1
|
Karnmueng P, Montakantikul P, Paiboonvong T, Plongla R, Chatsuwan T, Chumnumwat S. Mortality factors and antibiotic options in carbapenem-resistant Enterobacterales bloodstream infections: Insights from a high-prevalence setting with co-occurring NDM-1 and OXA-48. Clin Transl Sci 2024; 17:e13855. [PMID: 38853376 PMCID: PMC11163016 DOI: 10.1111/cts.13855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/27/2024] [Accepted: 05/17/2024] [Indexed: 06/11/2024] Open
Abstract
Bloodstream infections (BSI) caused by carbapenem-resistant Enterobacterales (CRE) are associated with a high mortality rate. This study aimed to investigate factors associated with 14-day mortality and identify a potential treatment option. A retrospective cohort study was conducted on patients with CRE-BSI in Thailand from 2015 to 2020. The multivariate Cox proportional-hazards model was employed to identify factors influencing 14-day mortality. Out of 134 diagnosed cases of CRE-BSI, the all-cause 14-day mortality rate was 35.1%. The most prevalent organism isolated was Klebsiella pneumoniae (85.8%), followed by Escherichia coli (11.9%). Among the 60 isolates tested for carbapenemase genes, the majority exhibited co-occurring blaNDM-1 and blaOXA-48 (51.7%), followed by blaOXA-48 (31.7%) and blaNDM-1 (15.0%). In the multivariate analysis, neutropenia (adjusted hazard ratio [aHR] 2.55; 95% confidence interval [95%CI] 1.28-5.06; p = 0.008), sepsis/septic shock (aHR 3.02; 95%CI 1.33-6.86; p = 0.008), and previous metronidazole exposures (aHR 3.58; 95%CI 1.89-6.71; p < 0.001) were identified as independent factors for 14-day mortality. The fosfomycin-based regimen was found to be protective (aHR 0.37; 95%CI 0.15-0.92; p = 0.032). In patients with CRE-BSI, particularly in regions with a high occurrence of co-occurring blaNDM-1 and blaOXA-48, neutropenia, sepsis/septic shock, and previous metronidazole exposures emerged as independent risk factors for mortality. Moreover, the fosfomycin-based regimen showed an improvement in the survival rate.
Collapse
Affiliation(s)
- Palat Karnmueng
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
- Department of Pharmacy Practice, College of PharmacyRangsit UniversityPathum ThaniThailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
| | - Taniya Paiboonvong
- Department of Pharmacy Practice, College of PharmacyRangsit UniversityPathum ThaniThailand
| | - Rongpong Plongla
- Division of Infectious Diseases, Department of Medicine, Faculty of MedicineChulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand
- Center of Excellence in Antimicrobial Resistance and StewardshipChulalongkorn UniversityBangkokThailand
| | - Tanittha Chatsuwan
- Center of Excellence in Antimicrobial Resistance and StewardshipChulalongkorn UniversityBangkokThailand
- Department of Microbiology, Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Supatat Chumnumwat
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
| |
Collapse
|
2
|
Thampithak A, Chaisiri K, Siangsuebchart O, Phengjaturat K, Aonjumras W, Hemapanpairoa J. Prescription Pattern of Intravenous Fosfomycin in a Provincial Hospital in Thailand. Infect Chemother 2022; 54:699-710. [PMID: 36450288 PMCID: PMC9840959 DOI: 10.3947/ic.2022.0098] [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: 06/23/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In Thailand, active antibiotics against Gram-negative bacteria are limited. The re-emergence of intravenous (IV) fosfomycin is an alternative. IV fosfomycin has broad-spectrum activity, relative safety, and availability. The limitations of the clinical use of IV fosfomycin include the lack of susceptibility reports and unclear dosing. Therefore, this study was designed to examine the prescription pattern of IV fosfomycin in Chonburi Hospital, a provincial hospital in Thailand. MATERIALS AND METHODS A retrospective descriptive study involving in-patients aged ≥18 years who received IV fosfomycin between February 2019 and January 2020. Data were collected from the electronic patient records. RESULTS Of 265 patients, 254 (95.8%) and 11 (4.2%) received IV fosfomycin for treatment and prophylaxis, respectively. IV fosfomycin was prescribed for empirical and definitive treatment. All 166 organisms were Gram-negative bacteria (GNB), including Enterobacterales (47.0%), Acinetobacter baumannii (44.0%), and Pseudomonas aeruginosa (9.0%). Moreover, 141 (87.6%) isolates were carbapenem-resistant GNB (CR-GNB). The most commonly used IV fosfomycin regimen contained colistin or aminoglycosides. Furthermore, 35.3% of the combination regimens contained one active antibiotic. The appropriate dosage of IV fosfomycin for treating urinary tract infection was 71.8%. The 14-day all-cause mortality rate in CR-GNB was 45.0%. CONCLUSION IV fosfomycin is reserved for secondary use in treating nosocomial infection with resistant GNB. It is used synergistically with other antibiotics. At least one active antibiotic and the optimal fosfomycin dosage should be considered. An antimicrobial stewardship program should be implemented for the optimal use of fosfomycin.
