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Loftus MJ, Young-Sharma T, Lee SJ, Wati S, Badoordeen GZ, Blakeway LV, Byers S, Cheng AC, Cooper BS, Cottingham H, Jenney A, Hawkey J, Macesic N, Naidu R, Prasad A, Prasad V, Tudravu L, Vakatawa T, van Gorp E, Wisniewski JA, Rafai E, Peleg AY, Stewardson AJ. Attributable Mortality and Excess Length of Stay associated with Third-Generation Cephalosporin Resistant Enterobacterales Bloodstream Infections - a prospective cohort study in Suva, Fiji. J Glob Antimicrob Resist 2022; 30:286-293. [PMID: 35738385 PMCID: PMC9452645 DOI: 10.1016/j.jgar.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/11/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji. METHODS We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and multistate modelling to estimate the excess length of hospital stay. RESULTS From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs, 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio (aHR) 1.13, 95% CI 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission. CONCLUSION Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.
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Affiliation(s)
- M J Loftus
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | | | - S J Lee
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - S Wati
- Colonial War Memorial Hospital, Suva, Fiji
| | - G Z Badoordeen
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - L V Blakeway
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Smh Byers
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - B S Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, The United Kingdom; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - H Cottingham
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Awj Jenney
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Fiji National University, Suva, Fiji
| | - J Hawkey
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - N Macesic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Centre to Impact AMR, Monash University, Melbourne, Australia
| | - R Naidu
- Colonial War Memorial Hospital, Suva, Fiji
| | - A Prasad
- Colonial War Memorial Hospital, Suva, Fiji
| | - V Prasad
- Colonial War Memorial Hospital, Suva, Fiji
| | - L Tudravu
- Colonial War Memorial Hospital, Suva, Fiji
| | - T Vakatawa
- Colonial War Memorial Hospital, Suva, Fiji
| | - E van Gorp
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - J A Wisniewski
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - E Rafai
- Fiji Ministry of Health and Medical Services, Suva, Fiji
| | - A Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia.
| | - A J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.
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Henderson A, Paterson DL, Chatfield MD, Tambyah PA, Lye DC, De PP, Lin RTP, Chew KL, Yin M, Lee TH, Yilmaz M, Cakmak R, Alenazi TH, Arabi YM, Falcone M, Bassetti M, Righi E, Ba R, Kanj SS, Bhally H, Iredell J, Mendelson M, Boyles TH, Looke DFM, Runnegar NJ, Miyakis S, Walls G, Ai Khamis M, Zikri A, Crowe A, Ingram PR, Daneman NN, Griffin P, Athan E, Roberts L, Beatson SA, Peleg AY, Cottrell KK, Bauer MJ, Tan E, Chaw K, Nimmo GR, Harris-Brown T, Harris PNA. Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study. Clin Infect Dis 2020; 73:e3842-e3850. [PMID: 33106863 DOI: 10.1093/cid/ciaa1479] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. METHODS Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. RESULTS 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%). CONCLUSION After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.
