN, diabetes, anatomic or congenital abnormalities of the urinary system, infections by treatment-resistant organisms, nosocomial infection, urolithiasis, renal obstruction, prior renal surgery, advanced age, pregnancy, renal transplant recipients, and immunosuppressed or immunocompromised patients. Pregnant patients and patients with renal transplants on immunosuppression are at an elevated risk of severe complications. Imaging studies are often requested to aid with the diagnosis, identify precipitating factors, and differentiate lower UTI from renal parenchymal involvement, particularly in high-risk individuals. Imaging is usually not appropriate for the first-time presentation of suspected APN in an uncomplicated patient. The primary imaging modalities used in high-risk patients with suspected APN are CT, MRI, and ultrasound, although CT was usually not appropriate for initial imaging in a pregnant patient with no other complications. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Andrew D Smith
- University of Alabama at Birmingham, Birmingham, Alabama.
| | - Paul Nikolaidis
- Vice-Chair, Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gaurav Khatri
- UT Southwestern Medical Center, Dallas, Texas; Chief, Division of Body MRI; Interim Chief, Division of Abdominal Imaging; Program Director, Body MRI Fellowship
| | - Suzanne T Chong
- Indiana University, Indianapolis, Indiana; Committee on Emergency Radiology-General, Small, Emergency and/or Rural Practice
| | | | | | - John L Gore
- University of Washington, Seattle, Washington; American Urological Association
| | - Rajan T Gupta
- Duke University Medical Center, Durham, North Carolina
| | - Richard Kwun
- Swedish Medical Center, Issaquah, Washington; American College of Emergency Physicians
| | - Andrej Lyshchik
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Refky Nicola
- Roswell Park Cancer Institute, Jacobs School of Medicine and Biomedical Science, Buffalo, New York
| | - Andrei S Purysko
- Cleveland Clinic, Cleveland, Ohio; ACR Learning Network, Prostate MR Image Quality Improvement Collaborative, Physician Leader
| | - Stephen J Savage
- Medical University of South Carolina, Charleston, South Carolina; American Urological Association; Professor and Vice Chairman of Urology
| | - Myles T Taffel
- New York University Langone Medical Center, New York, New York; Associate Section of Body Imaging
| | - Don C Yoo
- Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, Rhode Island; Commission on Nuclear Medicine and Molecular Imaging
| | - Erin W Delaney
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama; Primary care physician
| | - Mark E Lockhart
- University of Alabama at Birmingham, Birmingham, Alabama; Chair UAB Department Appointments, Promotions, and Tenure Committee
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Effect of Reduced Fluoroquinolone Use on Cephalosporin Use, Susceptibilities and Clostridioides difficile Infections. Antibiotics (Basel) 2022; 11:antibiotics11101312. [PMID: 36289969 PMCID: PMC9598913 DOI: 10.3390/antibiotics11101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Overuse of fluoroquinolones has led to concerning rates of resistance, particularly among Gram-negative organisms. They are also highly implicated as a risk factor for Clostridioides difficile infection, and reports of other serious adverse events led to recommendations to restrict their use. Our health system began targeting the reduction in unnecessary fluoroquinolone prescribing in 2018, aiming to promote their safe and effective use. Broad-spectrum cephalosporins are often used as an alternative to fluoroquinolones. We sought to evaluate whether decreased fluoroquinolone use was associated with increased third- and fourth-generation cephalosporin use and whether these changes in utilization impacted other outcomes, including C. difficile infection (CDI) rates and susceptibilities among Gram-negative organisms. Methods: This retrospective descriptive analysis included adult patients who received a fluoroquinolone or broad-spectrum cephalosporin in a three-year time period across a large healthcare system. The primary objective was to evaluate the change in days of therapy (DOT) of fluoroquinolones and third- and fourth-generation cephalosporins. Secondary objectives included rates of resistance among common Gram-negative organisms, CDI, and analyses stratified by antibiotic indication. Results: Cephalosporin use increased by an average of 1.70 DOT/1000 PD per month (p < 0.001). Additionally, fluoroquinolone use decreased by an average of 1.18 DOT/1000 PD per month (p < 0.001). C. difficile infections decreased by 0.37 infections/10,000 patient-days per month (p < 0.001). Resistance to fluoroquinolones remained stable from 2018 to 2020, and a declining trend was observed in 2021. Conclusion: This study demonstrated that reduced fluoroquinolone use in a large healthcare system was associated with increased usage of broad-spectrum cephalosporins, decreased CDI and improvements in resistance patterns.
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A retrospective review of oral cephalosporins versus fluoroquinolones for the treatment of pyelonephritis. PLoS One 2022; 17:e0274194. [PMID: 36084051 PMCID: PMC9462734 DOI: 10.1371/journal.pone.0274194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 08/23/2022] [Indexed: 11/27/2022] Open
Abstract
Background The current Infectious Diseases Society of America guidelines for the treatment of acute uncomplicated pyelonephritis (AUP) advise caution when using oral beta-lactams due to concern for potentially inferior efficacy compared to fluoroquinolones (FQs) and trimethoprim-sulfamethoxazole; however, studies specifically evaluating the efficacy of oral cephalosporins (CPs) in AUP are limited. Objective To assess the safety and efficacy of oral CPs versus FQs for the treatment of AUP. Design, setting and participants This is a retrospective, chart review study conducted at a single-center, tertiary care hospital. Measurements The primary endpoint was treatment failure within 30 days, defined as a change in antibiotic or return to ED or clinic due to persistent symptoms. Secondary endpoints included adverse drug reactions (ADRs) and C. difficile infection (CDI) within 30 days. Results Of the 343 patients included in the study, treatment failure occurred in 54/338 (16.0%) patients and was similar between oral CPs and FQs (35/229 [15.3%] vs. 19/109 [17.4%]). A higher percentage of treatment failures were observed for third generation (3GC) and first generation (1GC) CPs compared to second generation CPs (2GC) (3GC: 15/65 [23.4%]; 1GC: 11/49 [22.4%]; 2GC: 9/115 [7.8%]). Documented ADRs were low (6/343 [1.7%]) and no cases of CDI were documented. Conclusions Oral CPs appear to be as safe and effective as FQs for the treatment of AUP. Fewer treatment failures were noted with 2GCs as compared to 3GCs and 1GCs.
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Faine BA, Rech MA, Vakkalanka P, Gross A, Brown C, Harding SJ, Slocum G, Zimmerman D, Zepeski A, Rewitzer S, Howington GT, Campbell M, Dawson J, Treu CN, Nelson L, Jones M, Flack T, Porter B, Sarangarm P, Mattson AE, Bailey A, Kelly G, Talan DA. High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020. Acad Emerg Med 2022; 29:1096-1105. [PMID: 35652493 PMCID: PMC9543902 DOI: 10.1111/acem.14545] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/20/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Uropathogen resistance, fluoroquinolone-resistance (FQR), and extended spectrum beta-lactamase (ESBL), has been observed to be emerging worldwide with prevalences above recommended thresholds for routine empirical treatment. The primary aim of our study was to determine the prevalence of FQR from a geographically diverse sample of United States emergency departments (EDs). METHODS We conducted a multi-center, observational cohort study using a network of 15 geographically diverse US EDs. All patients ≥18 years of age with the primary or secondary diagnosis of urinary tract infection (UTI) in the ED identified using International Classification of Diseases (ICD-10) diagnosis code of cystitis, pyelonephritis, or UTI from 2018 to 2020 were included. We calculated descriptive statistics for uropathogens and susceptibilities. Logistic regression analysis was used to identify antimicrobial resistance risk factors associated with FQR Escherichia coli. RESULTS Among 3779 patients who met inclusion criteria, median age was 62.9 years (interquartile range [IQR]: 41-77.6) and 76.3% were female. The most common diagnoses were complicated (41.2%) and uncomplicated cystitis (40.3%). E. coli was the most common pathogen (63.2%), followed by Klebsiella pneumoniae (13.2%) and Enterococcus species (5.8%). Across all sites, overall E. coli FQ-resistance prevalence was 22.1%, ranging from 10.5 to 29.7% by site. The prevalence of ESBL-producing uropathogen was 7.4%, ranging from 3.6% to 11.6% by site. Previous IV or oral antimicrobial use in the past 90-days and history of a multi-drug resistant pathogen were associated with FQ-resistant E. coli (odds ratio [OR] 2.68, 95% confidence interval [CI]: 2.04-3.51, and OR 6.93, 95% CI: 4.95-9.70, respectively). Of the patients who had FQ-resistant E. coli or an ESBL-producing uropathogen isolated, 116 (37.1%) and 61 (36.7%) did not have any documented risk factors for resistance. CONCLUSION FQ-resistant E. coli is widely prevalent across US sites highlighting the need for ongoing monitoring of antimicrobial resistance and, at some locations, modification of empirical treatments.
