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Paniagua-García M, Bravo-Ferrer JM, Pérez-Galera S, Kostyanev T, de Kraker MEA, Feifel J, Palacios-Baena ZR, Schotsman J, Cantón R, Daikos GL, Carevic B, Dragovac G, Tan LK, Raka L, Hristea A, Viale P, Akova M, Cano Á, Reguera JM, Bartoloni A, Florescu SA, Benea S, Bukarica L, Asensio Á, Korten V, Grundmann H, Goossens H, Bonten MJ, Gutiérrez-Gutiérrez B, Rodríguez-Baño J. Attributable mortality of infections caused by carbapenem-resistant Enterobacterales: results from a prospective, multinational case-control-control matched cohorts study (EURECA). Clin Microbiol Infect 2024; 30:223-230. [PMID: 38267096 DOI: 10.1016/j.cmi.2023.11.008] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES To assess the mortality attributable to infections caused by carbapenem-resistant Enterobacterales (CRE) and to investigate the effect of clinical management on differences in observed outcomes in a multinational matched cohort study. METHODS A prospective matched-cohorts study (NCT02709408) was performed in 50 European hospitals from March 2016 to November 2018. The main outcome was 30-day mortality with an active post-discharge follow-up when applied. The CRE cohort included patients with complicated urinary tract infections, complicated intra-abdominal infections, pneumonia, or bacteraemia from other sources because of CRE. Two control cohorts were selected: patients with infection caused by carbapenem-susceptible Enterobacterales (CSE) and patients without infection. Matching criteria included type of infection for the CSE group, hospital ward of CRE detection, and duration of hospital admission up to CRE detection. Multivariable and stratified Cox regression was applied. RESULTS The cohorts included 235 patients with CRE infection, 235 patients with CSE infection, and 705 non-infected patients. The 30-day mortality (95% CI) was 23.8% (18.8-29.6), 10.6% (7.2-15.2), and 8.4% (6.5-10.6), respectively. The difference in 30-day mortality rates between patients with CRE infection when compared with patients with CSE infection was 13.2% (95% CI, 6.3-20.0), (HR, 2.57; 95% CI, 1.55-4.26; p < 0.001), and 15.4% (95% CI, 10.5-20.2) when compared with non-infected patients (HR, 3.85; 95% CI, 2.57-5.77; p < 0.001). The population attributable fraction for 30-day mortality for CRE vs. CSE was 19.28%, and for CRE vs. non-infected patients was 9.61%. After adjustment for baseline variables, the HRs for mortality were 1.87 (95% CI, 0.99-3.50; p 0.06) and 3.65 (95% CI, 2.29-5.82; p < 0.001), respectively. However, when treatment-related time-dependent variables were added, the HR of CRE vs. CSE reduced to 1.44 (95% CI, 0.78-2.67; p 0.24). DISCUSSION CRE infections are associated with significant attributable mortality and increased adjusted hazard of mortality when compared with CSE infections or patients without infection. Underlying patient characteristics and a delay in appropriate treatment play an important role in the CRE mortality.
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Affiliation(s)
- María Paniagua-García
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Jose M Bravo-Ferrer
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
| | - Salvador Pérez-Galera
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Tomislav Kostyanev
- Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Research Group for Global Capacity Building, National Food Institute, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jan Feifel
- Institute of Statistics, Ulm University, Ulm, Germany
| | - Zaira R Palacios-Baena
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
| | - Joost Schotsman
- Department of Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
| | - George L Daikos
- Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Gorana Dragovac
- University of Novi Sad, Faculty of Medicine and Institute of Public Health of Vojvodina, Novi Sad, Serbia
| | | | - Lul Raka
- University of Prishtina "Hasan Prishtina" and National Institute of Public Health of Kosovo, Prishtina, Kosovo
| | - Adriana Hristea
- University of Medicine and Pharmacy 'Carol Davila' Bucharest, Romania
| | | | - Murat Akova
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
| | - Ángela Cano
- CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/ Universidad de Córdoba (Departamento de Ciencias Médicas y Quirúrgicas), Córdoba, Spain
| | - Jose María Reguera
- Servicio de Enfermedades Infecciosas, Hospital Regional Universitario de Málaga/Ibima, Málaga, Spain
| | | | | | - Serban Benea
- University of Medicine and Pharmacy 'Carol Davila' Bucharest, Romania
| | | | - Ángel Asensio
- Preventive Medicine Department, Hospital Universitario Puerta del Hierro, Madrid, Spain
| | - Volkan Korten
- Marmara University School of Medicine, Istanbul, Turkey
| | - Hajo Grundmann
- Institute for Infection Prevention and Hospital Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Herman Goossens
- Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marc J Bonten
- Institute of Statistics, Ulm University, Ulm, Germany
| | - Belén Gutiérrez-Gutiérrez
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain.