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Affiliation(s)
- A Henderson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD
| | - D L Paterson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - M D Chatfield
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - P A Tambyah
- Department of Infectious Diseases, National University Hospital, Singapore
| | - D C Lye
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore,Hospital, Singapore
| | - P P De
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
| | - R T P Lin
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - K L Chew
- Division of Microbiology, National University Hospital, Singapore
| | - M Yin
- Department of Infectious Diseases, National University Hospital, Singapore
| | - T H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - M Yilmaz
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - R Cakmak
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - T H Alenazi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Y M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - M Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - M Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino Genoa, Italy
| | - E Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Santa Maria Misericordia Hospital, Udine, Italy.,Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rogers Ba
- Monash University, Centre for Inflammatory Diseases, Victoria, Australia.,Monash Infectious Diseases, Monash Health, Victoria, Australia
| | - S S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - H Bhally
- Department of Medicine and Infectious Diseases, North Shore Hospital, Auckland
| | - J Iredell
- Marie Bashir Institute for Infectious Disease and Biosecurity, University of Sydney, Sydney, Australia.,Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, Australia
| | - M Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - T H Boyles
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D F M Looke
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, Australia
| | - N J Runnegar
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, Australia
| | - S Miyakis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.,Department of Infectious Diseases, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - G Walls
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - M Ai Khamis
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - A Zikri
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - A Crowe
- Department of Infectious Diseases, St Vincent's Hospital, Melbourne, Australia.,Department of Microbiology, St Vincent's Hospital, Melbourne, Australia
| | - P R Ingram
- School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch , Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia
| | - N N Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - P Griffin
- University of Queensland, Brisbane, Australia.,Department of Medicine and Infectious Diseases, Mater Hospital and Mater Medical Research Institute, Brisbane, Australia.,QIMR Berghofer, Brisbane, Queensland, Australia
| | - E Athan
- Department of Infectious Diseases, Barwon Health and Deakin University, Geelong, Victoria, Australia
| | - L Roberts
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, The University of Queensland, Queensland, Australia
| | - S A Beatson
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, The University of Queensland, Queensland, Australia
| | - A Y Peleg
- Infection & Immunity Program, Biomedicine Discovery Institute, Monash University, Clayton, Australia.,Department of Microbiology, Monash University, Clayton, Australia
| | - K K Cottrell
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - M J Bauer
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - E Tan
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - K Chaw
- Department of Microbiology, Pathology Queensland, Toowoomba Laboratory, Australia.,Department of Microbiology, Mater Pathology, Australia.,Infectious Diseases Department, Redcliffe Hospital, Australia
| | - G R Nimmo
- Department of Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - T Harris-Brown
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - P N A Harris
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Department of Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Loftus MJ, Curtis SJ, Naidu R, Cheng AC, Jenney AWJ, Mitchell BG, Russo PL, Rafai E, Peleg AY, Stewardson AJ. Prevalence of healthcare-associated infections and antimicrobial use among inpatients in a tertiary hospital in Fiji: a point prevalence survey. Antimicrob Resist Infect Control 2020; 9:146. [PMID: 32859255 PMCID: PMC7456377 DOI: 10.1186/s13756-020-00807-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/19/2020] [Indexed: 12/03/2022] Open
Abstract
Background Healthcare-associated infections (HAIs) and antimicrobial use (AMU) are important drivers of antimicrobial resistance, yet there is minimal data from the Pacific region. We sought to determine the point prevalence of HAIs and AMU at Fiji’s largest hospital, the Colonial War Memorial Hospital (CWMH) in Suva. A secondary aim was to evaluate the performance of European Centre for Diseases Prevention and Control (ECDC) HAI criteria in a resource-limited setting. Methods We conducted a point prevalence survey of HAIs and AMU at CWMH in October 2019. Survey methodology was adapted from the ECDC protocol. To evaluate the suitability of ECDC HAI criteria in our setting, we augmented the survey to identify patients with a clinician diagnosis of a HAI where diagnostic testing criteria were not met. We also assessed infection prevention and control (IPC) infrastructure on each ward. Results We surveyed 343 patients, with median (interquartile range) age 30 years (16–53), predominantly admitted under obstetrics/gynaecology (94, 27.4%) or paediatrics (83, 24.2%). Thirty patients had one or more HAIs, a point prevalence of 8.7% (95% CI 6.0% to 12.3%). The most common HAIs were surgical site infections (n = 13), skin and soft tissue infections (7) and neonatal clinical sepsis (6). Two additional patients were identified with physician-diagnosed HAIs that failed to meet ECDC criteria due to insufficient investigations. 206 (60.1%) patients were receiving at least one antimicrobial. Of the 325 antimicrobial prescriptions, the most common agents were ampicillin (58/325, 17.8%), cloxacillin (55/325, 16.9%) and metronidazole (53/325, 16.3%). Use of broad-spectrum agents such as piperacillin/tazobactam (n = 6) and meropenem (1) was low. The majority of prescriptions for surgical prophylaxis were for more than 1 day (45/76, 59.2%). Although the number of handwashing basins throughout the hospital exceeded World Health Organization recommendations, availability of alcohol-based handrub was limited and most concentrated within high-risk wards. Conclusions The prevalence of HAIs in Fiji was similar to neighbouring high-income countries, but may have been reduced by the high proportion of paediatric and obstetrics patients, or by lower rates of inpatient investigations. AMU was very high, with duration of surgical prophylaxis an important target for future antimicrobial stewardship initiatives.