Collapse
Affiliation(s)
- Anusorn Thampithak
- Division of Pharmacology and Biopharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | | | | | | | - Wiwarin Aonjumras
- Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Jatapat Hemapanpairoa
- Department of Pharmacy Practice and Pharmaceutical Care, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| |
Collapse
|
3
|
Tangsawad W, Kositamongkol C, Chongtrakool P, Phisalprapa P, Jitmuang A. The burden of carbapenem-resistant Enterobacterales infection in a large Thai tertiary care hospital. Front Pharmacol 2022; 13:972900. [PMID: 36120317 PMCID: PMC9479096 DOI: 10.3389/fphar.2022.972900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Carbapenem-resistant Enterobacterales (CRE) are resistant to several other classes of antimicrobials, reducing treatment options and increasing mortality. We studied the clinical characteristics and burden of hospitalized adult patients with CRE infections in a setting where treatment options are limited. Methods: A retrospective cohort study included adult inpatients between January 2015–December 2019 at Siriraj Hospital in Bangkok, Thailand. Clinical and microbiological data were reviewed. Results: Of 420 patients with CRE infections, the mean age was 65.00 ± 18.89 years, 192 (45.72%) were male, and 112 (26.90%) were critically ill. Three hundred and eighty (90.48%) had Klebsiella pneumoniae, and 40 (9.52%) had Escherichia coli infections. The mean APACHE II score was 14.27 ± 6.36. Nearly half had previous hospitalizations (48.81%), 41.2% received antimicrobials, and 88.1% had undergone medical procedures before the onset of infection. The median time of onset of CRE infection was 16 days after admission. Common sites of infection were bacteremia (53.90%) and pneumonia (45.47%). Most CRE-infected patients had septic shock (63.10%) and Gram-negative co-infections (62.85%). Colistin (29.95%) and non-colistin (12.91%) monotherapies, and colistin-based (44.78%) and non-colistin-based (12.36%) combination therapies were the best available antimicrobial therapies (BAAT). The median length of hospitalization was 31 days, and the median hospitalization cost was US$10,435. The in-hospital mortality rate was 68.33%. Septic shock [adjusted odds ratio (aOR) 10.73, 5.65–20.42, p <0 .001], coinfection (aOR 2.43, 1.32–4.47, p = 0.004), mechanical ventilation (aOR 2.33, 1.24–4.36, p = 0.009), and a high SOFA score at onset (aOR 1.18, 1.07–1.30, p <0 .001) were associated with mortality. Conclusion: CRE infection increases mortality, hospital stays, and healthcare costs. A colistin-based regimen was the BAAT in this study. Therefore, newer antimicrobial agents are urgently needed.
