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Mauritz MD, Claus B, Forster J, Petzold M, Schneitler S, Halfmann A, Hauswaldt S, Nurjadi D, Toepfner N. The EC-COMPASS: Long-term, multi-centre surveillance of Enterobacter cloacae complex - a clinical perspective. J Hosp Infect 2024; 148:11-19. [PMID: 38554809 DOI: 10.1016/j.jhin.2024.03.010] [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: 01/08/2024] [Revised: 03/02/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Enterobacter cloacae complex (ECCO) comprises closely related Enterobacterales, causing a variety of infections ranging from mild urinary tract infections to severe bloodstream infections. ECCO has emerged as a significant cause of healthcare-associated infections, particularly in neonatal and adult intensive care. AIM The Enterobacter Cloacae COMplex PASsive Surveillance (EC-COMPASS) aims to provide a detailed multi-centre overview of ECCO epidemiology and resistance patterns detected in routine microbiological diagnostics in four German tertiary-care hospitals. METHODS In a sentinel cluster of four German tertiary-care hospitals, all culture-positive ECCO results between 1st January 2020 and 31st December 2022, were analysed based on Hybase® laboratory data. FINDINGS Analysis of 31,193 ECCO datasets from 14,311 patients revealed a higher incidence in male patients (P<0.05), although no significant differences were observed in ECCO infection phenotypes. The most common sources of ECCO were swabs (42.7%), urine (17.5%), respiratory secretions (16.1%), blood cultures (8.9%) and tissue samples (5.6%). The annual bacteraemia rate remained steady at approximately 33 cases per hospital. Invasive ECCO infections were predominantly found in oncology and intensive care units. Incidences of nosocomial outbreaks were infrequent and limited in scope. Notably, resistance to carbapenems was consistently low. CONCLUSION EC-COMPASS offers a profound clinical perspective on ECCO infections in German tertiary-healthcare settings, highlighting elderly men in oncology and intensive care units as especially vulnerable to ECCO infections. Early detection strategies targeting at-risk patients could improve ECCO infection management.
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Affiliation(s)
- M D Mauritz
- Department of General Pediatrics and Adolescent Medicine, Children's and Adolescents' Hospital, Datteln, Germany; Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany.
| | - B Claus
- Department of Children's Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany; PedScience Research Institute, Datteln, Germany
| | - J Forster
- Institute for Hygiene and Microbiology, University of Wuerzburg, Wuerzburg, Germany
| | - M Petzold
- Institute for Medical Microbiology and Virology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - S Schneitler
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - A Halfmann
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - S Hauswaldt
- Department of Infectious Diseases and Microbiology, University of Luebeck, Luebeck, Germany
| | - D Nurjadi
- Department of Infectious Diseases and Microbiology, University of Luebeck, Luebeck, Germany
| | - N Toepfner
- Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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Eikenboom AM, Lambregts MMC, de Boer MGJ, le Cessie S. Influence of initial misdiagnosis on mortality in patients with bacteraemia: propensity score matching and propensity score weighting analyses. BMC Infect Dis 2024; 24:389. [PMID: 38605292 PMCID: PMC11007998 DOI: 10.1186/s12879-024-09299-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/07/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The diagnostic process is a key element of medicine but it is complex and prone to errors. Infectious diseases are one of the three categories of diseases in which diagnostic errors can be most harmful to patients. In this study we aimed to estimate the effect of initial misdiagnosis of the source of infection in patients with bacteraemia on 14 day mortality using propensity score methods to adjust for confounding. METHODS Data from a previously described longitudinal cohort of patients diagnosed with monobacterial bloodstream infection (BSI) at the Leiden University Medical Centre (LUMC) between 2013 and 2015 were used. Propensity score matching and inversed probability of treatment weighting (IPTW) were applied to correct for confounding. The average treatment effect on the treated (ATT), which in this study was the average effect of initial misdiagnosis on the misdiagnosed (AEMM), was estimated. Methodological issues that were encountered when applying propensity score methods were addressed by performing additional sensitivity analyses. Sensitivity analyses consisted of varying caliper in propensity score matching and using different truncated weights in inversed probability of treatment weighting. RESULTS Data of 887 patients were included in the study. Propensity scores ranged between 0.015 and 0.999 and 80 patients (9.9%) had a propensity score > 0.95. In the matched analyses, 35 of the 171 misdiagnosed patients died within 14 days (20.5%), versus 10 of the 171 correctly diagnosed patients (5.8%), yielding a difference of 14.6% (7.6%; 21.6%). In the total group of patients, the observed percentage of patients with an incorrect initial diagnosis that died within 14 days was 19.8% while propensity score reweighting estimated that their probability of dying would have been 6.5%, if they had been correctly diagnosed (difference 13.3% (95% CI 6.9%;19.6%)). After adjustment for all variables that showed disbalance in the propensity score a difference of 13.7% (7.4%; 19.9%) was estimated. Sensitivity analyses yielded similar results. However, performing weighted analyses without truncation yielded unstable results. CONCLUSION Thus, we observed a substantial increase of 14 day mortality in initially misdiagnosed patients. Furthermore, several patients received propensity scores extremely close to one and were almost sure to be initially misdiagnosed.