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Affiliation(s)
- M J Loftus
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - S J Curtis
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - R Naidu
- Colonial War Memorial Hospital, Suva, Fiji
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A W J Jenney
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.,Fiji National University, Suva, Fiji
| | - B G Mitchell
- School of Nursing and Midwifery, University of Newcastle, Callaghan, Australia
| | - P L Russo
- Department of Nursing Research, Cabrini Institute, Malvern, Australia.,Department of Nursing and Midwifery, Monash University, Frankston, Australia
| | - E Rafai
- Fiji Ministry of Health and Medical Services, Suva, Fiji
| | - A Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia. .,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia.
| | - A J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.
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Smibert OC, Aung AK, Woolnough E, Carter GP, Schultz MB, Howden BP, Seemann T, Spelman D, McGloughlin S, Peleg AY. Mobile phones and computer keyboards: unlikely reservoirs of multidrug-resistant organisms in the tertiary intensive care unit. J Hosp Infect 2018; 99:295-298. [PMID: 29501730 DOI: 10.1016/j.jhin.2018.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/09/2018] [Indexed: 11/24/2022]
Abstract
Few studies have used molecular epidemiological methods to study transmission links to clinical isolates in intensive care units. Ninety-four multidrug-resistant organisms (MDROs) cultured from routine specimens from intensive care unit (ICU) patients over 13 weeks were stored (11 meticillin-resistant Staphylococcus aureus (MRSA), two vancomycin-resistant enterococci and 81 Gram-negative bacteria). Medical staff personal mobile phones, departmental phones, and ICU keyboards were swabbed and cultured for MDROs; MRSA was isolated from two phones. Environmental and patient isolates of the same genus were selected for whole genome sequencing. On whole genome sequencing, the mobile phone isolates had a pairwise single nucleotide polymorphism (SNP) distance of 183. However, >15,000 core genome SNPs separated the mobile phone and clinical isolates. In a low-endemic setting, mobile phones and keyboards appear unlikely to contribute to hospital-acquired MDROs.
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Affiliation(s)
- O C Smibert
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - A K Aung
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - E Woolnough
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - G P Carter
- Melbourne Diagnostic Unit, Doherty Institute, University of Melbourne, Victoria, Australia
| | - M B Schultz
- Melbourne Diagnostic Unit, Doherty Institute, University of Melbourne, Victoria, Australia
| | - B P Howden
- Melbourne Diagnostic Unit, Doherty Institute, University of Melbourne, Victoria, Australia
| | - T Seemann
- Melbourne Diagnostic Unit, Doherty Institute, University of Melbourne, Victoria, Australia
| | - D Spelman
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - S McGloughlin
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - A Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Infection and Immunity Program, Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
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5
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Cameron DR, Lin YH, Trouillet-Assant S, Tafani V, Kostoulias X, Mouhtouris E, Skinner N, Visvanathan K, Baines SL, Howden B, Monk IR, Laurent F, Stinear TP, Howden BP, Peleg AY. Vancomycin-intermediate Staphylococcus aureus isolates are attenuated for virulence when compared with susceptible progenitors. Clin Microbiol Infect 2017; 23:767-773. [PMID: 28396035 DOI: 10.1016/j.cmi.2017.03.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/29/2017] [Accepted: 03/30/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Vancomycin-intermediate Staphylococcus aureus (VISA) is associated with genetic changes that may also impact upon pathogenicity. In the current study, we compared the virulence of clinical VISA strains with their isogenic vancomycin-susceptible progenitors (VSSA). METHODS Production of the critical virulence protein, α toxin, was assessed using Western blot analysis and was correlated to agr activity using a bioluminescent agr-reporter. Cytotoxicity and intracellular persistence were compared ex vivo for VSSA and VISA within non-professional phagocytes (NPP). Virulence and host immune responses were further explored in vivo using a