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Affiliation(s)
- Brett A. Faine
- Department of Emergency Medicine and PharmacyUniversity of Iowa Hospitals and ClinicsHawkinsIowaUSA
| | - Megan A. Rech
- Department of Emergency MedicineLoyola University Medical CenterMaywoodIllinoisUSA
| | | | - Alan Gross
- University of Illinois at Chicago College of PharmacyChicagoIllinoisUSA
| | - Caitlin Brown
- Assistant Professor of Pharmacy and Emergency MedicineMayo Clinic School of Medicine and ScienceRochesterMinnesotaUSA
| | - Stephanie J. Harding
- Infectious Diseases Clinical Pharmacy SpecialistWesley Medical CenterWichitaKansasUSA
| | - Giles Slocum
- Emergency Medicine Clinical Pharmacy Specialist, Assistant Professor, Department of Pharmacy Emergency MedicineRush University Medical CenterChicagoIllinoisUSA
| | - David Zimmerman
- Associate Professor of Pharmacy at Duquesne University School of PharmacyEmergency Medicine Pharmacist at University of Pittsburgh Medical Center‐ Mercy HospitalPittsburghPennsylvaniaUSA
| | - Anne Zepeski
- Emergency Medicine Clinical PharmacistUniversity of IowaIowa CityIowaUSA
| | | | - Gavin T. Howington
- Department of Pharmacy Practice and ScienceUniversity of Kentucky College of PharmacyEmergency Medicine Clinical Pharmacy SpecialistLexingtonKentuckyUSA
| | - Matt Campbell
- Emergency Medicine Clinical Coordinator, Department of PharmacyCleveland ClinicClevelandOhioUSA
| | - Jordan Dawson
- Emergency Medicine and Critical CareDenver Health Medical CenterDenverColoradoUSA
| | - Cierra N. Treu
- New York‐Presbyterian Brooklyn Methodist HospitalBrooklynNew YorkUSA
| | - Lucas Nelson
- Emergency Center Pharmacist LeadPark Nicollet, Methodist HospitalSaint Louis ParkMinnesotaUSA
| | - Mandy Jones
- Emergency Medicine Clinical Pharmacy SpecialistUK HealthCare, Fellow, Center for Interprofessional Healthcare Education, University of KentuckyLexingtonKentuckyUSA
| | - Tara Flack
- Emergency Medicine Clinical PharmacistIndiana University Health Methodist HospitalIndianapolisIndianaUSA
| | - Blake Porter
- Emergency Medicine Pharmacist ClinicianUniversity of Vermont Medical CenterBurlingtonVermontUSA
| | | | - Alicia E. Mattson
- Emergency Medicine Clinical PharmacistInstructor of Pharmacy, Mayo ClinicRochesterMinnesotaUSA
| | - Abby Bailey
- Emergency Medicine University of Kentucky HealthCareLexingtonKentuckyUSA
| | - Gregory Kelly
- Rutgers Ernest Mario College of Pharmacy, Emergency Medicine Clinical Pharmacy SpecialistRobert Wood Johnson University Hospital‐New BrunswickNew BrunswickNew JerseyUSA
| | - David A. Talan
- The David Geffen School of Medicine at UCLA, Chairman Emeritus, Dept. of Emergency Medicine, Faculty, Division of Infectious DiseasesOlive View‐UCLA Medical CenterSylmarCaliforniaUSA
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Jang YR, Won J, Han J, Chung W, Ahn SJ. Comparison of antimicrobial resistance in patients with obstructive pyelonephritis associated with ureteral stones and uncomplicated pyelonephritis. Medicine (Baltimore) 2022; 101:e30376. [PMID: 36042611 PMCID: PMC9410613 DOI: 10.1097/md.0000000000030376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate the clinical outcomes of causative microorganisms in obstructive pyelonephritis associated with ureteral stones (OPU) and their antibiotic susceptibilities. This retrospective cohort study included female patients diagnosed with community-acquired acute pyelonephritis (APN) at a tertiary-care hospital between 2008 and 2017. A comparison of APN cases associated with the obstruction of the upper urinary tract by ureteral stones and APN cases without complications was performed. Propensity score (PS) matching was used to adjust the heterogeneity within each group. Of the 588 female patients with community-acquired APN, 107 were diagnosed with OPU and 481 with uncomplicated APN. After PS matching, Enterobacteriaceae strains isolated from OPU cases were more resistant to fluoroquinolones (51.9% vs 16.0%, P < .001). Extended-spectrum β-lactamase was detected in 22.2% and 21.0% of the Enterobacteriaceae strains isolated from OPU and uncomplicated APN cases, respectively (P = 1.000). The treatment failure rate was similar in OPU and uncomplicated APN groups (16.0% vs 21.0%, P = .545). Patients with OPU may be empirically treated with antibiotics in accordance with the treatment protocol for general pyelonephritis. Clinicians should exercise caution in prescribing fluoroquinolones for treating OPU.
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Affiliation(s)
- Young Rock Jang
- Department of Infectious Disease, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Division of Infectious Disease, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea
- *Correspondence: Young Rock Jang, Division of Infectious Disease, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea, 217 Bangchuk-ro, Dong-gu, Incheon 22532, Korea (e-mail: ) and Su Joa Ahn, Department of Radiology, Gil Medical Center, Gachon University College of Medicine, ADD 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Korea (e-mail: )
| | - Jeongyeon Won
- Department of Infectious Disease, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jung Han
- Department of Urology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Wookyung Chung
- Department of Nephrology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Su Joa Ahn
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- *Correspondence: Young Rock Jang, Division of Infectious Disease, Department of Internal Medicine, Incheon Medical Center, Incheon, Korea, 217 Bangchuk-ro, Dong-gu, Incheon 22532, Korea (e-mail: ) and Su Joa Ahn, Department of Radiology, Gil Medical Center, Gachon University College of Medicine, ADD 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Korea (e-mail: )
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19
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Davis WH, Magee MR, Monks SM, Geno KA, Crawford SB. Assessment of nationally recommended antibiotics for treatment of UTI in U.S.-Mexico border emergency departments. Am J Emerg Med 2022; 61:12-17. [PMID: 36027632 DOI: 10.1016/j.ajem.2022.08.023] [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: 05/20/2022] [Revised: 07/26/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) seen in the emergency department are commonly treated as an outpatient with oral antibiotics. Given that antibiotics are available for over-the-counter purchase in Mexico, there is speculation that potential misuse and overuse of antibiotics in United States-Mexico border areas could lead to antibiotic resistance patterns that would render some empiric treatments for UTIs less effective. The purpose of this study was to examine the effectiveness of Infectious Disease Society of America (IDSA) guideline-recommended antibiotics for treatment of outpatient UTI diagnosed in the emergency department. Data were collected from a county hospital on the U.S.-Mexico border with a metropolitan area of over 2 million people. Secondary analysis included frequency of urine culture isolated, resistance rates of urine pathogens, and prescriber habits. METHODS This study was a retrospective chart review of adult patients diagnosed and treated for UTI from August 1, 2019, to February 29, 2020. Culture results of included patients were analyzed against in vitro-tested antibiotics. Bacterial isolate frequency, resistance rates, and prescribing habits were collected. RESULTS A total of 985 patient charts were reviewed, of which 520 patients met inclusion criteria for analysis of prescribing habits. Of these, 329 positive bacterial culture growths were included in the analysis of antibiotic resistance rates. Oral antibiotics with comparatively lower resistance rates were amoxicillin/clavulanate, cefdinir, cefuroxime, and nitrofurantoin. Oral antibiotics with notably high resistance rates included trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline, ciprofloxacin, levofloxacin, and cephalexin. Nitrofurantoin was prescribed most frequently for outpatient treatment of UTI/cystitis (41.6%) while cephalexin was the most commonly prescribed antibiotic for outpatient treatment of pyelonephritis (50%). CONCLUSION Our findings suggest that, while part of standard IDSA guidelines, fluoroquinolones and TMP-SMX are not ideal empiric antibiotics for treatment of outpatient UTI in the U.S.-Mexico border region studied due to high resistance rates. Although not listed as first line agents per current IDSA recommendations, 2nd and 3rd generation cephalosporins, and amoxicillin/clavulanate would be acceptable options given resistance patterns demonstrated in accordance with IDSA allowance for tailoring selection to local resistance. Nitrofurantoin appears to be consistent with recommendations and demonstrates a favorable resistance profile for treatment of outpatient UTI within this region.
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Affiliation(s)
- William H Davis
- Paul Foster School of Medicine, Texas Tech University Health Sciences El Paso, El Paso, TX, USA
| | - Matthew R Magee
- Paul Foster School of Medicine, Texas Tech University Health Sciences El Paso, El Paso, TX, USA
| | - Stormy M Monks
- Department of Emergency Medicine, Texas Tech University Health Sciences El Paso, El Paso, TX, USA
| | - K Aaron Geno
- Department of Pathology, Texas Tech University Health Sciences El Paso, El Paso, TX, USA
| | - Scott B Crawford
- Department of Emergency Medicine, Texas Tech University Health Sciences El Paso, El Paso, TX, USA.