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Affiliation(s)
- Anna M Eikenboom
- Department of Infectious Diseases, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
- Department of Clinical Epidemiology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
- Department of Biomedical Data Sciences, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
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Ramsay KA, Rehman A, Wardell ST, Martin LW, Bell SC, Patrick WM, Winstanley C, Lamont IL. Ceftazidime resistance in Pseudomonas aeruginosa is multigenic and complex. PLoS One 2023; 18:e0285856. [PMID: 37192202 DOI: 10.1371/journal.pone.0285856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/02/2023] [Indexed: 05/18/2023] Open
Abstract
Pseudomonas aeruginosa causes a wide range of severe infections. Ceftazidime, a cephalosporin, is a key antibiotic for treating infections but a significant proportion of isolates are ceftazidime-resistant. The aim of this research was to identify mutations that contribute to resistance, and to quantify the impacts of individual mutations and mutation combinations. Thirty-five mutants with reduced susceptibility to ceftazidime were evolved from two antibiotic-sensitive P. aeruginosa reference strains PAO1 and PA14. Mutations were identified by whole genome sequencing. The evolved mutants tolerated ceftazidime at concentrations between 4 and 1000 times that of the parental bacteria, with most mutants being ceftazidime resistant (minimum inhibitory concentration [MIC] ≥ 32 mg/L). Many mutants were also resistant to meropenem, a carbapenem antibiotic. Twenty-eight genes were mutated in multiple mutants, with dacB and mpl being the most frequently mutated. Mutations in six key genes were engineered into the genome of strain PAO1 individually and in combinations. A dacB mutation by itself increased the ceftazidime MIC by 16-fold although the mutant bacteria remained ceftazidime sensitive (MIC < 32 mg/L). Mutations in ampC, mexR, nalC or nalD increased the MIC by 2- to 4-fold. The MIC of a dacB mutant was increased when combined with a mutation in ampC, rendering the bacteria resistant, whereas other mutation combinations did not increase the MIC above those of single mutants. To determine the clinical relevance of mutations identified through experimental evolution, 173 ceftazidime-resistant and 166 sensitive clinical isolates were analysed for the presence of sequence variants that likely alter function of resistance-associated genes. dacB and ampC sequence variants occur most frequently in both resistant and sensitive clinical isolates. Our findings quantify the individual and combinatorial effects of mutations in different genes on ceftazidime susceptibility and demonstrate that the genetic basis of ceftazidime resistance is complex and multifactorial.
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Affiliation(s)
- Kay A Ramsay
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Attika Rehman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Samuel T Wardell
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand
| | - Lois W Martin
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia
- Children's Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Wayne M Patrick
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Craig Winstanley
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Iain L Lamont
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Dow G, MacLaggan T, Allard J. Impact of a bloodstream infection stewardship program in hospitalized patients. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:196-207. [PMID: 36337596 PMCID: PMC9629734 DOI: 10.3138/jammi-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Bloodstream infections (BSIs) in hospitalized patients represent sentinel events requiring timely and responsive antimicrobial prescribing. These infections represent an attractive but seldom-evaluated stewardship opportunity. METHODS Retrospective pre-post study design, with review of patient charts 18 months before and after initiation of a hospital Bloodstream Infection Stewardship Program (BSISP). Pre-intervention, the ward and attending physician were notified of all positive blood cultures. Post-intervention, an infectious disease (ID) pharmacist collaborating with an ID consultant was also notified. RESULTS Two hundred twenty-six eligible BSIs were identified pre-intervention and 195 post-intervention. The urinary tract was the most common source of infection; most common bloodstream isolates were Escherichia coli, Staphylococcus aureus, beta-hemolytic streptococci, and Klebsiella pneumoniae; 71.7% of infections were community acquired. Empiric therapy was not given in 17.3% of cases and inadequate in 16.4% of patients. Therapy was altered on the basis of Gram stain results ('directed therapy') in 54.6% of episodes and was inadequate in 3.5%. Compared to pre-intervention, the post-intervention cohort received directed therapy on average 4.36 hours earlier (p = 0.003), was more likely to receive appropriate definitive therapy (99.0% post versus 79.1% pre, p <0.001), stepped down to oral therapy earlier (6.0 versus 8.0 days, p = 0.031), and received fewer directed prescriptions (214 per 100 cases post versus 260 per 100 cases pre; p = 0.001), including fewer prescriptions of quinolones and clindamycin. CONCLUSIONS A BSISP could be an effective strategy for improving antimicrobial prescribing in hospitalized patients with a BSI.