murine model of bacteraemia. RESULTS VISA isolates produced up to 20-fold less α toxin compared with VSSA, and this was corroborated by either loss of agr activity due to agr mutation, or altered agr activity in the absence of mutation. VISA were less cytotoxic towards NPP and were associated with enhanced intracellular persistence, suggesting that NPP may act as a reservoir for VISA. Infection with VSSA strains produced higher mortality in a murine bacteraemia model (≥90% 7-day mortality) compared with infection with VISA isolates (20% to 50%, p <0.001). Mice infected with VISA produced a dampened immune response (4.6-fold reduction in interleukin-6, p <0.001) and persistent organ bacterial growth was observed for VISA strains out to 7 days. CONCLUSIONS These findings highlight the remarkable adaptability of S. aureus, whereby, in addition to having reduced antibiotic susceptibility, VISA alter the expression of pathogenic factors to circumvent the host immune response to favour persistent infection over acute virulence.
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Affiliation(s)
- D R Cameron
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Australia
| | - Y-H Lin
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia
| | - S Trouillet-Assant
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, International Centre of Infectiology Research, France
| | - V Tafani
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, International Centre of Infectiology Research, France
| | - X Kostoulias
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Australia
| | - E Mouhtouris
- Department of Surgery, The University of Melbourne, Australia
| | - N Skinner
- Department of Medicine, The University of Melbourne, Australia
| | - K Visvanathan
- Department of Medicine, The University of Melbourne, Australia
| | - S L Baines
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia
| | - B Howden
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia
| | - I R Monk
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia
| | - F Laurent
- Department of Microbiology, French National Reference Centre for Staphylococci, Hospices Civils de Lyon, International Centre of Infectiology Research, France
| | - T P Stinear
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia
| | - B P Howden
- Department of Microbiology and Immunology, The University of Melbourne at the Doherty Institute of Infection & Immunity, Australia; Infectious Diseases and Microbiology Departments, Austin Health, Australia.
| | - A Y Peleg
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Australia; Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Australia.
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6
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Macesic N, Morrissey CO, Cheng AC, Spencer A, Peleg AY. Changing microbial epidemiology in hematopoietic stem cell transplant recipients: increasing resistance over a 9-year period. Transpl Infect Dis 2014; 16:887-96. [PMID: 25298044 DOI: 10.1111/tid.12298] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 06/03/2014] [Accepted: 07/12/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED Infections remain important contributors to mortality in hematopoietic stem cell transplantation (HSCT). METHOD We studied the evolving epidemiology and trends in susceptibility of bacterial and Candida isolates at an Australian HSCT center. A total of 528 HSCTs in 508 patients were performed from April 2001 to May 2010. A total of 605 isolates were eligible for study inclusion; 318 (53%) were gram-positive, 268 (44%) were gram-negative, and 19 (3%) were Candida species. RESULTS The most common site for isolates was blood (380 isolates, 63%). Staphylococcus aureus was the most common gram-positive organism (n = 107, 34%), but trends to increasing coagulase-negative staphylococci (P = 0.002) and vancomycin-resistant Enterococcus (P < 0.001) were observed. Escherichia coli was the most common gram-negative isolate (n = 74, 28%). Fluoroquinolone resistance increased with widespread use of protocol fluoroquinolone prophylaxis (P = 0.001). Carbapenem resistance was found in 44% of Pseudomonas or Acinetobacter isolates. Bloodstream infection with a multidrug-resistant organism (odds ratio 3.61, 95% confidence interval: 1.40-9.32, P = 0.008) was an independent predictor of mortality at 7 days after a positive blood culture. CONCLUSIONS Antimicrobial resistance is an increasing problem in this vulnerable patient population, and not only has an impact on choice of empiric therapy for febrile neutropenia but also on mortality.