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Mahoney MT, Brigman HV, Johnston BD, Johnson JR, Hirsch EB. Prevalence and characteristics of multidrug-resistant Escherichia coli sequence type ST131 at two academic centers in Boston and Minneapolis, USA. Am J Infect Control 2022; 51:434-439. [PMID: 35764181 DOI: 10.1016/j.ajic.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Escherichia coli sequence type (ST) ST131, with its emergent resistance-associated H30Rx, H30R1, and C1-M27 clonal subsets, accounts for the greatest share of extraintestinal E. coli infections and most extended-spectrum β-lactamase (ESBL)-producing E. coli. METHODS We characterized and compared consecutive E. coli urine isolates from two geographically distinct medical centers in Minneapolis, Minnesota (n = 172) and Boston, Massachusetts (n = 143) for ESBL phenotype, CTX-M-type ESBL genes, phylogenetic groups, selected ST131 subclones, and 40 extraintestinal virulence genes. RESULTS Whereas the Boston vs. Minneapolis isolates had a similar prevalence of phylogenetic groups (mainly B2: 79% vs 73%), ST131 (34% vs 28%), H30 (28% vs 21%), and H30Rx (6% vs 5%), the emerging C1-M27 subclone occurred uniquely among Boston (6%) isolates. ESBL production was more prevalent among Boston isolates (15% vs 8%) and among ST131 isolates. Identified ESBL genes included blaCTX-M-27 (Boston only) and blaCTX-M-15. Ciprofloxacin resistance was ST131-associated and similarly prevalent across centers. Boston isolates had higher virulence gene scores. CONCLUSIONS Despite numerous similarities to Minneapolis isolates, Boston ST131 isolates demonstrated more prevalent ESBL production, higher virulence gene scores, and, uniquely, the C1-M27 subclone and blaCTX-M-27. Broader surveillance is needed to define the prevalence of ST131's globally successful C1-M27 subclone across the U.S.
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21
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Chaudhary N, Mohan B, Mavuduru RS, Kumar Y, Taneja N. Characterization, genome analysis and in vitro activity of a novel phage vB_EcoA_RDN8.1 active against multi-drug resistant and extensively drug-resistant biofilm-forming uropathogenic Escherichia coli isolates, India. J Appl Microbiol 2022; 132:3387-3404. [PMID: 34989075 DOI: 10.1111/jam.15439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/23/2022]
Abstract
AIM We aimed to study host range, stability, genome and antibiofilm activity of a novel phage vB_EcoA_RDN8.1 active against multi-drug resistant (MDR) and extensively drug-resistant (XDR) biofilm-forming uropathogenic Escherichia coli isolates. METHODS AND RESULTS A novel lytic phage vB_EcoA_RDN8.1 active against UPEC strains resistant to third-generation cephalosporins, fluoroquinolones, aminoglycosides, imipenem, beta-lactamase inhibitor combination and polymyxins was isolated from community raw sewage water of Chandigarh. It exhibited a clear plaque morphology and a burst size of 250. In the time-kill assay, the maximum amount of killing was achieved at MOI 1.0. vB_EcoA_RDN8.1 belongs to the family Autographiviridae, has a genome size of 39.5 kb with a GC content of 51.6%. It was stable over a wide range of temperatures and pH. It was able to inhibit biofilm formation which may be related to an endolysin encoded by ORF 19. CONCLUSIONS The vB_EcoA_RDN8.1 is a novel lytic phage that has the potential for inclusion into phage cocktails being developed for the treatment of urinary tract infections (UTIs) caused by highly drug-resistant UPEC. SIGNIFICANCE AND IMPACT OF THE STUDY We provide a detailed characterization of a novel lytic Escherichia phage with antibiofilm activity having a potential application against MDR and XDR UPEC causing UTIs.
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Affiliation(s)
- Naveen Chaudhary
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Balvinder Mohan
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravimohan S Mavuduru
- Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yashwant Kumar
- Central Research Institute, National Salmonella and Escherichia Centre, Kasauli, India
| | - Neelam Taneja
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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22
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Johnson JR, Clabots C, Porter SB, Bender T, Johnston BD, Thuras P. Intestinal Persistence of Colonizing Escherichia coli Strains, Especially ST131-H30, in Relation to Bacterial and Host Factors. J Infect Dis 2022; 225:2197-2207. [PMID: 34979558 PMCID: PMC9200155 DOI: 10.1093/infdis/jiab638] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/30/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Superior gut colonization may underlie the pandemic emergence of the resistance-associated H30 subclone of Escherichia coli sequence type 131 (ST131-H30). Little is known about the associated host and bacterial characteristics, or the comparative persistence of non-ST131 intestinal E. coli. METHODS Generic and fluoroquinolone-resistant E. coli isolates from volunteers' serial fecal samples underwent clonal analysis and extensive polymerase chain reaction (PCR)-based characterization (phylogroup, selected sequence types, virulence genes). Kaplan-Meier survival analysis and Cox proportional hazards survival analysis using penalized regression (a machine-learning method) were used to identify correlates of strain persistence. RESULTS Screening of 2005 subjects at the Minneapolis VA Medical Center identified 222 subjects (117 veterans, 105 human and animal household members) for longitudinal fecal surveillance. Analysis of their 585 unique-by-subject fecal E. coli strains identified multiple epidemiological, ecological, and bacterial correlates of strain persistence. ST131-H30, a strong univariable correlate of persistence, was superseded in multivariable analysis by outpatient status, fluoroquinolone resistance, and diverse (predominantly iron uptake-related) virulence genes. CONCLUSIONS ST131-H30 exhibits exceptional intestinal persistence, possibly due to a combination of fluoroquinolone resistance and virulence factors, which may be primarily colonization factors. This identifies both likely contributors to the ST131-H30 pandemic and potential targets for interventions against it.
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Affiliation(s)
- James R Johnson
- Correspondence: James R. Johnson, MD, Infectious Diseases (111F), VA Medical Center, 1 Veterans Drive, Minneapolis, MN 55417 ()
| | - Connie Clabots
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Stephen B Porter
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Tricia Bender
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Brian D Johnston
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA,University of Minnesota, Minneapolis, Minnesota, USA
| | - Paul Thuras
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA,University of Minnesota, Minneapolis, Minnesota, USA
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Effect of Antimicrobial Stewardship on Oral Quinolone Use and Resistance Patterns over 8 Years (2013-2020). Antibiotics (Basel) 2021; 10:antibiotics10111426. [PMID: 34827364 PMCID: PMC8615025 DOI: 10.3390/antibiotics10111426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/28/2021] [Accepted: 11/18/2021] [Indexed: 12/24/2022] Open
Abstract
Since 2014, several global and national guidelines have been introduced to address the problem of antimicrobial resistance. We conducted a campaign in a tertiary hospital to promote appropriate quinolone use through educational lectures in 2018. The aim of this retrospective study was to evaluate the changes in the following: prescription characteristics, trend of oral quinolone use, and antibiotic susceptibility of bacteria from 2013 to 2020. Antimicrobial use was assessed as days of therapy per 1000 patient-days. We found a significant reduction in unnecessary antibiotic prescriptions between December 2013 and December 2020. Significant negative trends were detected in the use of quinolones over 8 years (outpatients, coefficient = −0.15655, p < 0.001; inpatients, coefficient = −0.004825, p = 0.0016). In particular, the monthly mean use of quinolones among outpatients significantly decreased by 11% from 2013 to 2014 (p < 0.05) and reduced further by 31% from 2017 to 2020 (p < 0.001). A significant positive trend was observed in the susceptibility of Pseudomonas aeruginosa to levofloxacin (p < 0.001). These results demonstrate that the use of oral quinolones was further reduced following educational intervention and the bacterial susceptibility improved with optimal quinolone usage compared to that in 2013.
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Atlaw NA, Keelara S, Correa M, Foster D, Gebreyes W, Aidara-Kane A, Harden L, Thakur S, Cray PJF. Identification of CTX-M Type ESBL E. coli from Sheep and Their Abattoir Environment Using Whole-Genome Sequencing. Pathogens 2021; 10:1480. [PMID: 34832635 PMCID: PMC8618867 DOI: 10.3390/pathogens10111480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/17/2022] Open
Abstract
Widespread dissemination of extended-spectrum beta-lactamase (ESBL) Escherichia coli (E. coli) in animals, retail meats, and patients has been reported worldwide except for limited information on small ruminants. Our study focused on the genotypic characterization of ESBL E. coli from healthy sheep and their abattoir environment in North Carolina, USA. A total of 113 ESBL E. coli isolates from sheep (n = 65) and their abattoir environment (n = 48) were subjected to whole-genome sequencing (WGS). Bioinformatics tools were used to analyze the WGS data. Multiple CTX-M-type beta-lactamase genes were detected, namely blaCTX-M-1, blaCTX-M-14, blaCTX-M-15, blaCTX-M-27, blaCTX-M-32, blaCTX-M-55, and blaCTX-M-65. Other beta-lactamase genes detected included blaCMY-2, blaTEM-1A/B/C, and blaCARB-2. In addition, antimicrobial resistance (AMR) genes and/or point mutations that confer resistance to quinolones, aminoglycosides, phenicols, tetracyclines, macrolides, lincosamides, and folate-pathway antagonists were identified. The majority of the detected plasmids were shared between isolates from sheep and the abattoir environment. Sequence types were more clustered around seasonal sampling but dispersed across sample types. In conclusion, our study reported wide dissemination of ESBL E. coli in sheep and the abattoir environment and associated AMR genes, point mutations, and plasmids. This is the first comprehensive AMR and WGS report on ESBL E. coli from sheep and abattoir environments in the United States.