Collapse
Affiliation(s)
- Watcharaphon Tangsawad
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanis Kositamongkol
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piriyaporn Chongtrakool
- Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pochamana Phisalprapa
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anupop Jitmuang
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Anupop Jitmuang,
| |
Collapse
|
4
|
Sirichayanugul T, Srisawat C, Thummakomut C, Prawang A, Huynh NS, Saokaew S, Phisalprapa P, Kanchanasurakit S. Development and internal validation of simplified predictive scoring (ICU-SEPSA score) for mortality in patients with multidrug resistant infection. Front Pharmacol 2022; 13:938028. [PMID: 36120359 PMCID: PMC9472650 DOI: 10.3389/fphar.2022.938028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/02/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Mortality from multidrug-resistant (MDR) pathogens is an urgent healthcare crisis worldwide. At present we do not have any simplified screening tools to predict the risk of mortality associated with MDR infections. The aim of this study was to develop a screening tool to predict mortality in patients with multidrug-resistant organisms. Methods: A retrospective cohort study to evaluate mortality risks in patients with MDR infections was conducted at Phrae Hospital. Univariable and multivariable analyses were used to classify possible risk factors. The model performance was internally validated utilizing the mean of three measures of discrimination corrected by the optimism using a 1000-bootstrap procedure. The coefficients were transformed into item scores by dividing each coefficient with the lowest coefficient and then rounding to the most adjacent number. The area under the receiver operating characteristic curve (AuROC) was used to determine the performance of the model. Results: Between 1 October 2018 and 30 September 2020, a total of 504 patients with MDR infections were enrolled. The ICU-SEPSA score composed of eight clinical risk factors: 1) immunocompromised host, 2) chronic obstructive pulmonary disease, 3) urinary tract infection, 4) sepsis, 5) placement of endotracheal tube, 6) pneumonia, 7) septic shock, and 8) use of antibiotics within the past 3 months. The model showed good calibration (Hosmer-Lemeshow χ2 = 19.27; p-value = 0.50) and good discrimination after optimism correction (AuROC 84.6%, 95% confidence interval [Cl]: 81.0%–88.0%). The positive likelihood ratio of low risk (score ≤ 5) and high risk (score ≥ 8) were 2.07 (95% CI: 1.74–2.46) and 12.35 (95% CI: 4.90–31.13), respectively. Conclusion: A simplified predictive scoring tool wad developed to predict mortality in patients with MDR infections. Due to a single-study design of this study, external validation of the results before applying in other clinical practice settings is warranted.
Collapse
Affiliation(s)
| | - Chansinee Srisawat
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Chawin Thummakomut
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Abhisit Prawang
- College of Pharmacy, Rangsit University, Phathum Thani, Thailand
| | - Nina S Huynh
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, United States
| | - Surasak Saokaew
- Division of Social and Administration Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bander Sunway, Malaysia
- Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bander Sunway, Malaysia
| | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Pochamana Phisalprapa, ; Sukrit Kanchanasurakit,
| | - Sukrit Kanchanasurakit
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Division of Pharmaceutical Care, Department of Pharmacy, Phrae Hospital, Phrae, Thailand
- *Correspondence: Pochamana Phisalprapa, ; Sukrit Kanchanasurakit,
| |
Collapse
|
5
|
Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
Collapse
Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
6
|
Fosfomycin and nitrofurantoin: classic antibiotics and perspectives. J Antibiot (Tokyo) 2021; 74:547-558. [PMID: 34244614 DOI: 10.1038/s41429-021-00444-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Antibiotics are essential molecules for the treatment and prophylaxis of many infectious diseases. However, drugs that combat microbial infections can become a human health threat due to their high and often indiscriminate consumption, considered one of the factors of antimicrobial resistance (AMR) emergence. The AMR crisis, the decrease in new drug development by the pharmaceutical industry, and reduced economic incentives for research have all reduced the options for treating infections, and new strategies are necessary, including the return of some traditional but "forgotten" antibiotics. However, prescriptions for these older drugs including nitrofurantoin and oral fosfomycin, have been based on the results of pioneer studies, and the limited knowledge generated 50-70 years ago may not be enough. To avoid harming patients and further increasing multidrug resistance, systematic evaluation is required, mainly for the drugs prescribed for community-acquired infections, such as urinary tract infections (UTI). Therefore, this review has the objective of reporting the use of two classic drugs from the nitrofuran and phosphonic acid classes for UTI control nowadays. Furthermore, we also explore new approaches used for these antibiotics, including new combination regimes for spectral amplification, and the prospects for reducing bacterial resistance in the fight against bacteria responsible for UTI.