| | - Jesús Rodríguez-Baño
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
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Pérez-Galera S, Bravo-Ferrer JM, Paniagua M, Kostyanev T, de Kraker ME, Feifel J, Sojo-Dorado J, Schotsman J, Cantón R, Daikos GL, Carevic B, Dragovac G, Tan LK, Raka L, Hristea A, Viale P, Akova M, Reguera JM, Valiente de Santis L, Torre-Cisneros J, Cano Á, Roilides E, Radulovic L, Kirakli C, Shaw E, Falagas ME, Pintado V, Goossens H, Bonten MJ, Gutiérrez-Gutiérrez B, Rodriguez-Baño J. Risk factors for infections caused by carbapenem-resistant Enterobacterales: an international matched case-control-control study (EURECA). EClinicalMedicine 2023; 57:101871. [PMID: 36895801 PMCID: PMC9989660 DOI: 10.1016/j.eclinm.2023.101871] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Data on risk factors for carbapenem-resistant Enterobacterales (CRE) with wider applicability are needed to inform preventive measures and efficient design of randomised trials. METHODS An international matched case-control-control study was performed in 50 hospitals with high CRE incidence from March 2016 to November 2018 to investigate different aspects of infections caused by CRE (NCT02709408). Cases were patients with complicated urinary tract infection (cUTI), complicated intraabdominal (cIAI), pneumonia or bacteraemia from other sources (BSI-OS) due to CRE; control groups were patients with infection caused by carbapenem-susceptible Enterobacterales (CSE), and by non-infected patients, respectively. Matching criteria included type of infection for CSE group, ward and duration of hospital admission. Conditional logistic regression was used to identify risk factors. FINDINGS Overall, 235 CRE case patients, 235 CSE controls and 705 non-infected controls were included. The CRE infections were cUTI (133, 56.7%), pneumonia (44, 18.7%), cIAI and BSI-OS (29, 12.3% each). Carbapenemase genes were found in 228 isolates: OXA-48/like, 112 (47.6%), KPC, 84 (35.7%), and metallo-β-lactamases, 44 (18.7%); 13 produced two. The risk factors for CRE infection in both type of controls were (adjusted OR for CSE controls; 95% CI; p value) previous colonisation/infection by CRE (6.94; 2.74-15.53; <0.001), urinary catheter (1.78; 1.03-3.07; 0.038) and exposure to broad spectrum antibiotics, as categorical (2.20; 1.25-3.88; 0.006) and time-dependent (1.04 per day; 1.00-1.07; 0.014); chronic renal failure (2.81; 1.40-5.64; 0.004) and admission from home (0.44; 0.23-0.85; 0.014) were significant only for CSE controls. Subgroup analyses provided similar results. INTERPRETATION The main risk factors for CRE infections in hospitals with high incidence included previous colonization, urinary catheter and exposure to broad spectrum antibiotics. FUNDING The study was funded by the Innovative Medicines Initiative Joint Undertaking (https://www.imi.europa.eu/) under Grant Agreement No. 115620 (COMBACTE-CARE).