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Affiliation(s)
- Nigatu Aklilu Atlaw
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Shivaramu Keelara
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Maria Correa
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Derek Foster
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Wondwossen Gebreyes
- Department of Veterinary Preventive Medicine, The Ohio State University, 1920 Coffey Rd., Columbus, OH 43210, USA;
| | - Awa Aidara-Kane
- Department Food Safety and Zoonoses, Foodborne Diseases, World Health Organization, 1202 Geneva, Switzerland;
| | - Lyndy Harden
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Siddhartha Thakur
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
| | - Paula J. Fedorka Cray
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA; (N.A.A.); (S.K.); (M.C.); (D.F.); (L.H.); (S.T.)
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Factors Associated with Acute Community-Acquired Pyelonephritis Caused by Extended-Spectrum β-Lactamase-Producing Escherichia coli. J Clin Med 2021; 10:jcm10215192. [PMID: 34768712 PMCID: PMC8584794 DOI: 10.3390/jcm10215192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
This study aimed to identify the factors associated with the presence of extended-spectrum ß-lactamase-(ESBL) in patients with acute community-acquired pyelonephritis (APN) caused by Escherechia coli (E. coli), with a view of optimising empirical antibiotic therapy in this context. We performed a retrospective analysis of patients with community-acquired APN and confirmed E. coli infection, collecting data related to demographic characteristics, comorbidities, and treatment. The associations of these factors with the presence of ESBL were quantified by fitting multivariate logistic models. Goodness-of-fit and predictive performance were measured using the ROC curve. We included 367 patients of which 51 presented with ESBL, of whom 90.1% had uncomplicated APN, 56.1% were women aged ≤55 years, 33.5% had at least one mild comorbidity, and 12% had recently taken antibiotics. The prevalence of ESBL-producing E. coli was 13%. In the multivariate analysis, the factors independently associated with ESBL were male sex (OR 2.296; 95% CI 1.043-5.055), smoking (OR 4.846, 95% CI 2.376-9.882), hypertension (OR 3.342, 95% CI 1.423-7.852), urinary incontinence (OR 2.291, 95% CI 0.689-7.618) and recurrent urinary tract infections (OR 4.673, 95% CI 2.271-9.614). The area under the ROC curve was 0.802 (IC 95% 0.7307-0.8736), meaning our model can correctly classify an individual with ESBL-producing E. coli infection in 80.2% of cases.
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Rewitzer S, Montgomery J, Zepeski A, Finer L, Faine BA. Intravenous Antibiotic Susceptibility for Urinary Tract Infection Prior to Emergency Department Discharge. Hosp Pharm 2021; 56:513-518. [PMID: 34720154 DOI: 10.1177/0018578720925386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Urinary tract infection (UTI) is a common infectious disease managed in the emergency department (ED). Patients may be initially treated with an intravenous (IV) antibiotic and subsequently discharged with an oral antibiotic regimen. Objective The purpose of this study was to determine whether the current Infectious Diseases Society of America guideline recommendation for an initial dose of long-acting IV antibiotic for treatment of UTI when the prevalence of fluoroquinolone resistance exceeds 10% improves the likelihood of providing in vitro susceptibility to the isolated uropathogen. Methods This was a retrospective study of patients in ED presenting between May 2009 and August 2018 who received treatment for UTI. The primary outcome was susceptibility of uropathogen to the IV antibiotic administered. Secondary outcomes included susceptibility to the oral antibiotic regimen prescribed at discharge, repeat health care visit within 30 days related to UTI follow-up, adverse events (AEs) associated with antibiotic use, and identification of risk factors associated with pathogen resistance. Results A total of 255 patients were included for analysis. Of these patients, 230 (90.2%) had pathogens susceptible to the administered IV antibiotic. The oral regimen susceptibility was 81.6% with 29 patients returning for UTI follow-up and 4 patients reporting AEs related to antibiotic use. Men and long-term care facility residents were more likely to have resistant uropathogens. Conclusion Administration of a long-acting IV antibiotic for treatment of UTI prior to ED discharge is recommended when the fluoroquinolone resistance rate exceeds 10% to improve in vitro susceptibility coverage.
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Affiliation(s)
- Stacey Rewitzer
- University of Iowa Hospitals & Clinics, Iowa City, USA.,University of Iowa Carver College of Medicine, Iowa City, USA.,University of Iowa College of Pharmacy, Iowa City, USA
| | | | - Anne Zepeski
- University of Iowa Hospitals & Clinics, Iowa City, USA.,University of Iowa Carver College of Medicine, Iowa City, USA.,University of Iowa College of Pharmacy, Iowa City, USA
| | - Lexie Finer
- University of Iowa College of Public Health, Iowa City, USA
| | - Brett A Faine
- University of Iowa Hospitals & Clinics, Iowa City, USA.,University of Iowa Carver College of Medicine, Iowa City, USA.,University of Iowa College of Pharmacy, Iowa City, USA
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Matlock A, Garcia JA, Moussavi K, Long B, Liang SYT. Advances in novel antibiotics to treat multidrug-resistant gram-negative bacterial infections. Intern Emerg Med 2021; 16:2231-2241. [PMID: 33956311 PMCID: PMC8100742 DOI: 10.1007/s11739-021-02749-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/16/2021] [Indexed: 01/01/2023]
Abstract
Antimicrobial resistance is a growing threat to public health and an increasingly common problem for acute care physicians to confront. Several novel antibiotics have been approved in the past decade to combat these infections; however, physicians may be unfamiliar with how to appropriately utilize them. The purpose of this review is to evaluate novel antibiotics active against resistant gram-negative bacteria and highlight clinical information regarding their use in the acute care setting. This review focuses on novel antibiotics useful in the treatment of infections caused by resistant gram-negative organisms that may be seen in the acute care setting. These novel antibiotics include ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilistatin/relebactam, cefiderocol, plazomicin, eravacycline, and omadacycline. Acute care physicians should be familiar with these novel antibiotics so they can utilize them appropriately.
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Affiliation(s)
- Aaron Matlock
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234 USA
| | - Joshua Allan Garcia
- Assistant Professor, Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA USA
| | - Kayvan Moussavi
- Assistant Professor, Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234 USA
| | - Stephen Yuan-Tung Liang
- Department of Emergency Medicine and Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO USA
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Highly Active Cranberry's Polyphenolic Fraction: New Advances in Processing and Clinical Applications. Nutrients 2021; 13:nu13082546. [PMID: 34444706 PMCID: PMC8399388 DOI: 10.3390/nu13082546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 02/07/2023] Open
Abstract
Cranberry is a fruit originally from New England and currently growing throughout the east and northeast parts of the USA and Canada. The supplementation of cranberry extracts as nutraceuticals showed to contribute to the prevention of urinary tract infections, and most likely it may help to prevent cardiovascular and gastroenteric diseases, as highlighted by several clinical trials. However, aiming to validate the efficacy and safety of clinical applications as long-term randomized clinical trials (RCTs), further investigations of the mechanisms of action are required. In addition, a real challenge for next years is the standardization of cranberry’s polyphenolic fractions. In this context, the optimization of the extraction process and downstream processing represent a key point for a reliable active principle for the formulation of a food supplement. For this reason, new non-conventional extraction methods have been developed to improve the quality of the extracts and reduce the overall costs. The aim of this survey is to describe both technologies and processes for highly active cranberry extracts as well as the effects observed in clinical studies and the respective tolerability notes.
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Ferreira M, Gameiro P. Fluoroquinolone-Transition Metal Complexes: A Strategy to Overcome Bacterial Resistance. Microorganisms 2021; 9:microorganisms9071506. [PMID: 34361943 PMCID: PMC8303200 DOI: 10.3390/microorganisms9071506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/01/2021] [Accepted: 07/08/2021] [Indexed: 01/12/2023] Open
Abstract
Fluoroquinolones (FQs) are antibiotics widely used in the clinical practice due to their large spectrum of action against Gram-negative and some Gram-positive bacteria. Nevertheless, the misuse and overuse of these antibiotics has triggered the development of bacterial resistance mechanisms. One of the strategies to circumvent this problem is the complexation of FQs with transition metal ions, known as metalloantibiotics, which can promote different activity and enhanced pharmacological behaviour. Here, we discuss the stability of FQ metalloantibiotics and their possible translocation pathways. The main goal of the present review is to frame the present knowledge on the conjunction of biophysical and biological tools that can help to unravel the antibacterial action of FQ metalloantibiotics. An additional goal is to shed light on the studies that must be accomplished to ensure stability and viability of such metalloantibiotics. Potentiometric, spectroscopic, microscopic, microbiological, and computational techniques are surveyed. Stability and partition constants, interaction with membrane porins and elucidation of their role in the influx, determination of the antimicrobial activity against multidrug-resistant (MDR) clinical isolates, elucidation of the mechanism of action, and toxicity assays are described for FQ metalloantibiotics.