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Affiliation(s)
- N Macesic
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
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7
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Qureshi ZA, Paterson DL, Peleg AY, Adams-Haduch JM, Shutt KA, Pakstis DL, Sordillo E, Polsky B, Sandkovsky G, Bhussar MK, Doi Y. Clinical characteristics of bacteraemia caused by extended-spectrum β-lactamase-producing Enterobacteriaceae in the era of CTX-M-type and KPC-type β-lactamases. Clin Microbiol Infect 2011; 18:887-93. [PMID: 21951551 DOI: 10.1111/j.1469-0691.2011.03658.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Clin Microbiol Infect 2012; 18: 887-893 ABSTRACT: A multicentre, case-control study was conducted to assess risk factors and patient outcomes of bacteraemia caused by Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) and Klebsiella pneumoniae carbapenemases (KPCs). One hundred and five and 20 patients with bacteraemia caused by ESBL-producing and KPC-producing organisms were matched to controls who had bacteraemia caused by non-ESBL/KPC-producing organisms, respectively. Independent risk factors for ESBL production included admission from a nursing home (OR 4.64; 95% CI 2.64-8.16), chronic renal failure (OR 2.09; 95% CI 1.11-3.92), the presence of a gastrostomy tube (OR 3.36; 95% CI 1.38-8.18), length of hospital stay before infection (OR 1.02; 95% CI 1.01-1.03), transplant receipt (OR 2.48; 95% CI 1.24-4.95), and receipt of antibiotics with Gram-negative activity in the preceding 30 days (OR 1.76; 95% CI 1.00-3.08). Twenty-eight-day crude mortality rates for patients infected with ESBL-producing or KPC-producing organisms and controls were 29.1% (34/117) and 19.5% (53/272), respectively (OR 1.70; 95% CI 1.04-2.80). On multivariate analysis, inadequate empirical therapy (OR 2.26; 95% CI 1.18-4.34), onset of bacteraemia while in the intensive-care unit (OR 2.74; 95% CI 1.47-5.11), Apache II score (OR 1.17; 95% CI 1.12-1.23) and malignancy (OR 2.66; 95% CI 1.31-5.41) were independent risk factors for mortality. CTX-M was the most common ESBL type in Escherichia coli, whereas SHV predominated in Klebsiella spp. and Enterobacter spp.
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Affiliation(s)
- Z A Qureshi
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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Johnson LE, D'Agata EMC, Paterson DL, Clarke L, Qureshi ZA, Potoski BA, Peleg AY. Pseudomonas aeruginosa bacteremia over a 10-year period: multidrug resistance and outcomes in transplant recipients. Transpl Infect Dis 2009; 11:227-34. [PMID: 19302282 DOI: 10.1111/j.1399-3062.2009.00380.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM Transplant recipients are at risk for hospital-acquired infections (HAIs), including those caused by Pseudomonas aeruginosa. Of all HAIs, bloodstream infection (BSI) remains one of the most life-threatening. METHODS Over a 10-year period, we studied 503 patients, including 149 transplant recipients, with pseudomonal BSI from the University of Pittsburgh Medical Center. Trends in antimicrobial susceptibility, risk factors for multidrug resistance (MDR), and outcomes were compared between transplant and non-transplant patients. RESULTS Resistance to all antibiotic classes was significantly greater in pseudomonal blood culture isolates from transplant compared with non-transplant patients (P<0.001). Of isolates from transplant recipients (n=207), 43% were MDR, compared with 18% of isolates from non-transplant patients (n=391) (odds ratio [OR] 3.47; 95% confidence interval [CI] 2.34-5.14, P<0.001). Among all patients, independent risk factors for MDR P. aeruginosa BSI included previous transplantation (OR 2.38; 95% CI 1.51-3.76, P<0.001), hospital-acquired BSI (OR 2.41; 95% CI 1.39-4.18, P=0.002), and prior intensive care unit (ICU) admission (OR 2.04; 95% CI 1.15-3.63, P=0.015). Mortality among transplant recipients was 42%, compared with 32% in non-transplant patients (OR 1.55; 95% CI 0.87-2.76, P=0.108). For transplant recipients, onset of BSI in the ICU was the only independent predictor of mortality (OR 8.00; 95% CI 1.71-37.42, P=0.008). CONCLUSIONS Transplant recipients are at greater risk of MDR P. aeruginosa BSI, with an appreciable mortality. Future management must concentrate on the implementation of effective preventative strategies.