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Affiliation(s)
- Salvador Pérez-Galera
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jose M. Bravo-Ferrer
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
| | - María Paniagua
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
| | - Tomislav Kostyanev
- Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Laboratoire National de Santé, Luxembourg, Luxembourg
| | - Marlieke E.A. de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jan Feifel
- Institute of Statistics, Ulm University, Ulm, Germany
| | - Jesús Sojo-Dorado
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
| | - Joost Schotsman
- Department of Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - George L. Daikos
- Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Gorana Dragovac
- Faculty of Medicine and Institute of Public Health of Vojvodina, University of Novi Sad, Novi Sad, Serbia
| | | | - Lul Raka
- University of Prishtina “Hasan Prishtina” and National Institute of Public Health of Kosovo, Prishtina, Kosovo
| | - Adriana Hristea
- University of Medicine and Pharmacy ‘Carol Davila’, Bucharest, Romania
| | | | - Murat Akova
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
| | - Jose María Reguera
- Servicio de Enfermedades Infecciosas, Hospital Regional Universitario de Málaga, Ibima, Málaga, Spain
| | - Lucía Valiente de Santis
- Servicio de Enfermedades Infecciosas, Hospital Regional Universitario de Málaga, Ibima, Málaga, Spain
| | - Julián Torre-Cisneros
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Enfermedades Infecciosas Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Universidad de Córdoba (Departamento de Ciencias Médicas y Quirúrgicas), Córdoba, Spain
| | - Ángela Cano
- Servicio de Enfermedades Infecciosas Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Universidad de Córdoba (Departamento de Ciencias Médicas y Quirúrgicas), Córdoba, Spain
| | - Emmanuel Roilides
- Hippokration General Hospital of Thessaloniki, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Cenk Kirakli
- Dr. Suat Seren Chest Diseases and Surgery Training Hospital, Izmir, Turkey
| | - Evelyn Shaw
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Institut d’Investigacions Biomèdiques de Bellvitge/IDIBELL, Barcelona, Spain
| | - Matthew E. Falagas
- Henry Dunant Hospital Center, Athens, Greece
- Metropolitan General Hospital, Athens, Greece
| | - Vicente Pintado
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Herman Goossens
- Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | | | - Belén Gutiérrez-Gutiérrez
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Rodriguez-Baño
- Unidad de Enfermedades y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Corresponding author. Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Avda Dr Fedriani 3, Seville 41009, Spain.
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El-Sokkary R, Uysal S, Erdem H, Kullar R, Pekok AU, Amer F, Grgić S, Carevic B, El-Kholy A, Liskova A, Özdemir M, Khan EA, Uygun-Kizmaz Y, Pandak N, Pandya N, Arapović J, Karaali R, Oztoprak N, Petrov MM, Alabadla R, Alay H, Kholy JAE, Landelle C, Khedr R, Mamtora D, Dragovac G, Fernandez R, Evren EU, Raka L, Cascio A, Dauby N, Oncul A, Balin SO, Cag Y, Dirani N, Dogan M, Dumitru IM, Gad MA, Darazam IA, Naghili B, Del Vecchio RF, Licker M, Marino A, Akhtar N, Kamal M, Angioni G, Medić D, Esmaoğlu A, Gergely SB, Silva-Pinto A, Santos L, Miftode IL, Tekin R, Wongsurakiat P, Khan MA, Kurekci Y, Pilli HP, Grozdanovski K, Miftode E, Baljic R, Vahabolgu H, Rello J. Profiles of multidrug-resistant organisms among patients with bacteremia in intensive care units: an international ID-IRI survey. Eur J Clin Microbiol Infect Dis 2021; 40:2323-2334. [PMID: 34155547 DOI: 10.1007/s10096-021-04288-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 03/28/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