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Bou Chebl R, Assaf M, Kattouf N, Abou Arbid S, Haidar S, Geha M, Makki M, Tamim H, Abou Dagher G. The prevalence and predictors of extended spectrum B-lactamase urinary tract infections among emergency department patients: A retrospective chart review. Am J Emerg Med 2021; 49:304-309. [PMID: 34182275 DOI: 10.1016/j.ajem.2021.06.044] [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: 03/10/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Inadequate initial antibiotic treatment of ESBL urinary tract infections (UTI) can lead to increase in the number of antibiotics used, return visits, longer hospitalizations, increased morbidity and mortality and increased costs. Given the important health implications on patients, this study aimed to examine the prevalence and predictors of ESBL UTIs among Emergency Department (ED) patients of a tertiary care center in Beirut, Lebanon. DESIGN, SETTING AND PARTICIPANTS Single-center retrospective observational study involving all adult UTI patients who presented to the ED of the American University of Beirut Medical Center, a tertiary care center between August 2019 and August 2020. RESULTS Out of the 886 patients that were included, 24.9% had an ESBL organism identified by urine culture. They had higher bladder catheter use within the previous 90 days, antibiotic use within last 90 days, and were more likely to have a history of an ESBL producing isolate from any body site in the last year. Antibiotic use in the last 90 days and a history of ESBL producing isolate at any site in the previous year were significantly associated with developing an ESBL UTI (OR = 1.66, p = 0.001 and OR = 2.53, p < 0.001 respectively). Patients diagnosed with cystitis were less likely to have an ESBL organism (OR = 0.4 95%CI [0.20-0.81], p = 0.01) CONCLUSION: The prevalence of ESBL organisms was found to be 24.9% in urinary tract infections. The predictors of an ESBL UTI infection were antibiotic use in the last 90 days, a history of ESBL producing isolate at any site in the previous year. Based on the findings of our study, we can consider modifying initial empiric antibiotic treatment for patients presenting with a UTI with the above stated risk factors.
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Affiliation(s)
- Ralphe Bou Chebl
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Mohamad Assaf
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Nadim Kattouf
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Samer Abou Arbid
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Saadeddine Haidar
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Mirabelle Geha
- American University of Beirut, Department of Emergency Medicine, Lebanon
| | - Maha Makki
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Campbell S, Hauler G, Immler EL, Seiti S, Dandache P, Srinivas P. Pharmacist-led Penicillin Allergy Assessment in the Emergency Department Reduced Empiric Fluoroquinolone Use. Clin Infect Dis 2021; 71:e506-e508. [PMID: 32109275 DOI: 10.1093/cid/ciaa175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/27/2020] [Indexed: 11/14/2022] Open
Abstract
In a retrospective, quasi-experimental study of 380 adult patients with a reported penicillin allergy who received antibiotics at a community hospital emergency department, a pharmacist-led penicillin allergy assessment via medical records review and patient interview improved guideline-preferred antibiotic use by 13% (P = .018) and reduced fluoroquinolone use by 11% (P = .035).
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Affiliation(s)
- Samantha Campbell
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, Ohio, USA
| | - Gregory Hauler
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, Ohio, USA
| | - Ellen L Immler
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, Ohio, USA
| | - Susan Seiti
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, Ohio, USA
| | - Patricia Dandache
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Third-Generation Cephalosporin Resistance and Associated Discordant Antibiotic Treatment in Emergency Department Febrile Urinary Tract Infections. Ann Emerg Med 2021; 78:357-369. [PMID: 33781606 DOI: 10.1016/j.annemergmed.2021.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/17/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE Third-generation cephalosporin-resistant (3GCR) Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis (EKP) are an increasingly common cause of community-onset urinary tract infections (UTIs) in the United States. The 3GCR antimicrobial resistance pattern in these Enterobacterales species is most commonly due to production of extended-spectrum β-lactamases. We sought to provide contemporary, emergency department (ED)-focused data on 3GCR-EKP UTI regional prevalence, presentation, antibiotic susceptibility, and empiric treatment patterns, and outcomes. METHODS We performed a retrospective cohort study of all adults admitted with a febrile UTI at 21 Kaiser Permanente Northern California EDs between January 2017 and June 2019. Inclusion criteria included fever; admitting diagnosis of UTI, pyelonephritis, or sepsis; and ED urine culture with greater than 100,000 colony-forming units/mL of an EKP species. 3GCR was defined as in vitro resistance to ceftriaxone, ceftazidime, or both. 3GCR-EKP cases were compared with non-3GCR-EKP controls for the following: demographics, comorbidities, presenting clinical features, urinary isolate antimicrobial susceptibility, treatment, and clinical outcomes. The primary outcome measure was the rate of discordant initial empiric antibiotic treatment (administered within 6 hours of ED arrival) when compared with antimicrobial susceptibility testing. Secondary outcomes included hospital length of stay and 90-day mortality, adjusted for comorbidities and severity of illness. RESULTS There were 4,107 patients (median age 73 years and 35% men) who met study inclusion criteria. Of these patients, 530 (12.9%) had a 3GCR-EKP urinary tract infection. The proportion of subjects possessing risk factors for a health care-associated or extended-spectrum β-lactamase infection was 92.8% of case patients and 86.1% of controls. When comparing 3GCR-EKP case and non-3GCR-EKP control isolates, ciprofloxacin susceptibility rates were 21% versus 88%, and piperacillin/tazobactam susceptibility rates were 89% versus 97%, respectively. Initial empiric antibiotic therapy was discordant with antimicrobial susceptibility testing results in 63% of case patients versus 7% of controls (odds ratio 21.0; 95% confidence interval 16.9 to 26.0). The hospital length of stay was longer for 3GCR-EKP case patients, with an adjusted mean difference of 29.7 hours (95% CI 19.0 to 40.4). Ninety-day mortality was 12% in case patients versus 8% in controls (adjusted odds ratio 1.56; 95% confidence interval 1.07 to 2.28). CONCLUSION In this large, 2017 to 2019 Northern California ED study, nearly 13% of febrile EKP UTIs requiring hospitalization were caused by 3GCR-EKP, and in these cases, initial empiric therapy was often discordant with antimicrobial susceptibility testing. 3GCR-EKP infections were associated with a longer hospital length of stay and higher 90-day mortality. Similar data from other regions and for outpatient UTIs are needed.
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Mohamed M, Clabots C, Porter SB, Bender T, Thuras P, Johnson JR. Large Fecal Reservoir of Escherichia coli Sequence Type 131-H30 Subclone Strains That Are Shared Within Households and Resemble Clinical ST131-H30 Isolates. J Infect Dis 2021; 221:1659-1668. [PMID: 31848601 DOI: 10.1093/infdis/jiz669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Emerging antimicrobial-resistant Escherichia coli represent mainly the nested (fluoroquinolone-resistant [FQR]) H30R and H30Rx subclones within sequence type 131 (ST131). Intestinal colonization and within-household transmission may underlie H30R's emergence. METHODS We screened fecal samples from 741 volunteers (383 veterans, 358 household members, including pets) for ST131 and FQR E. coli (FQREC) and used molecular profiling to resolve unique strains. Selected strains underwent PCR-based detection of phylogroups, sequence types (STs), H30, H30Rx, and 53 virulence genes (VGs). Within-household strain sharing was compared with household, host, and bacterial characteristics. Fecal isolates were compared with clinical isolates. RESULTS Colonization prevalence was 5.1% for H30R, 8% for ST131 (67% FQREC), and 10% for FQREC (52% ST131). ST131 isolates exhibited more VGs than non-ST131 isolates. Strain sharing (27% of multisubject households, 18% of corresponding subjects) was associated with the elderly, FQREC, H30R, H30Rx, ST73, and specific VGs. Fecal ST131 and FQREC isolates resembled contemporaneous and historical clinical isolates according to all studied traits. CONCLUSIONS Veterans and their human household members commonly carry and extensively share FQREC, predominantly H30R, thereby likely facilitating the ST131 pandemic. Strain sharing corresponds with multiple bacterial characteristics, including FQ resistance and specific VGs, which may promote intestinal colonization and/or host-to-host transmission.
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Affiliation(s)
- Muhanad Mohamed
- Division of Infectious Diseases and International Medicine , University of Minnesota, Minneapolis, Minnesota, USA
| | - Connie Clabots
- Infectious Diseases Section , Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Stephen B Porter
- Infectious Diseases Section , Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Tricia Bender
- Infectious Diseases section, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Paul Thuras
- Mental Health PSL, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - James R Johnson
- Division of Infectious Diseases and International Medicine , University of Minnesota, Minneapolis, Minnesota, USA
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Neu DW, Guidry TJ, Gillion AR, Pattanaik DN. Impact of Beta-Lactam Allergies on Selection of Antimicrobials in an Inpatient Setting Among Veteran Population. Mil Med 2021; 187:e567-e571. [DOI: 10.1093/milmed/usab004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/27/2020] [Accepted: 01/27/2021] [Indexed: 01/09/2023] Open
Abstract
ABSTRACT
Purpose
Beta-lactam antibiotics are among the most common and widely used antibiotics. However, reported allergy to this class of antibiotics is also common, leading to the use of alternative broad-spectrum antibiotics by healthcare providers. This has led to the emergence of various negative health outcomes. The purpose of the study is to investigate the impact of using alternative antibiotics secondary to a beta-lactam allergy among U.S. veterans who have otherwise multiple comorbidities.
Methods
This retrospective observational analysis was conducted over a 5-year period (January 1, 2011 to December 31, 2016) at the Memphis Veterans Affairs Medical Center (VAMC). Admitted patients with a documented beta-lactam allergy were categorized to preferred or non-preferred status based on initial antibiotic therapy antibiotic, allergy history, published guidelines, and local antibiogram. Preferred therapy was defined as the optimal antibiotic treatment for a given indication based on patient allergy history, published Infectious Disease Society of America guidelines, and local antibiogram of Memphis VAMC. The therapy was classified as “non-preferred” if it did not satisfy the preferred therapy criteria. Non-preferred treatments were further assessed for appropriateness based on indication and patient-specific factors. Chi-square and Fisher’s exact tests were conducted to find a difference in rates of negative sequelae among patients receiving preferred vs. non-preferred treatments and appropriate vs. inappropriate treatments.