Collapse
|
7
|
Saelim W, Changpradub D, Thunyaharn S, Juntanawiwat P, Nulsopapon P, Santimaleeworagun W. Colistin plus Sulbactam or Fosfomycin against Carbapenem-Resistant Acinetobacter baumannii: Improved Efficacy or Decreased Risk of Nephrotoxicity? Infect Chemother 2021; 53:128-140. [PMID: 34409786 PMCID: PMC8032916 DOI: 10.3947/ic.2021.0007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/07/2021] [Indexed: 12/22/2022] Open
Abstract
Background Acinetobacter baumannii has been recognized as a cause of nosocomial infection. To date, polymyxins, the last-resort therapeutic agents for carbapenem-resistant A. baumannii (CRAB). Thus, the small number of effective antibiotic options against CRAB represents a challenge to human health. This study examined the appropriate dosage regimens of colistin alone or in combination with sulbactam or fosfomycin using Monte Carlo simulation with the aims of improving efficacy and reducing the risk of nephrotoxicity. Materials and Methods Clinical CRAB isolates were obtained from patients admitted to Phramongkutklao Hospital in 2014 and 2015. The minimum inhibitory concentration (MIC) of colistin for each CRAB isolate was determined using the broth dilution method, whereas those of sulbactam and fosfomycin were determined using the agar dilution method. Each drug regimen was simulated using the Monte Carlo technique to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR). Nephrotoxicity based on RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) criteria was indicated by colistin trough concentration exceeding
≥3.3 µg/mL. Results A total of 50 CRAB isolates were included. The MIC50 and MIC90 were 64 and 128 µg/mL, respectively, for sulbactam, 256 and 2,048 µg/mL, respectively, for fosfomycin, and 1 and 4 µg/mL, respectively, for colistin. In patients with creatinine clearance of 91 – 130 m/min, the dosing regimens of 180 mg every 12 h and 150 mg every 8 h achieved ≥ 90% of target of the area under the free drug plasma concentration–time curve from 0 to 24 hr (fAUC24)/MIC ≥25 against isolates MICs of ≤0.25 and ≤0.5 µg/mL, respectively, and their rates of colistin trough concentration more than ≥3.3 µg/mL were 35 and 54%, respectively. Colistin combined with sulbactam or fosfomycin decreased the colistin MIC of CRAB isolates from 1 – 16 µg/mL to 0.0625 – 1 and 0.0625 – 2 µg/mL, respectively. Based on CFR ≥ 90%, no colistin monotherapy regimens in patients with creatinine clearance of 91 – 130 mL/min were effective against all of the studied CRAB isolates. For improving efficacy and reducing the risk of nephrotoxicity, colistin 150 mg given every 12 h together with sulbactam (≥6 g/day) or fosfomycin (≥18 g/day) was effective in patients with creatinine clearance of 91 – 130 mL/min. Additionally, both colistin combination regimens were effective against five colistin-resistant A. baumannii isolates. Conclusion Colistin monotherapy at the maximum recommended dose might not cover some CRAB isolates. Colistin combination therapy appears appropriate for achieving the pharmacokinetic/pharmacodynamic targets of CRAB treatment.
Collapse
Affiliation(s)
- Weerayuth Saelim
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Dhitiwat Changpradub
- Division of Infectious Diseases, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Sudaluck Thunyaharn
- Faculty of Medical Technology, Nakhonratchasima College, Nakhon Ratchasima, Thailand
| | - Piraporn Juntanawiwat
- Division of Microbiology, Department of Clinical Pathology, Phramongkutklao Hospital, Bangkok, Thailand
| | - Parnrada Nulsopapon
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.,Antibiotic Optimization and Patient Care Project by Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group [PIRBIG]
| | - Wichai Santimaleeworagun
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.,Antibiotic Optimization and Patient Care Project by Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group [PIRBIG].
| |
Collapse
|