Evaluating trends in antibiotic resistance is a requisite. The study aimed to analyze the profile of multidrug-resistant organisms (MDROs) among hospitalized patients with bacteremia in intensive care units (ICUs) in a large geographical area. This is a 1-month cross-sectional survey for blood-borne pathogens in 57 ICUs from 24 countries with different income levels: lower-middle-income (LMI), upper-middle-income (UMI), and high-income (HI) countries. Multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan-drug-resistant isolates were searched. Logistic regression analysis determined resistance predictors among MDROs. Community-acquired infections were comparable to hospital-acquired infections particularly in LMI (94/202; 46.5% vs 108/202; 53.5%). Although MDR (65.1%; 502/771) and XDR (4.9%; 38/771) were common, no pan-drug-resistant isolate was recovered. In total, 32.1% of MDR were Klebsiella pneumoniae, and 55.3% of XDR were Acinetobacter baumannii. The highest MDR and XDR rates were in UMI and LMI, respectively, with no XDR revealed from HI. Predictors of MDR acquisition were male gender (OR, 12.11; 95% CI, 3.025-15.585) and the hospital-acquired origin of bacteremia (OR, 2.643; 95%CI, 1.462-3.894), and XDR acquisition was due to bacteremia in UMI (OR, 3.344; 95%CI, 1.189-5.626) and admission to medical-surgical ICUs (OR, 1.481; 95% CI, 1.076-2.037). We confirm the urgent need to expand stewardship activities to community settings especially in LMI, with more paid attention to the drugs with a higher potential for resistance. Empowering microbiology laboratories and reports to direct prescribing decisions should be prioritized. Supporting stewardship in ICUs, the mixed medical-surgical ones in particular, is warranted.
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Affiliation(s)
- Rehab El-Sokkary
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Serhat Uysal
- Department of Infectious Diseases and Clinical Microbiology, Kanuni Research and Training Hospital, Trabzon, Turkey
| | | | | | | | - Fatma Amer
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Svjetlana Grgić
- Department of Infectious Diseases, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina
| | | | - Amani El-Kholy
- Department of Clinical Pathology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Anna Liskova
- Hospital Nitra, St. Elisabeth University of Health Care and Social Work, Bratislava, Slovak Republic
| | - Mehmet Özdemir
- Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ejaz Ahmed Khan
- Shifa International Hospital, Islamabad, Shifa Tameer e Millat University, Islamabad, Pakistan
| | - Yesim Uygun-Kizmaz
- Kartal Kosuyolu High Specialization Training and Research Hospital, Istanbul, Turkey
| | | | | | - Jurica Arapović
- Department of Infectious Diseases, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina.,School of Medicine, University of Mostar, Mostar, Bosnia and Herzegovina
| | - Rıdvan Karaali
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nefise Oztoprak
- Antalya Training and Research Hospital, Health Sciences University, Antalya, Turkey
| | - Michael M Petrov
- Department of Microbiology and Immunology, Faculty of Pharmacy, Medical University of Plovdiv & "St. George" University Hospital, Plovdiv, Bulgaria
| | | | - Handan Alay
- School of Medicine, Ataturk University, Erzurum, Turkey
| | - Jehan Ali El Kholy
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Reham Khedr
- Department of Pediatric Oncology, National Cancer Institute - Cairo University / Children Cancer Hospital Egypt, Cairo, 57357, Egypt
| | | | - Gorana Dragovac
- Institute of Public Health of Vojvodina, Novi Sad, Serbia & University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | | | - Emine Unal Evren
- Dr. Suat Gunsel Hospital, University of Kyrenia, Kyrenia, Cyprus
| | - Lul Raka
- National Institute of Public Health of Kosova & University "Hasan Prishtina", Prishtina, Kosova
| | - Antonio Cascio
- Infectious and Tropical Disease Unit, AOU Policlinico "P. Giaccone" - Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties - University of Palermo, 90127 , Palermo, Italy
| | - Nicolas Dauby
- Environmental Health Research Centre, Public Health School, Université Libre de Bruxelles (ULB), Department of Infectious Diseases, CHU Saint-Pierre, Brussels, Belgium
| | - Ahsen Oncul
- Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | | | - Yasemin Cag
- Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | | | - Mustafa Dogan
- Namık Kemal University School of Medicine, Tekirdag, Turkey
| | - Irina Magdalena Dumitru