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Affiliation(s)
- Gordon Dow
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Timothy MacLaggan
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Jacques Allard
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
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Rapid DNA visual detection of polymicrobial bloodstream infection using filter paper. Sci Rep 2022; 12:4515. [PMID: 35296724 PMCID: PMC8927095 DOI: 10.1038/s41598-022-08487-4] [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: 11/30/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Bloodstream infection (BSI) is a major complication in patients with cancers due to therapy-induced neutropenia and underlying conditions, which increases hospitalization time and mortality rate. Targeted and timely antimicrobial management is crucial to save the patients’ lives and reduce the social and economic burdens. Blood culture is a routine clinical diagnostic method of BSI with a long turnaround time, and generally identifies monomicrobial BSI. Thus, polymicrobial BSI often goes undetected although it occurs more frequently in these patients and results in more severe outcomes compared to monomicrobial BSI. In this work, we apply glutaric anhydride, N-hydroxysuccinimide and N,N′-dicyclohexylcarbodiimide to fabricate a functional surface on cellulose filter paper. Targeting three pathogens (Escherichia coli, Saccharomyces cerevisiae, and human cytomegalovirus) commonly occurring in BSI in neutropenic patients, we demonstrate rapid and accurate triplex pathogen DNA detection using the functionalized paper. All three pathogen DNA was identified in 1–5 min with a detection limit of 0.1–0.5 ng/µL. The developed test tool has the potential to provide rapid polymicrobial BSI diagnosis in support of timely, accurate antimicrobial treatment, and could be integrated into an automatic sample-to-result portable equipment.
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Dryden M, Kantecki M, Yan JL, Stone GG, Leister-Tebbe H, Wilcox M. Treatment outcomes of secondary bacteraemia in patients treated with ceftaroline fosamil: pooled results from six phase III clinical trials. J Glob Antimicrob Resist 2022; 28:108-114. [PMID: 34922058 DOI: 10.1016/j.jgar.2021.10.027] [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: 04/13/2021] [Revised: 10/06/2021] [Accepted: 10/30/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This exploratory pooled analysis assessed the efficacy and safety of ceftaroline fosamil and comparators across six phase III clinical trials in adults with community-acquired pneumonia (CAP) or complicated skin and soft-tissue infection (cSSTI) and secondary bacteraemia. METHODS In each trial, FOCUS 1 and 2 (CAP), Asia CAP trial, CANVAS 1 and 2 (cSSTI) and COVERS (cSSTI), patients were randomised to ceftaroline fosamil [600 mg q12h by 1-h i.v. infusion, except in COVERS (600 mg q8h by 2-h i.v. infusion), adjusted for renal function] or comparator. Efficacy assessments included clinical and microbiological responses at test-of-cure visit [microbiological modified intent-to-treat (mMITT) population]. Safety outcomes were assessed. RESULTS The pooled mMITT population comprised 1976 patients, of whom 138 had baseline bacteraemia (ceftaroline fosamil, n = 72; comparator, n = 66). Predominant baseline blood pathogens were Staphylococcus aureus (n = 29), Streptococcus pneumoniae (n = 19) and other streptococci (n = 12). Clinical cure rates in bacteraemic patients were 55/72 (76.4%) and 51/66 (77.3%) for ceftaroline fosamil and comparators, respectively, and in non-bacteraemic patients were 822/966 (85.1%) and 717/872 (82.2%). Favourable microbiological response rates in bacteraemic patients were 56/72 (77.8%) for ceftaroline fosamil and 54/66 (81.8%) for comparators, and in non-bacteraemic patients were 825/966 (85.4%) and 719/872 (82.5%). Adverse events in bacteraemic patients were consistent with the known ceftaroline fosamil safety profile or the underlying indications. CONCLUSION These pooled clinical and microbiological efficacy data demonstrate generally favourable outcomes for ceftaroline fosamil in patients with CAP or cSSTI and secondary bacteraemia. [Trial Registration: NCT00621504, NCT00509106; NCT01371838; NCT00424190, NCT00423657; NCT01499277].