Findings
Of the 1806 admissions identified, data were collected on 95 unique patients with 147 different antibiotic regimens. There were 68 (52%) preferred treatment regimens and 64 (48%) non-preferred treatment regimens. Of the 64 non-preferred treatments, 43 (67%) were inappropriate. There was a statistically significant decrease in the number of adverse drug events and in the combined negative sequelae outcome among patients receiving preferred therapy vs. non-preferred therapy (2 vs. 12; P < .01 and 11 vs. 23; P < .01, respectively).
Implications
The receipt of non-preferred antibiotic therapy among veterans with a recorded beta-lactam allergy may be associated with an increased risk of developing negative outcomes. Among military personnel, removing unnecessary beta-lactam allergies would improve readiness with optimal antibiotic choices and avoidance of unnecessary risks, expediting return to full duty.
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Affiliation(s)
- Daniel W Neu
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Tommie Jo Guidry
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Amanda R Gillion
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Debendra N Pattanaik
- Pharmacy Department (119), Veterans Affairs Medical Center, Memphis, TN 38104, USA
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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Bokhary H, Pangesti KNA, Rashid H, Abd El Ghany M, Hill-Cawthorne GA. Travel-Related Antimicrobial Resistance: A Systematic Review. Trop Med Infect Dis 2021; 6:11. [PMID: 33467065 PMCID: PMC7838817 DOI: 10.3390/tropicalmed6010011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022] Open
Abstract
There is increasing evidence that human movement facilitates the global spread of resistant bacteria and antimicrobial resistance (AMR) genes. We systematically reviewed the literature on the impact of travel on the dissemination of AMR. We searched the databases Medline, EMBASE and SCOPUS from database inception until the end of June 2019. Of the 3052 titles identified, 2253 articles passed the initial screening, of which 238 met the inclusion criteria. The studies covered 30,060 drug-resistant isolates from 26 identified bacterial species. Most were enteric, accounting for 65% of the identified species and 92% of all documented isolates. High-income countries were more likely to be recipient nations for AMR originating from middle- and low-income countries. The most common origin of travellers with resistant bacteria was Asia, covering 36% of the total isolates. Beta-lactams and quinolones were the most documented drug-resistant organisms, accounting for 35% and 31% of the overall drug resistance, respectively. Medical tourism was twice as likely to be associated with multidrug-resistant organisms than general travel. International travel is a vehicle for the transmission of antimicrobial resistance globally. Health systems should identify recent travellers to ensure that adequate precautions are taken.
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Affiliation(s)
- Hamid Bokhary
- School of Public Health, The University of Sydney, Sydney, NSW 2006, Australia; (K.N.A.P.); (G.A.H.-C.)
- University Medical Center, Umm Al-Qura University, Al Jamiah, Makkah, Makkah Region 24243, Saudi Arabia
- The Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Westmead, NSW 2145, Australia; (H.R.); or (M.A.E.G.)
- The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Krisna N. A. Pangesti
- School of Public Health, The University of Sydney, Sydney, NSW 2006, Australia; (K.N.A.P.); (G.A.H.-C.)
- The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Harunor Rashid
- The Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Westmead, NSW 2145, Australia; (H.R.); or (M.A.E.G.)
- National Centre for Immunisation Research and Surveillance (NCIRS), Kids Research, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Moataz Abd El Ghany
- The Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Westmead, NSW 2145, Australia; (H.R.); or (M.A.E.G.)
- The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
- The Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Grant A. Hill-Cawthorne
- School of Public Health, The University of Sydney, Sydney, NSW 2006, Australia; (K.N.A.P.); (G.A.H.-C.)
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Torres EL, Cantu JR, Bazan DZ, Verduzco RA, Hernández-Muñoz JJ. Travel to Mexico and uropathogen-antibiotic susceptibility mismatch in the emergency department. Am J Emerg Med 2020; 46:619-624. [PMID: 33298347 DOI: 10.1016/j.ajem.2020.11.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/21/2020] [Accepted: 11/21/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION International travel results in an increased risk of colonization and infection with multidrug-resistant organisms. This study aimed to determine if recent travel to Mexico affects the rate of uropathogen-antibiotic susceptibility mismatch (UASM) in outpatients treated for urinary tract infection (UTI) in a South Texas emergency department (ED). METHODS A retrospective cohort of adult patients presenting to the ED and treated outpatient for UTI from October 1, 2014, to February 25, 2020, was conducted at a community hospital located within approximately 15 miles of the United States-Mexico border. Rates of UASM were compared between patients with a history of recent travel to Mexico and those who have not recently traveled. RESULTS A total of 192 patients were included, with 64 in the travel to Mexico group and 128 in the no travel group. UASM was significantly higher in the recent travel to Mexico group when compared to the no travel group (RR 1.49, 95% CI 1.03-2.13). Antibiotics most commonly associated with UASM included fluoroquinolones, cephalexin, and sulfamethoxazole-trimethoprim. There was no significant difference between the rates of resistance to first-line agents for the treatment of UTI among the two groups. CONCLUSION In addition to known antibiotic resistance risk factors, recent travel to Mexico may increase the risk of UASM for ED patients with UTI. Considering the potential consequences of UTI treatment failure, antimicrobial stewardship services in the ED should include screening for antibiotic resistance risk factors and urine culture follow-up to ensure appropriate outpatient antibiotic therapy, especially among patients with recent international travel.
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Affiliation(s)
- Erica L Torres
- Pharmacy Department, DHR Health, 5501 South McColl Road, Edinburg, TX 78539, United States.
| | - Jonathon R Cantu
- Pharmacy Department, DHR Health, 5501 South McColl Road, Edinburg, TX 78539, United States
| | - Daniela Z Bazan
- Pharmacy Department, DHR Health, 5501 South McColl Road, Edinburg, TX 78539, United States; Department of Pharmacy Practice, Texas A&M University Irma Lerma Rangel College of Pharmacy, 1010 West Avenue B, Kingsville, TX 78363, United States
| | - Rene A Verduzco
- Pharmacy Department, DHR Health, 5501 South McColl Road, Edinburg, TX 78539, United States; Department of Pharmacy Practice, Texas A&M University Irma Lerma Rangel College of Pharmacy, 1010 West Avenue B, Kingsville, TX 78363, United States
| | - José J Hernández-Muñoz
- Department of Pharmaceutical Sciences, Texas A&M University Irma Lerma Rangel College of Pharmacy, Mail Stop 1114, 159 Reynolds Medical Building, College Station, TX 77843, United States
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Critchley IA, Cotroneo N, Pucci MJ, Jain A, Mendes RE. Resistance among urinary tract pathogens collected in Europe during 2018. J Glob Antimicrob Resist 2020; 23:439-444. [PMID: 33212286 DOI: 10.1016/j.jgar.2020.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/07/2020] [Accepted: 10/27/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis are urinary tract infection (UTI) pathogens and extended spectrum β-lactamase (ESBL)-producing pathogens exhibit co-resistance to oral fluoroquinolones (FQ) and trimethoprim-sulphamethoxazole (TMP-SMX). This study assessed the prevalence of ESBL phenotypes and co-resistance to FQ and TMP-SMX. METHODS In total, 766 E. coli, 260 K. pneumoniae and 104 P. mirabilis from UTIs in 18 countries were evaluated for susceptibility in the SENTRY surveillance programme, and results interpreted using EUCAST criteria. RESULTS E. coli, K. pneumoniae and P. mirabilis accounted for 57.1%, 11.3% and 7.8%, respectively, of the isolates. Among E. coli, resistance to levofloxacin and TMP-SMX ranged from 21.8% to 32.7% for all isolates increasing to 66.5-67.0% among those with a ESBL phenotype (17.9% of all UTI E. coli from Europe were ESBL phenotypes). In contrast, all E. coli were susceptible to meropenem. For K. pneumoniae, resistance rates for levofloxacin and TMP-SMX were 32.2-40.0% increasing to 69.1-78.6% for ESBL phenotypes. Meropenem was the most active agent, with 7.7% resistance. Among P. mirabilis resistance to levofloxacin and TMP-SMX was 26-38.5% and increased to 100% for ESBL phenotypes. No meropenem-resistant P. mirabilis were reported. CONCLUSIONS High co-resistance rates were observed for oral antibiotics among ESBL phenotypes raising concerns regarding empiric use of FQ and TMP-SMX for treating resistant UTIs outside of the hospital. In contrast, intravenous carbapenems retain activity against resistant UTI pathogens. New oral options with the spectrum of the carbapenems would address an unmet need for managing resistant UTIs.