- Clinical Infectious Diseases Hospital Constanta, Ovidius University of Constanta, Constanța, Romania
| | - Maha Ali Gad
- Faculty of Medicine (Kasr Al-Ainy), Cairo University, Cairo, Egypt
| | - Ilad Alavi Darazam
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behrouz Naghili
- Imam Reza Hospital of Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Monica Licker
- Multidisciplinary Research Center on Antimicrobial Resistance, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Andrea Marino
- ARNAS Garibaldi, Unit of Infectious diseases, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Nasim Akhtar
- Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | | | | | - Deana Medić
- Institute for Public Health of Vojvodina and University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | - Aliye Esmaoğlu
- Erciyes University Medical Faculty Hospital, Kayseri, Turkey
| | - Szabo Balint Gergely
- South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Budapest, Hungary
| | - André Silva-Pinto
- Infectious Diseases Intensive Care Unit, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Lurdes Santos
- Infectious Diseases Intensive Care Unit, Centro Hospitalar Universitário de São João, Porto, Portugal
| | | | - Recep Tekin
- School of Medicine, Dicle University, Diyarbakir, Turkey
| | | | | | | | - Hema Prakash Pilli
- GITAM Institute of Medical Sciences and Research, Department of Microbiology, Rushikonda, Visakhapatnam, India
| | | | - Egidia Miftode
- St. Parascheva" Clinical Hospital of Infectious Diseases, Iasi, Romania
| | | | - Haluk Vahabolgu
- Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Jordi Rello
- Clinical Research CHRU (Nimes, France) and Vall d'Hebron Institute of Research, Barcelona, Spain
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Hoffman T, Lellouche J, Nutman A, Temkin E, Frenk S, Harbarth S, Carevic B, Cohen-Percia S, Kariv Y, Fallach N, Klausner J, Carmeli Y. The effect of prophylaxis with ertapenem versus cefuroxime/metronidazole on intestinal carriage of carbapenem-resistant or third-generation-cephalosporin-resistant Enterobacterales after colorectal surgery. Clin Microbiol Infect 2021; 27:1481-1487. [PMID: 33588061 DOI: 10.1016/j.cmi.2021.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/12/2020] [Revised: 01/11/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Compared to cephalosporin-based prophylaxis, ertapenem prophylaxis lowers the risk of surgical site infection among carriers of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PEs) undergoing colorectal surgery. We aimed to determine whether ertapenem prophylaxis leads to increased postoperative colonization with carbapenem-resistant Enterobacterales (CREs) and third-generation-cephalosporin-resistant Enterobacterales (3GCR-Es). METHODS This study was nested within a quality improvement study of prophylaxis for ESBL-PE carriers undergoing colorectal surgery. Patients were screened 4-6 days after surgery for carriage of ESBL-PEs or other 3GCR-Es and CREs. When CREs were detected, pre- and postsurgical clones were compared using Fourier-transform infrared (FT-IR) spectroscopy. RESULTS The sample consisted of 56 patients who carried ESBL-PEs before surgery and received cefuroxime/metronidazole prophylaxis (Group 1), 66 who carried ESBL-PEs before surgery and received ertapenem (Group 2), and 103 ESBL-PE non-carriers who received cefuroxime/metronidazole prophylaxis (Group 3). CRE carriage was detected postoperatively in one patient (1.5%) in Group 2 versus eight patients (14.3%) in Group 1 (RD -12.8%; 95%CI -22.4% to -3.1%). For seven out of nine patients, preoperative ESBL-PE and postoperative CRE isolates were compared; in five of them, the pre- and postoperative clones were identical. Postoperative 3GCR-E carriage was detected in 37 patients (56.1%) in Group 2 versus 46 patients in Group 1 (82.1%) (aRD -20.7%, 95%CI -37.3% to -4.1%). CONCLUSIONS Among ESBL-PE carriers undergoing colorectal surgery, detection of short-term postsurgical colonization by CREs and 3GCR-Es was significantly lower among patients who received ertapenem prophylaxis than those who received cephalosporin-metronidazole prophylaxis. Resistance development in a colonizing bacterial clone, rather than carbapenemase acquisition, was the major mechanism of carbapenem resistance.