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Affiliation(s)
- Matthew Dryden
- Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK.
| | | | | | | | | | - Mark Wilcox
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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7
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Gebretekle GB, Mariam DH, Mac S, Abebe W, Alemayehu T, Degu WA, Libman M, Yansouni CP, Fenta TG, Semret M, Sander B. Cost-utility analysis of antimicrobial stewardship programme at a tertiary teaching hospital in Ethiopia. BMJ Open 2021; 11:e047515. [PMID: 34921071 PMCID: PMC8685939 DOI: 10.1136/bmjopen-2020-047515] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Antimicrobial stewardship (AMS) significantly reduces inappropriate antibiotic use and improves patient outcomes. In low-resource settings, AMS implementation may require concurrent strengthening of clinical microbiology capacity therefore additional investments. We assessed the cost-effectiveness of implementing AMS at Tikur Anbessa Specialised Hospital (TASH), a tertiary care hospital in Ethiopia. DESIGN We developed a Markov cohort model to assess the cost-utility of pharmacist-led AMS with concurrent strengthening of laboratory capacity compared with usual care from a 'restricted societal' perspective. We used a lifetime time horizon and discounted health outcomes and cost at 3% annually. Data were extracted from a prospective study of bloodstream infections among patients hospitalised at TASH, supplemented by published literature. We assessed parameter uncertainty using deterministic and probabilistic sensitivity analyses. SETTING Tertiary care hospital in Ethiopia, with 800 beds and serves over half a million patients per year. POPULATION Cohort of adults and children inpatient population aged 19.8 years at baseline. INTERVENTION Laboratory-supported pharmacist-led AMS compared with usual care. Usual care is defined as empirical initiation of antibiotic therapy in the absence of strong laboratory and AMS. OUTCOME MEASURES Expected life-years, quality-adjusted life-years (QALYs), costs (US$2018) and incremental cost-effectiveness ratio. RESULTS Laboratory-supported AMS strategy dominated usual care, that is, AMS was associated with an expected incremental gain of 38.8 QALYs at lower expected cost (incremental cost savings:US$82 370) per 1000 patients compared with usual care. Findings were sensitive to medication cost, infection-associated mortality and AMS-associated mortality reduction. Probabilistic sensitivity analysis demonstrated that AMS programme was likely to be cost-effective at 100% of the simulation compared with usual care at 1%-51% of gross domestic product/capita. CONCLUSION Our study indicates that laboratory-supported pharmacist-led AMS can result in improved health outcomes and substantial healthcare cost savings, demonstrating its economic advantage in a tertiary care hospital despite greater upfront investments in a low-resource setting.
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Affiliation(s)
- Gebremedhin Beedemariam Gebretekle
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Damen Haile Mariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Stephen Mac
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Workeabeba Abebe
- Pediatrics and Child Health, Pediatric Cardiology Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tinsae Alemayehu
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
- American Medical Center, Specialty Center for Infectious Diseases and Travel Medicine, Addis Ababa, Ethiopia
| | - Wondwossen Amogne Degu
- School of Medicine, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Michael Libman
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
| | - Cedric P Yansouni
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Québec, Canada
| | - Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Makeda Semret
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
| | - Beate Sander
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
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Ababneh MA, Rababa'h AM, Almomani BA, Ayoub AM, Al-Azzam SI. A ten-year surveillance of P aeruginosa bloodstream infections in a tertiary care hospital: Trends and risk factors for mortality. Int J Clin Pract 2021; 75:e14409. [PMID: 34051030 DOI: 10.1111/ijcp.14409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Pseudomonas aeruginosa (P aeruginosa) is a leading cause of nosocomial bloodstream infections worldwide. This study aimed to evaluate the incidence of P aeruginosa bloodstream infections and to identify predictors of 30-day mortality. METHODS A retrospective study was conducted in an academic tertiary hospital in Jordan. The medical records of patients hospitalised over ten years (1 January 2008-31 December 2017) were reviewed to identify patients' positive blood culture of P aeruginosa. Annual incidence, antimicrobial susceptibility patterns and risk factors for 30-day mortality were analysed. RESULTS A total of 169 cases of P aeruginosa bloodstream infection were identified, with an overall incidence rate of 0.23 case/1000 admission. The overall crude 30-day mortality was 36.7%. Receipt of corticosteroids (OR = 4.5; P = .0017), severe sepsis and septic shock (OR = 2.7; P = .0476), admission to intensive care unit (OR = 5.9; P = .0004), end-stage renal disease (OR = 4.1; P = .0123), inappropriate empirical therapy (OR = 3.2; P = .0143) and inappropriate definitive therapy (OR = 2.9; P = .0110) were identified as independent risk factors for mortality. CONCLUSION The annual incidence of P aeruginosa BSIs was fluctuating over ten years period. Several predictors for 30-day mortality in patients with P aeruginosa BSIs were identified, including inappropriate empirical and definitive therapy.
