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Peri AM, Chatfield MD, Ling W, Furuya-Kanamori L, Harris PNA, Paterson DL. Rapid Diagnostic Tests and Antimicrobial Stewardship Programs for the Management of Bloodstream Infection: What Is Their Relative Contribution to Improving Clinical Outcomes? A Systematic Review and Network Meta-analysis. Clin Infect Dis 2024; 79:502-515. [PMID: 38676943 PMCID: PMC11327801 DOI: 10.1093/cid/ciae234] [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: 01/24/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Evidence about the clinical impact of rapid diagnostic tests (RDTs) for the diagnosis of bloodstream infections is limited, and whether RDT are superior to conventional blood cultures (BCs) embedded within antimicrobial stewardship programs (ASPs) is unknown. METHODS We performed network meta-analyses using results from studies of patients with bloodstream infection with the aim of comparing the clinical impact of RDT (applied on positive BC broth or whole blood) to conventional BC, both assessed with and without ASP with respect to mortality, length of stay (LOS), and time to optimal therapy. RESULTS Eighty-eight papers were selected, including 25 682 patient encounters. There was an appreciable amount of statistical heterogeneity within each meta-analysis. The network meta-analyses showed a significant reduction in mortality associated with the use of RDT + ASP versus BC alone (odds ratio [OR], 0.72; 95% confidence interval [CI], .59-.87) and with the use of RDT + ASP versus BC + ASP (OR, 0.78; 95% CI, .63-.96). No benefit in survival was found associated with the use of RDT alone nor with BC + ASP compared to BC alone. A reduction in LOS was associated with RDT + ASP versus BC alone (OR, 0.91; 95% CI, .84-.98) whereas no difference in LOS was shown between any other groups. A reduced time to optimal therapy was shown when RDT + ASP was compared to BC alone (-29 hours; 95% CI, -35 to -23), BC + ASP (-18 hours; 95% CI, -27 to -10), and to RDT alone (-12 hours; 95% CI, -20 to -3). CONCLUSIONS The use of RDT + ASP may lead to a survival benefit even when introduced in settings already adopting effective ASP in association with conventional BC.
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Affiliation(s)
- Anna Maria Peri
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Mark D Chatfield
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Weiping Ling
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Luis Furuya-Kanamori
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Patrick N A Harris
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, Queensland, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Infectious Diseases Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Black CA, Benavides R, Bandy SM, Dallas SD, Gawrys G, So W, Moreira AG, Aguilar S, Quidilla K, Smelter DF, Reveles KR, Frei CR, Koeller JM, Lee GC. Diverse Role of blaCTX-M and Porins in Mediating Ertapenem Resistance among Carbapenem-Resistant Enterobacterales. Antibiotics (Basel) 2024; 13:185. [PMID: 38391571 PMCID: PMC10885879 DOI: 10.3390/antibiotics13020185] [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: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Among carbapenem-resistant Enterobacterales (CRE) are diverse mechanisms, including those that are resistant to meropenem but susceptible to ertapenem, adding further complexity to the clinical landscape. This study investigates the emergence of ertapenem-resistant, meropenem-susceptible (ErMs) Escherichia coli and Klebsiella pneumoniae CRE across five hospitals in San Antonio, Texas, USA, from 2012 to 2018. The majority of the CRE isolates were non-carbapenemase producers (NCP; 54%; 41/76); 56% of all NCP isolates had an ErMs phenotype. Among ErMs strains, E. coli comprised the majority (72%). ErMs strains carrying blaCTX-M had, on average, 9-fold higher copies of blaCTX-M than CP-ErMs strains as well as approximately 4-fold more copies than blaCTX-M-positive but ertapenem- and meropenem-susceptible (EsMs) strains (3.7 vs. 0.9, p < 0.001). Notably, carbapenem hydrolysis was observed to be mediated by strains harboring blaCTX-M with and without a carbapenemase(s). ErMs also carried more mobile genetic elements, particularly IS26 composite transposons, than EsMs (37 vs. 0.2, p < 0.0001). MGE- ISVsa5 was uniquely more abundant in ErMs than either EsMs or ErMr strains, with over 30 more average ISVsa5 counts than both phenotype groups (p < 0.0001). Immunoblot analysis demonstrated the absence of OmpC expression in NCP-ErMs E. coli, with 92% of strains lacking full contig coverage of ompC. Overall, our findings characterize both collaborative and independent efforts between blaCTX-M and OmpC in ErMs strains, indicating the need to reappraise the term "non-carbapenemase (NCP)", particularly for strains highly expressing blaCTX-M. To improve outcomes for CRE-infected patients, future efforts should focus on mechanisms underlying the emerging ErMs subphenotype of CRE strains to develop technologies for its rapid detection and provide targeted therapeutic strategies.
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Affiliation(s)
- Cody A Black
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Raymond Benavides
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sarah M Bandy
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Steven D Dallas
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- University Health System, San Antonio, TX 78229, USA
| | - Gerard Gawrys
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- University Health System, San Antonio, TX 78229, USA
| | - Wonhee So
- College of Pharmacy, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Alvaro G Moreira
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
| | - Samantha Aguilar
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- University Health System, San Antonio, TX 78229, USA
| | - Kevin Quidilla
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Dan F Smelter
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- University Health System, San Antonio, TX 78229, USA
| | - Jim M Koeller
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Grace C Lee
- College of Pharmacy, The University of Texas at Austin, Austin, TX 78712, USA
- Joe R. and Teresa Lozano Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX 78229, USA
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