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Affiliation(s)
- Tomer Hoffman
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Infectious Disease Unit, Meir Medical Center, Kfar Saba, Israel
| | - Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Amir Nutman
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elizabeth Temkin
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Sammy Frenk
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Geneva, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Shimrit Cohen-Percia
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Yehuda Kariv
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Noga Fallach
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Joseph Klausner
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yehuda Carmeli
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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5
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Dubinsky-Pertzov B, Temkin E, Harbarth S, Fankhauser-Rodriguez C, Carevic B, Radovanovic I, Ris F, Kariv Y, Buchs NC, Schiffer E, Cohen Percia S, Nutman A, Fallach N, Klausner J, Carmeli Y. Carriage of Extended-spectrum Beta-lactamase-producing Enterobacteriaceae and the Risk of Surgical Site Infection After Colorectal Surgery: A Prospective Cohort Study. Clin Infect Dis 2020; 68:1699-1704. [PMID: 30204851 DOI: 10.1093/cid/ciy768] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 09/07/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Antibiotic prophylaxis that covers enteric pathogens is essential in preventing surgical site infections (SSIs) after colorectal surgery. Current prophylaxis regimens do not cover extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). We aimed to determine whether the risk of SSI following colorectal surgery is higher in ESBL-PE carriers than in noncarriers. METHODS We conducted a prospective cohort study of patients who underwent elective colorectal surgery in 3 hospitals in Israel, Switzerland, and Serbia between 2012 and 2017. We included patients who were aged ≥18 years, were screened for ESBL-PE carriage before surgery, received routine prophylaxis with a cephalosporin plus metronidazole, and did not have an infection at the time of surgery. The exposed group was composed of ESBL-PE-positive patients. The unexposed group was a random sample of ESBL-PE-negative patients. We collected data on patient and surgery characteristics and SSI outcomes. We fit logistic mixed effects models with study site as a random effect. RESULTS A total of 3600 patients were screened for ESBL-PE; 13.8% were carriers SSIs occurred in 55/220 carriers (24.8%) and 49/440 noncarriers (11.1%, P < .001). In multivariable analysis, ESBL-PE carriage more than doubled the risk of SSI (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.50-3.71). Carriers had higher risk of deep SSI (OR, 2.25; 95% CI, 1.27-3.99). SSI caused by ESBL-PE occurred in 7.2% of carriers and 1.6% of noncarriers (OR, 4.23; 95% CI, 1.70-10.56). CONCLUSIONS ESBL-PE carriers who receive cephalosporin-based prophylaxis are at increased risk of SSI following colorectal surgery.
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Affiliation(s)
- Biana Dubinsky-Pertzov
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Elizabeth Temkin
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Switzerland
| | - Carolina Fankhauser-Rodriguez
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Ivana Radovanovic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Frederic Ris
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Yehuda Kariv
- Department of Surgery, Tel Aviv Sourasky Medical Center, Israel
| | - Nicolas C Buchs
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Shimrit Cohen Percia
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
| | - Amir Nutman
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Noga Fallach
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
| | - Joseph Klausner
- Sackler Faculty of Medicine, Tel Aviv University, Israel
- Department of Surgery, Tel Aviv Sourasky Medical Center, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Israel
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6
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Niehus R, van Kleef E, Mo Y, Turlej-Rogacka A, Lammens C, Carmeli Y, Goossens H, Tacconelli E, Carevic B, Preotescu L, Malhotra-Kumar S, Cooper BS. Quantifying antibiotic impact on within-patient dynamics of extended-spectrum beta-lactamase resistance. eLife 2020; 9:e49206. [PMID: 32379042 PMCID: PMC7205461 DOI: 10.7554/elife.49206] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 03/22/2020] [Indexed: 12/22/2022] Open
Abstract
Antibiotic-induced perturbation of the human gut flora is expected to play an important role in mediating the relationship between antibiotic use and the population prevalence of antibiotic resistance in bacteria, but little is known about how antibiotics affect within-host resistance dynamics. Here we develop a data-driven model of the within-host dynamics of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae. We use blaCTX-M (the most widespread ESBL gene family) and 16S rRNA (a proxy for bacterial load) abundance data from 833 rectal swabs from 133 ESBL-positive patients followed up in a prospective cohort study in three European hospitals. We find that cefuroxime and ceftriaxone are associated with increased blaCTX-M abundance during treatment (21% and 10% daily increase, respectively), while treatment with meropenem, piperacillin-tazobactam, and oral ciprofloxacin is associated with decreased blaCTX-M (8% daily decrease for all). The model predicts that typical antibiotic exposures can have substantial long-term effects on blaCTX-M carriage duration.