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Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Abeer M Rababa'h
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Basima A Almomani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Abeer M Ayoub
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sayer I Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Rehman A, Jeukens J, Levesque RC, Lamont IL. Gene-Gene Interactions Dictate Ciprofloxacin Resistance in Pseudomonas aeruginosa and Facilitate Prediction of Resistance Phenotype from Genome Sequence Data. Antimicrob Agents Chemother 2021; 65:e0269620. [PMID: 33875431 PMCID: PMC8218647 DOI: 10.1128/aac.02696-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/10/2021] [Indexed: 12/12/2022] Open
Abstract
Ciprofloxacin is one of the most widely used antibiotics for treating Pseudomonas aeruginosa infections. However, P. aeruginosa acquires mutations that confer ciprofloxacin resistance, making treatment more difficult. Resistance is multifactorial, with mutations in multiple genes influencing the resistance phenotype. However, the contributions of individual mutations and mutation combinations to the amounts of ciprofloxacin that P. aeruginosa can tolerate are not well understood. Engineering P. aeruginosa strain PAO1 to contain mutations in any one of the resistance-associated genes gyrA, nfxB, rnfC, parC, and parE showed that only gyrA mutations increased the MIC for ciprofloxacin. Mutations in parC and parE increased the MIC of a gyrA mutant, making the bacteria ciprofloxacin resistant. Mutations in nfxB and rnfC increased the MIC, conferring resistance, only if both were mutated in a gyrA background. Mutations in all of gyrA, nfxB, rnfC, and parC/E further increased the MIC. These findings reveal an epistatic network of gene-gene interactions in ciprofloxacin resistance. We used this information to predict ciprofloxacin resistance/susceptibility for 274 isolates of P. aeruginosa from their genome sequences. Antibiotic susceptibility profiles were predicted correctly for 84% of the isolates. The majority of isolates for which prediction was unsuccessful were ciprofloxacin resistant, demonstrating the involvement of additional as yet unidentified genes and mutations in resistance. Our data show that gene-gene interactions can play an important role in antibiotic resistance and can be successfully incorporated into models predicting resistance phenotype.
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Affiliation(s)
- Attika Rehman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Julie Jeukens
- Institut de biologie intégrative et des systèmes (IBIS), Université Laval, Quebec City, Québec, Canada
| | - Roger C. Levesque
- Institut de biologie intégrative et des systèmes (IBIS), Université Laval, Quebec City, Québec, Canada
| | - Iain L. Lamont
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
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Habyarimana T, Murenzi D, Musoni E, Yadufashije C, N Niyonzima F. Bacteriological Profile and Antimicrobial Susceptibility Patterns of Bloodstream Infection at Kigali University Teaching Hospital. Infect Drug Resist 2021; 14:699-707. [PMID: 33654414 PMCID: PMC7914060 DOI: 10.2147/idr.s299520] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/12/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Worldwide, bacterial bloodstream infections (BSIs) constitute an important cause of morbidity and mortality in clinical settings. Due to the limited laboratory facilities in sub-Saharan Africa, poor diagnosis of BSIs results in poor clinical outcomes and leads to a risk of antimicrobial resistance. The present work was carried out to describe the microbiological features of BSIs using the data collected from Centre Hospitalier Universitaire de Kigali (CHUK). METHODS A retrospective study was carried out at CHUK. The blood culture results of 2,910 cases - from adults, children and infants - were reviewed in the Microbiology service from October 2017 to October 2018. The following variables were considered: age, gender, admitting department, blood culture results, and antimicrobials sensitivity test results. Data were entered and analyzed using Microsoft Excel 2013. RESULTS Twelve percent (341/2,910) of blood culture results reviewed were positive with 108 (31.7%) Gram positive bacteria and 233 (68.3%) Gram negative bacteria. The most prevalent pathogens were Klebsiella pneumoniae 108 (31.7%) and Staphylococcus aureus 100 (29.3%). This study revealed a high resistance to commonly prescribed antibiotics such as penicillin, trimethoprim sulfamethoxazole, and Ampicillin with 91.8, 83.3, and 81.8% of resistance, respectively. However, bacteria were sensitive to imipenem and vancomycin with 98.1 and 94.3% of sensitivity, respectively. The pediatrics and neonatology departments showed a high number of positive culture with 97/341 (28.4%), and 93/341 (27%) respectively. The overall prevalence of multidrug resistance was 77.1%. CONCLUSION The prevalence of bacterial pathogens in BSIs was found to be high. The antibiotic resistance to the commonly used antibiotics was high. Appropriate treatment of BSIs should be based on the current knowledge of bacterial resistance pattern. This study will help in formulating management of diagnostic guidelines and antibiotic policy.