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Genotypic antimicrobial resistance characterization of E. coli from dairy calves at high risk of respiratory disease administered enrofloxacin or tulathromycin. Sci Rep 2020; 10:19327. [PMID: 33168881 PMCID: PMC7653923 DOI: 10.1038/s41598-020-76232-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/26/2020] [Indexed: 01/15/2023] Open
Abstract
The objective of this study was to evaluate the longitudinal effect of enrofloxacin or tulathromycin use in calves at high risk of bovine respiratory disease (BRD) on antimicrobial resistance genes and mutation in quinolone resistance-determining regions (QRDR) in fecal E. coli. Calves at high risk of developing BRD were randomly enrolled in one of three groups receiving: (1) enrofloxacin (ENR; n = 22); (2) tulathromycin (TUL; n = 24); or (3) no treatment (CTL; n = 21). Fecal samples were collected at enrollment and at 7, 28, and 56 days after beginning treatment, cultured for Escherichiacoli (EC) and DNA extracted. Isolates were screened for cephalosporin, quinolone and tetracycline resistance genes using PCR. QRDR screening was conducted using Sanger sequencing. The only resistance genes detected were aac(6′)Ib-cr (n = 13), bla-CTX-M (n = 51), bla-TEM (n = 117), tetA (n = 142) and tetB (n = 101). A significantly higher detection of gyrA mutated at position 248 at time points 7 (OR = 11.5; P value = 0.03) and 28 (OR = 9.0; P value = 0.05) was observed in the ENR group when compared to calves in the control group. Our findings support a better understanding of the potential impacts from the use of enrofloxacin in calves on the selection and persistence of resistance.
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Talan DA, Takhar SS, Krishnadasan A, Mower WR, Pallin DJ, Garg M, Femling J, Rothman RE, Moore JC, Jones AE, Lovecchio F, Jui J, Steele MT, Stubbs AM, Chiang WK, Moran GJ. Emergence of Extended-Spectrum β-Lactamase Urinary Tract Infections Among Hospitalized Emergency Department Patients in the United States. Ann Emerg Med 2020; 77:32-43. [PMID: 33131912 DOI: 10.1016/j.annemergmed.2020.08.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE Enterobacteriaceae resistant to ceftriaxone, mediated through extended-spectrum β-lactamases (ESBLs), commonly cause urinary tract infections worldwide, but have been less prevalent in North America. Current US rates are unknown. We determine Enterobacteriaceae antimicrobial resistance rates among US emergency department (ED) patients hospitalized for urinary tract infection. METHODS We prospectively enrolled adults hospitalized for urinary tract infection from 11 geographically diverse university-affiliated hospital EDs during 2018 to 2019. Among participants with culture-confirmed infection, we evaluated prevalence of antimicrobial resistance, including that caused by ESBL-producing Enterobacteriaceae, resistance risk factors, and time to in vitro-active antibiotics. RESULTS Of 527 total participants, 444 (84%) had cultures that grew Enterobacteriaceae; 89 of 435 participants (20.5%; 95% confidence interval 16.9% to 24.5%; 4.6% to 45.4% by site) whose isolates had confirmatory testing had bacteria that were ESBL producing. The overall prevalence of ESBL-producing Enterobacteriaceae infection among all participants with urinary tract infection was 17.2% (95% confidence interval 14.0% to 20.7%). ESBL-producing Enterobacteriaceae infection risk factors were hospital, long-term care, antibiotic exposure within 90 days, and a fluoroquinolone- or ceftriaxone-resistant isolate within 1 year. Enterobacteriaceae resistance rates for other antimicrobials were fluoroquinolone 32.3%, gentamicin 13.7%, amikacin 1.3%, and meropenem 0.3%. Ceftriaxone was the most common empirical antibiotic. In vitro-active antibiotics were not administered within 12 hours of presentation to 48 participants (53.9%) with ESBL-producing Enterobacteriaceae infection, including 17 (58.6%) with sepsis. Compared with other Enterobacteriaceae infections, ESBL infections were associated with longer time to in vitro-active treatment (17.3 versus 3.5 hours). CONCLUSION Among adults hospitalized for urinary tract infection in many US locations, ESBL-producing Enterobacteriaceae have emerged as a common cause of infection that is often not initially treated with an in vitro-active antibiotic.
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Affiliation(s)
- David A Talan
- Department of Emergency Medicine, Department of Medicine, Divsion of Infectious Diseases, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Mills Peninsula Medical Center, Burlingame, CA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William R Mower
- Department of Emergency Medicine, Department of Medicine, Divsion of Infectious Diseases, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Manish Garg
- Department of Emergency Medicine, Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Jon Femling
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, NM
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins Medical Center, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN
| | - Alan E Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, University of Mississippi School of Medicine, Jackson, MS
| | - Frank Lovecchio
- Department of Emergency Medicine, Valleywise Health Medical Center, University of Arizona College of Medicine, Phoenix, AZ
| | - Jonathan Jui
- Department of Emergency Medicine, Oregon Health & Science University Hospital, Oregon Health & Science University, Portland, OR
| | - Mark T Steele
- Department of Emergency Medicine, Truman Medical Center, University of Missouri-Kansas City School of Medicine, MO
| | - Amy M Stubbs
- Department of Emergency Medicine, Truman Medical Center, University of Missouri-Kansas City School of Medicine, MO
| | - William K Chiang
- Department of Emergency Medicine, Bellevue Hospital Center, New York University School of Medicine, New York, NY
| | - Gregory J Moran
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Amin M, Wasito EB, Triyono EA. Comparison between Exposure of Ciprofloxacin and Cefotaxime on Developing of Escherichia coli ESBL. FOLIA MEDICA INDONESIANA 2020. [DOI: 10.20473/fmi.v56i2.21203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study aimed to compare ciprofloxacin and cefotaxime exposure to develop ESBL producing Escherichia coli (E. coli). A total of 16 isolates of cefotaxime sensitive E. coli and ciprofloxacin were exposed to ciprofloxacin and cefotaxime for 14 days using the Kirby-Bauer antibiotic disc diffusion method. Colonies that grew on the edge of the inhibiting zone were exposed each day by the same method. Furthermore, we observed the occurrence of resistance to cefotaxime as ESBL screening test. Isolates were resistant, the following day the ESBL was confirmed by the Modified Double Disk Sinergy Test (MDDST) method using Cefotaxime (CTX), Ceftazidime (CAZ), Aztreonam (ATM), and Amoxilin Clavulanate (AMC) antibiotic discs. From 16 isolates of ESBL producing E. coli exposed to ciprofloxacin, it was obtained 4 (25%) to ESBL E. coli. ESBL production occurred after E. coli was exposed to ciprofloxacin on days 5, 6, 7, and 12. While those exposed to cefotaxime none becomes ESBL E. coli. There was no difference between ciprofloxacin and cefotaxime exposure to develop ESBL producing E. coli (p=0.101; Chi-square).
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Durham SH, Hohmann NS, Ragan AH. Implementation of a Urinary Tract Infection Treatment Protocol to Improve Prescribing Practices in the Long-Term Care Facility of a Veteran’s Healthcare System. PHARMACY 2020; 8:pharmacy8030129. [PMID: 32722253 PMCID: PMC7558276 DOI: 10.3390/pharmacy8030129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/21/2022] Open
Abstract
Urinary tract infections (UTIs) are a commonly diagnosed problem in long-term care facilities (LTCFs), but antimicrobial treatment is often incorrectly prescribed. Although bacterial resistance to antimicrobials commonly used for UTIs, such as trimethoprim/sulfamethoxazole and fluoroquinolones, has been dramatically increasing, they are still commonly prescribed. The purpose of this project was to determine if implementation of a standard treatment protocol for UTIs, which emphasized correct UTI diagnosis and use of nitrofurantoin and cefpodoxime/ceftriaxone as empiric therapy per the institutional antibiogram, changed clinician prescribing practices. This quasi-experimental model utilized two years of pre-intervention and two years of post-intervention data. Three hundred patient encounters were included. Antibiotics prescribed in the pre-intervention period included: trimethoprim/sulfamethoxazole (32%), ciprofloxacin (14%), amoxicillin (13%), levofloxacin (9%), cefpodoxime (9%), ceftriaxone (8%), amoxicillin/clavulanate (5%), nitrofurantoin (4%), and other (6%). By contrast, antibiotics prescribed in the post-intervention period included: cefpodoxime (46%), nitrofurantoin (30%), ceftriaxone (10%), trimethoprim/sulfamethoxazole (8%), amoxicillin/clavulanate (1%), and other (5%). These differences in prescribed drug between the pre-intervention and post-intervention encounters were statistically significant (p < 0.001). Overall, appropriate empiric treatment was prescribed in only 48/217 encounters (22%) during the pre-intervention period, but this increased to 73/83 encounters (88%) in the post-intervention period (p < 0.001). The results indicate that the treatment protocol was successful in changing prescribing practices and decreasing the use of inappropriate antimicrobials at the LTCF.