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Affiliation(s)
- L E Johnson
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Peleg AY, Tilahun Y, Fiandaca MJ, D'Agata EMC, Venkataraman L, Moellering RC, Eliopoulos GM. Utility of peptide nucleic acid fluorescence in situ hybridization for rapid detection of Acinetobacter spp. and Pseudomonas aeruginosa. J Clin Microbiol 2009; 47:830-2. [PMID: 19116347 PMCID: PMC2650942 DOI: 10.1128/jcm.01724-08] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/07/2008] [Accepted: 12/22/2008] [Indexed: 11/20/2022] Open
Abstract
The utility of peptide nucleic acid fluorescence in situ hybridization (PNA FISH) for the detection of Acinetobacter spp. and Pseudomonas aeruginosa was evaluated on broth suspensions and spiked blood cultures of ATCC strains and clinical isolates with select gram-negative rods. After testing 60 clinical isolates, PNA FISH had a sensitivity and specificity of 100% and 100%, respectively, for Acinetobacter spp. and 100% and 95%, respectively, for P. aeruginosa. PNA FISH was able to detect both pathogens simultaneously and directly from spiked blood cultures.
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Affiliation(s)
- A Y Peleg
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Manuel O, Humar A, Preiksaitis J, Doucette K, Shokoples S, Peleg AY, Cobos I, Kumar D. Comparison of quantiferon-TB gold with tuberculin skin test for detecting latent tuberculosis infection prior to liver transplantation. Am J Transplant 2007; 7:2797-801. [PMID: 17941955 DOI: 10.1111/j.1600-6143.2007.02011.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Screening for latent tuberculosis infection (LTBI) is recommended prior to organ transplantation. The Quantiferon-TB Gold assay (QFT-G) may be more accurate than the tuberculin skin test (TST) in the detection of LTBI. We prospectively compared the results of QFT-G to TST in patients with chronic liver disease awaiting transplantation. Patients were screened for LTBI with both the QFT-G test and a TST. Concordance between test results and predictors of a discordant result were determined. Of the 153 evaluable patients, 37 (24.2%) had a positive TST and 34 (22.2%) had a positive QFT-G. Overall agreement between tests was 85.1% (kappa= 0.60, p < 0.0001). Discordant test results were seen in 12 TST positive/QFT-G negative patients and in 9 TST negative/QFT-G positive patients. Prior BCG vaccination was not associated with discordant test results. Twelve patients (7.8%), all with a negative TST, had an indeterminate result of the QFT-G and this was more likely in patients with a low lymphocyte count (p = 0.01) and a high MELD score (p = 0.001). In patients awaiting liver transplantation, both the TST and QFT-G were comparable for the diagnosis of LTBI with reasonable concordance between tests. Indeterminate QFT-G result was more likely in those with more advanced liver disease.
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Affiliation(s)
- O Manuel
- Transplant Infectious Diseases, and Microbiology, University of Alberta, Edmonton, Alberta, Canada.