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Affiliation(s)
| | - Didier Murenzi
- Pathology Department, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Emile Musoni
- Pathology Department, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
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Lodise TP, Kanakamedala H, Hsu WC, Cai B. Impact of Incremental Delays in Appropriate Therapy on the Outcomes of Hospitalized Adult Patients with Gram-negative Bloodstream Infections: "Every day matters". Pharmacotherapy 2020; 40:889-901. [PMID: 33112456 DOI: 10.1002/phar.2446] [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: 11/09/2022]
Abstract
BACKGROUND Serious bloodstream infections (BSIs) are often caused by Gram-negative (GN) bacteria in hospitalized patients. Treatment of these infections has been further complicated by the continued rise and spread of drug-resistant pathogens, including carbapenem resistant (CR) strains of Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa. METHODS This retrospective cohort analysis used real-world data from a large United States hospital-based database to examine the association between key clinical outcomes and different lengths of time to appropriate treatment between October 2010 and September 2015. RESULTS Of 40,549 patients with GN-BSIs who were identified, 1117 (2.8%) had a CR GN-BSI. Overall, outcomes of hospitalized adult patients with GN-BSIs incrementally worsened the longer appropriate therapy was delayed. Patients with CR GN-BSIs had a median infection-associated length of stay (LOS) of 8, 9, 10, and 13 days, whereas patients with CS GN-BSIs had a median infection-associated LOS of 6, 7, 8, and 11 days for patients with days to appropriate therapy of 0, 1-2, 3-4, and ≥ 5 days, respectively. Among patients with CR GN-BSIs, the percentage of patients discharged home was 38%, 33%, 35%, and 31%, whereas in patients with CS GN-BSIs, the percentage of patients discharged home was 58%, 53%, 48%, and 43% for patients with days to appropriate therapy of 0, 1-2, 3-4, and ≥ 5 days, respectively. CONCLUSION The findings from this study highlight the clear need to deliver appropriate therapy more expeditiously in patients with CS and CR GN-BSIs.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | | | | | - Bin Cai
- Shionogi Inc, Florham Park, New Jersey, USA
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12
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Evans RN, Pike K, Rogers CA, Reynolds R, Stoddart M, Howe R, Wilcox M, Wilson P, Gould FK, MacGowan A. Modifiable healthcare factors affecting 28-day survival in bloodstream infection: a prospective cohort study. BMC Infect Dis 2020; 20:545. [PMID: 32711452 PMCID: PMC7382856 DOI: 10.1186/s12879-020-05262-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 07/16/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Bloodstream infection is common in the UK and has significant mortality depending on the pathogen involved, site of infection and other patient factors. Healthcare staffing and ward activity may also impact on outcomes in a range of conditions, however there is little specific National Health Service (NHS) data on the impact for patients with bloodstream infection. Bloodstream Infections - Focus on Outcomes is a multicentre cohort study with the primary aim of identifying modifiable risk factors for 28-day mortality in patients with bloodstream infection due to one of six key pathogens. METHODS Adults under the care of five NHS Trusts in England and Wales between November 2010 and May 2012 were included. Multivariable Cox regression was used to quantify the association between modifiable risk factors, including staffing levels and timing of appropriate therapy, and 28-day mortality, after adjusting for non-modifiable risk factors such as patient demographics and long-term comorbidities. RESULTS A total of 1676 patients were included in the analysis population. Overall, 348/1676 (20.8%) died within 28 days. Modifiable factors associated with 28-day mortality were ward speciality, ward activity (admissions and discharges), movement within ward speciality, movement from critical care, and time to receipt of appropriate antimicrobial therapy in the first 7 days. For each additional admission or discharge per 10 beds, the hazard increased by 4% (95% CI 1 to 6%) in medical wards and 11% (95% CI 4 to 19%) in critical care. Patients who had moved wards within speciality or who had moved out of a critical care ward had a reduction in hazard of mortality. In the first 7 days, hazard of death increased with increasing time to receipt of appropriate antimicrobial therapy. CONCLUSION This study underlines the importance of appropriate antimicrobials within the first 7 days, and the potential for ward activity and ward movements to impact on survival in bloodstream infection.