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Affiliation(s)
- Spencer H. Durham
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849-5341, USA;
- Correspondence: ; Tel.: +334-844-7138
| | - Natalie S. Hohmann
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849-5341, USA;
| | - Addison H. Ragan
- Department of Pharmacy, Central Alabama Veterans Health Care System, Montgomery, AL 36109, USA;
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Raphael E, Chambers HF. Differential Trends in Extended-Spectrum Beta-Lactamase-Producing Escherichia coli Infections in Four Health Care Facilities in a Single Metropolitan Area: A Retrospective Analysis. Microb Drug Resist 2020; 27:154-161. [PMID: 32589493 DOI: 10.1089/mdr.2020.0058] [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: 11/13/2022] Open
Abstract
Background: Prevalence of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-E. coli) is increasing worldwide, but greatly varies geographically. We compared the prevalence of ESBL-E. coli infections at four distinct health care facilities in San Francisco, California. Methods: Antimicrobial susceptibility reports were obtained for E. coli isolates from (1) a county hospital, (2) a public skilled nursing facility, (3) a university hospital, and (4) a Veterans Affairs (VA) Medical Center. We compared change in frequency of ESBL-E. coli and antimicrobial resistance to trimethoprim-sulfamethoxazole between 2012 and 2018. Results: From 2012 to 2018, frequency of ESBL-E. coli increased in urine and nonurine isolates from the county hospital (urine: 1.1% per year, 95% confidence interval [CI]: 0.5-1.6, p < 0.01; nonurine: 1.9% per year, 95% CI: 0.9-2.9, p < 0.01) and in urine isolates from the VA hospital (0.9% per year, 95% CI: 0.3-1.4, p < 0.01). The frequency of trimethoprim-sulfamethoxazole resistance fluctuated in all facilities. Conclusions: At the skilled nursing facility, the prevalence of ESBL-E. coli was highest, but remained stable over time, while the prevalence of ESBL-E. coli increased among urine and nonurine isolates at the county hospital and urine isolates at the VA hospital. The temporal trend of ESBL-E. coli infections, even within one city, varied by health care facility.
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Affiliation(s)
- Eva Raphael
- Department of Family and Community Medicine and University of California, San Francisco, San Francisco, California, USA
| | - Henry F Chambers
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Lin K, Zahlanie Y, Ortwine JK, Mang NS, Wei W, Brown LS, Prokesch BC. Decreased Outpatient Fluoroquinolone Prescribing Using a Multimodal Antimicrobial Stewardship Initiative. Open Forum Infect Dis 2020; 7:ofaa182. [PMID: 32548204 PMCID: PMC7284006 DOI: 10.1093/ofid/ofaa182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system. Methods In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics. Results Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively. Conclusion A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.
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Affiliation(s)
- Kevin Lin
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Yorgo Zahlanie
- Division of Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica K Ortwine
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Norman S Mang
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wenjing Wei
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA.,Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - L Steven Brown
- Department of Health System Research, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Bonnie C Prokesch
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Ketz J, Saxena V, Arregui S, Jackson A, Schwartz GJ, Yagisawa T, Fairchild RL, Hains DS, Schwaderer AL. Developmental loss, but not pharmacological suppression, of renal carbonic anhydrase 2 results in pyelonephritis susceptibility. Am J Physiol Renal Physiol 2020; 318:F1441-F1453. [PMID: 32390512 DOI: 10.1152/ajprenal.00583.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Carbonic anhydrase II knockout (Car2-/-) mice have depleted numbers of renal intercalated cells, which are increasingly recognized to be innate immune effectors. We compared pyelonephritis susceptibility following reciprocal renal transplantations between Car2-/- and wild-type mice. We examined the effect of pharmacological CA suppression using acetazolamide in an experimental murine model of urinary tract infection. Car2-/- versus wild-type mice were compared for differences in renal innate immunity. In our transplant scheme, mice lacking CA-II in the kidney had increased pyelonephritis risk. Mice treated with acetazolamide had lower kidney bacterial burdens at 6 h postinfection, which appeared to be due to tubular flow from diuresis because comparable results were obtained when furosemide was substituted for acetazolamide. Isolated Car2-/- kidney cells enriched for intercalated cells demonstrated altered intercalated cell innate immune gene expression, notably increased calgizzarin and insulin receptor expression. Intercalated cell number and function along with renal tubular flow are determinants of pyelonephritis risk.
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Affiliation(s)
- John Ketz
- Center for Clinical and Translational Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Vijay Saxena
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Samuel Arregui
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Ashley Jackson
- Center for Clinical and Translational Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - George J Schwartz
- Division of Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Takafumi Yagisawa
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David S Hains
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Andrew L Schwaderer
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, Indianapolis, Indiana
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All-electrical monitoring of bacterial antibiotic susceptibility in a microfluidic device. Proc Natl Acad Sci U S A 2020; 117:10639-10644. [PMID: 32350139 DOI: 10.1073/pnas.1922172117] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The lack of rapid antibiotic susceptibility tests adversely affects the treatment of bacterial infections and contributes to increased prevalence of multidrug-resistant bacteria. Here, we describe an all-electrical approach that allows for ultrasensitive measurement of growth signals from only tens of bacteria in a microfluidic device. Our device is essentially a set of microfluidic channels, each with a nanoconstriction at one end and cross-sectional dimensions close to that of a single bacterium. Flowing a liquid bacteria sample (e.g., urine) through the microchannels rapidly traps the bacteria in the device, allowing for subsequent incubation in drugs. We measure the electrical resistance of the microchannels, which increases (or decreases) in proportion to the number of bacteria in the microchannels. The method and device allow for rapid antibiotic susceptibility tests in about 2 h. Further, the short-time fluctuations in the electrical resistance during an antibiotic susceptibility test are correlated with the morphological changes of bacteria caused by the antibiotic. In contrast to other electrical approaches, the underlying geometric blockage effect provides a robust and sensitive signal, which is straightforward to interpret without electrical models. The approach also obviates the need for a high-resolution microscope and other complex equipment, making it potentially usable in resource-limited settings.
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Urine Cultures in Acute Pyelonephritis: Knowing What You Are Up Against. Ann Emerg Med 2020; 74:596-598. [PMID: 31543125 DOI: 10.1016/j.annemergmed.2019.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Indexed: 11/20/2022]
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Riddle MS. Travel, Diarrhea, Antibiotics, Antimicrobial Resistance and Practice Guidelines—a Holistic Approach to a Health Conundrum. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-0717-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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48
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Strazzulla A, Bokobza S, Ombandza E, Kherallah K, Hommel S, Draidi R, Bonutto C, Zamponi DB, Gauzit R, Diamantis S. Impact of an Antimicrobial Stewardship Program on Resistance to Fluoroquinolones of Urinary Enterobacteriaceae Isolated From Nursing Home Residents: A Retrospective Cohort Study. J Am Med Dir Assoc 2020; 21:1322-1326. [PMID: 32199718 DOI: 10.1016/j.jamda.2020.01.111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/23/2020] [Accepted: 01/31/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study investigated the impact of an antimicrobial stewardship program on fluoroquinolone (FLQ) resistance in urinary Enterobacteriaceae isolated from residents of 3 French nursing homes. DESIGN A multicentric retrospective before-and-after study was conducted. SETTING AND PARTICIPANTS All the first urinary Enterobacteriaceae isolates obtained from nursing home residents were included. Two time frames were analyzed: 2013-2015 and 2016-2017. METHODS The antimicrobial stewardship program started in 2015 and was based on (1) 1-day training for use of an "antimicrobial stewardship kit for nursing homes;" and (2) daily support and training of the coordinating physician by an antibiotic mobile team (AMT) in 2 of 3 nursing homes. RESULTS Overall, 338 urinary isolates were analyzed. Escherichia coli was the most frequent species (212/338, 63%). A significant reduction of resistance to ofloxacin was observed between 2013-2015 and 2016-2017 in general (Δ = -16%, P = .004) and among isolates obtained from patients hospitalized in the county nursing home with AMT support (Δ = -28%, P < .01). A nonstatistically significant reduction in ofloxacin resistance was also observed in the hospital nursing home with AMT support (Δ = -18%, P = .06). CONCLUSIONS AND IMPLICATIONS Our antimicrobial stewardship program resulted in a decrease in resistance to FLQ among urinary Enterobacteriaceae isolated from nursing home residents. The support of an AMT along with continuous training of the coordinating physician seems to be an important component to ensure efficacy of the intervention.
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Affiliation(s)
- Alessio Strazzulla
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, Melun, France; Internal Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France.
| | | | | | | | | | - Raouf Draidi
- Antibiotic Mobile Team, Hospital of Provins, France
| | | | - Dominique Bonnet Zamponi
- Observatoire du Médicament des Dispositifs Médicaux et de l'Innovation Thérapeutique, Paris, France
| | - Rémy Gauzit
- Antibiotic Mobile Team, Cochin University Hospital, Paris, France
| | - Sylvain Diamantis
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, Melun, France
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Liang SY, Camins BC. Urine Culture and Uncomplicated Cystitis: A Bigger Picture? Ann Emerg Med 2020; 73:308-309. [PMID: 30797295 DOI: 10.1016/j.annemergmed.2018.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Bernard C Camins
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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Rizzo K, Horwich-Scholefield S, Epson E. Carbapenem and Cephalosporin Resistance among Enterobacteriaceae in Healthcare-Associated Infections, California, USA 1. Emerg Infect Dis 2019; 25:1389-1393. [PMID: 31211678 PMCID: PMC6590759 DOI: 10.3201/eid2507.181938] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We analyzed antimicrobial susceptibility test results reported in healthcare-associated infections by California hospitals during 2014-2017. Approximately 3.2% of Enterobacteriaceae reported in healthcare-associated infections were resistant to carbapenems and 26.9% were resistant to cephalosporins. The proportion of cephalosporin-resistant Escherichia coli increased 7% (risk ratio 1.07, 95% CI 1.04-1.11) per year during 2014-2017.
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