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Tong SYC, Peleg AY, Yoong J, Handke R, Szer J, Slavin M. Breakthrough Scedosporium prolificans infection while receiving voriconazole prophylaxis in an allogeneic stem cell transplant recipient. Transpl Infect Dis 2007; 9:241-3. [PMID: 17605752 DOI: 10.1111/j.1399-3062.2007.00203.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Breakthrough invasive fungal infections among patients with hematologic malignancies receiving voriconazole are being reported with increasing frequency, with zygomycete infections predominating. We report a case of disseminated Scedosporium prolificans infection in a patient receiving voriconazole prophylaxis. Despite poor in vitro activity of voriconazole for this organism, synergy studies using the checkerboard method demonstrated synergy with the combination of voriconazole and terbinafine. This regimen, in conjunction with central venous line removal and intravitreal voriconazole, contributed to the recovery of the patient. S. prolificans is a life-threatening mold that should be considered in patients with breakthrough invasive fungal infections while on voriconazole prophylaxis.
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Affiliation(s)
- S Y C Tong
- Victorian Infectious Diseases Service, Department of Microbiology, Royal Melbourne Hospital, Melbourne, Australia.
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Peleg AY, Munckhof WJ, Kleinschmidt SL, Stephens AJ, Huygens F. Life-threatening community-acquired methicillin-resistant Staphylococcus aureus infection in Australia. Eur J Clin Microbiol Infect Dis 2005; 24:384-7. [PMID: 15926063 DOI: 10.1007/s10096-005-1329-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Eight patients with invasive bacteremic community-acquired methicillin-resistant Staphylococcus aureus infection in southeast Queensland, Australia, are reported. One patient died of septic shock. Haematogenous seeding to lungs, bone, and other sites was common. All isolates carried the virulence factor Panton-Valentine leukocidin and were either the southwest Pacific clone or the newly described Queensland clone. Clinicians should consider community-acquired methicillin-resistant Staphylococcus aureus infection in any patient presenting to hospital with severe staphylococcal sepsis or pneumonia.
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Affiliation(s)
- A Y Peleg
- Infectious Diseases Unit, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria 3181, Australia.
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Peleg AY, Woods ML. Continuous and 4 h infusion of amphotericin B: a comparative study involving high-risk haematology patients. J Antimicrob Chemother 2004; 54:803-8. [PMID: 15308606 DOI: 10.1093/jac/dkh403] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess whether a continuous infusion of amphotericin B (CI-AmB) is less nephrotoxic than a 4 h infusion in haematology patients with fever and neutropenia, including bone-marrow transplant recipients. Efficacy was assessed as a secondary end-point. PATIENTS AND METHODS We conducted a retrospective cohort study over a 2 year period. A total of 1073 haematology admissions were reviewed (98.3% complete) and 81 admissions were eligible for study entry; 39 received CI-AmB and 42 a 4 h infusion of AmB. RESULTS Renal impairment occurred significantly less frequently with CI-AmB compared with a 4 h infusion of AmB [10% versus 45%, respectively, odds ratio (OR) 0.14; 95% confidence interval (CI) 0.04-0.5, P < 0.001]. The difference was maintained among allogeneic transplant recipients (P = 0.007) and patients receiving concurrent nephrotoxic drugs (P < 0.001). An AmB infusion rate of <0.08 mg/kg/h was associated with a significant reduction in renal impairment (P < 0.001). A difference in survival was observed between the continuous and 4 h infusion of AmB (95% versus 79%, respectively, OR 5.1; 95% CI 1.02-25.1, P = 0.03). CONCLUSIONS CI-AmB appears to be significantly less nephrotoxic than 4 h infusion AmB in haematology patients with fever and neutropenia--including high-risk bone-marrow transplant recipients--without increasing mortality. An AmB infusion rate of <0.08 mg/kg/h appears to be a safe threshold, associated with reduced renal impairment.
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Affiliation(s)
- A Y Peleg
- Infectious Diseases Unit, Department of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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