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Affiliation(s)
- Rebecca N Evans
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK.
| | - Katie Pike
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
| | - Rosy Reynolds
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Robin Howe
- Public Health Wales, Microbiology, Cardiff University Hospital of Wales, Cardiff, UK
| | - Mark Wilcox
- Department of Microbiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter Wilson
- Clinical Microbiology, UCLH NHS Foundation Trust, London, UK
| | - F Kate Gould
- Department of Medical Microbiology, Freeman Hospital, Newcastle-upon-Tyne NHS Trust, Newcastle-Upon-Tyne, UK
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13
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Lambregts MMC, Wijnakker R, Bernards AT, Visser LG, le Cessie S, de Boer MGJ. Mortality after Delay of Adequate Empiric Antimicrobial Treatment of Bloodstream Infection. J Clin Med 2020; 9:E1378. [PMID: 32392843 PMCID: PMC7290963 DOI: 10.3390/jcm9051378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Timely empiric antimicrobial therapy is one of the cornerstones of the management of suspected bloodstream infection (BSI). However, studies about the effects of empiric therapy on mortality have reported inconsistent results. The objective of this study was to estimate the effect of delay of appropriate empiric therapy on early mortality in patients with BSI. Methods: Data for the propensity score matching (PSM) study were obtained from a cohort of patients with BSI. Inadequate empiric treatment was defined as in vitro resistance to the antimicrobial regimen administered <6 h after blood cultures were taken. The primary outcome measure was 14-day mortality. Thirty-day mortality and median length of stay (LOS) were secondary outcomes. PSM was applied to control for confounding. Results: Of a total of 893 included patients with BSI, 35.7% received inadequate initial empiric treatment. In the PSM cohort (n = 334), 14-day mortality was 9.6% for inadequate antibiotic treatment, compared to. 10.2% in adequate empiric treatment (p = 0.85). No prolonged median LOS was observed in patients who initially received inadequate therapy (10.5 vs. 10.7 days, p = 0.89). Conclusions: In this study, we found no clear effect of inadequate empirical treatment on mortality in a low-risk BSI population. The importance of early empiric therapy compared to other determinants, may be limited. This may not apply for specific subpopulations, e.g., patients with sepsis.
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Affiliation(s)
- Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (R.W.); (L.G.V.); (M.G.J.d.B.)
| | - Roos Wijnakker
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (R.W.); (L.G.V.); (M.G.J.d.B.)
| | - Alexandra T. Bernards
- Department of Medical Microbiology, Leiden University Medical Center, 2333ZA Leiden, The Netherlands;
| | - Leo G. Visser
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (R.W.); (L.G.V.); (M.G.J.d.B.)
| | - Saskia le Cessie
- Department of Clinical Epidemiology and Department of Biomedical Data Sciences, Leiden University Medical Center, 2333ZA Leiden, The Netherlands;
| | - Mark G. J. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, The Netherlands; (R.W.); (L.G.V.); (M.G.J.d.B.)
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14
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Grant JM, Porter C, Charles MK, Bryce E, Wong T, Stefanovic A, Shajari S, Roscoe DL. Potential influence of rapid diagnostics on timeliness of management decisions for patients with positive blood cultures. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2020; 5:21-28. [PMID: 36339013 PMCID: PMC9603315 DOI: 10.3138/jammi.2019-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/22/2019] [Indexed: 06/16/2023]
Abstract
Background The Accelerate Pheno system (AXDX) provides rapid identification (ID; 90 minutes) and antimicrobial susceptibility testing (AST; approximately 7 hours) from positive blood culture (BC) bottles. We assessed the potential of AXDX results to influence more timely antibiotic interventions with a convenience sample of 158 positive BCs. Methods BCs with a mono-microbial Gram stain likely to be on the AXDX panel were run in parallel with the standard of care (SOC). Using results from the SOC, the medical microbiologist on call (MMOC) noted interventions made at the time of BC Gram stain and when ID and AST results were available. The timing of MMOC intervention was noted and compared with fastest potential SOC time and AXDX time. Results Of 158 specimens selected for analysis, 144 were evaluable. ID was available 11.9 hours and AST 27.7 hours faster than SOC. Correct ID was provided for 85.2% of specimens and AST for 59.0% of specimens, with 97.5% essential agreement compared with the SOC. One hundred and thirteen clinical interventions were made on 100 specimens: 54.9% were narrowing; 33.6%, escalation; 6.2%, consultation with ID; and 3.5%, further investigation. If AXDX data had been used immediately once available, interventions would have been possible 24 hours earlier for ID interventions and 39 hours earlier for AST results. Conclusions Results from rapid diagnostic panels such as AXDX have the potential to support timely antimicrobial de-escalation and other decisions to benefit patients, especially if paired with stewardship interventions.
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Affiliation(s)
- Jennifer M Grant
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Charlene Porter
- Department of Pathology and Laboratory Medicine, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Marthe K Charles
- Department of Pathology and Laboratory Medicine, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Elizabeth A Bryce
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Titus Wong
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Aleksandra Stefanovic
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Salomeh Shajari
- Department of Quality and Patient Safety, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Diane L Roscoe
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Souhail B, Le Maréchal M, Manuello R, Chrétien R, Charlot P, Déroudilhes G, Della Guardia M, Blanc V, Fribourg A, Degand N, Roger PM. Antibiotic therapy for Enterococcus bacteraemia: warning for the antimicrobial stewardship team. Eur J Clin Microbiol Infect Dis 2019; 38:2087-2095. [DOI: 10.1007/s10096-019-03645-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/15/2019] [Indexed: 01/23/2023]
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16
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Collazos-Blanco A, Pérez-García F, Sánchez-Carrillo C, de Egea V, Muñoz P, Bouza E. Estimation of missed bloodstream infections without the third blood culture set: a retrospective observational single-centre study. Clin Microbiol Infect 2018; 25:469-473. [PMID: 29964233 DOI: 10.1016/j.cmi.2018.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The question of whether to obtain two or three sets of blood cultures to assess the aetiology of bloodstream infections (BSIs) remains open to debate. Few studies have assessed the proportion of BSIs missed without the third blood culture set (BCS). The aim of our study was to determine the proportion of BSIs that would be missed without the third BCS in a hospital where obtaining three BCSs is the standard of care. METHODS We performed a descriptive retrospective study in Hospital Gregorio Marañón (Madrid) from 2010 to 2013. We included all episodes of BSI in which three BCSs were systematically obtained. RESULTS We included 4000 episodes of BSI between 2010 and 2013. Without the third BCS, we would have missed 298 (7.5%) episodes of BSI: 141 (47.3%) by gram-positive microorganisms, 147 (49.3%) by gram-negative microorganisms, and 10 (3.4%) by yeasts. In 132/298 (44.3%) of the episodes another clinical sample was obtained within a week of the BCS extraction; in 101/298 (33.9%), the same microorganism was present in a significant clinical sample other than blood. CONCLUSIONS Our data suggest that performing a third BCS is useful, as not doing this could result in an unacceptable number of BSIs going undetected.
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Affiliation(s)
- A Collazos-Blanco
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - F Pérez-García
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - C Sánchez-Carrillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - V de Egea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, Universidad Complutense de Madrid, Spain; CIBER Enfermedades Respiratorias (CB06/06/0058), Spain
| | - E Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, Universidad Complutense de Madrid, Spain; CIBER Enfermedades Respiratorias (CB06/06/0058), Spain
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Dik JWH, Friedrich AW, Nathwani D, Sinha B. Combating the Complex Global Challenge of Antimicrobial Resistance: What can Antimicrobial Stewardship Contribute? Infect Dis Rep 2017; 9:7158. [PMID: 28458802 PMCID: PMC5391536 DOI: 10.4081/idr.2017.7158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 12/12/2022] Open
Abstract
Not available
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Affiliation(s)
- Jan-Willem H Dik
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Alexander W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | | | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, the Netherlands
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