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Affiliation(s)
| | - Esther van Kleef
- National Institute for Public Health and theEnvironmentBilthovenNetherlands
| | - Yin Mo
- University of OxfordOxfordUnited Kingdom
| | | | | | | | | | - Evelina Tacconelli
- University of TuebingenTuebingenGermany
- Infectious Diseases, University of VeronaVeronaItaly
| | | | - Liliana Preotescu
- Matei Balş National Institute for Infectious DiseasesBucharestRomania
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7
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Nutman A, Temkin E, Harbarth S, Carevic B, Ris F, Fankhauser-Rodriguez C, Radovanovic I, Dubinsky-Pertzov B, Cohen-Percia S, Kariv Y, Buchs N, Schiffer E, Fallach N, Klausner J, Carmeli Y. Personalized Ertapenem Prophylaxis for Carriers of Extended-spectrum β-Lactamase–producing Enterobacteriaceae Undergoing Colorectal Surgery. Clin Infect Dis 2019; 70:1891-1897. [DOI: 10.1093/cid/ciz524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 06/18/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Carriers of extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE) who receive cephalosporin-based prophylaxis have twice the risk of surgical site infection (SSI) following colorectal surgery as noncarriers. We tested whether ESBL-PE screening and personalized prophylaxis with ertapenem reduces SSI risk among carriers.
Methods
We conducted a prospective nonrandomized, nonblinded, interventional study in 3 hospitals in Israel, Switzerland, and Serbia. Patients were screened for ESBL-PE carriage before elective colorectal surgery. During the baseline phase, departmental guidelines advised prophylaxis with a cephalosporin plus metronidazole. In the intervention phase, guidelines were changed for ESBL-PE carriers to receive ertapenem. The primary outcome was any type of SSI within 30 days. We calculated adjusted risk differences (ARDs) following logistic regression.
Results
The intention-to-treat analysis compared 209 ESBL-PE carriers in the baseline phase to 269 in the intervention phase. SSI rates were 21.5% and 17.5%, respectively (ARD, –4.7% [95% confidence interval {CI}, –11.8% to 2.4%]). Unplanned crossover was high (15%), so to assess efficacy we performed an as-treated analysis comparing 247 patients who received cephalosporin-based prophylaxis with 221 who received ertapenem. SSI rates were 22.7% and 15.8%, respectively (ARD, –7.7% [95% CI, –14.6% to –.8%]), and rates of SSI caused by ESBL-PE were 6.5% and 0.9%, respectively (ARD, –5.6% [95% CI, –8.9% to –2.3%]). There was no significant difference in the rate of deep SSI. The number needed to treat to prevent 1 SSI in ESBL-PE carriers was 13.
Conclusions
Screening for ESBL-PE carriage before colorectal surgery and personalizing prophylaxis for carriers is efficacious in reducing SSI.
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Affiliation(s)
- Amir Nutman
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Elizabeth Temkin
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, World Health Organization Collaborating Center, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Frederic Ris
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Carolina Fankhauser-Rodriguez
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, World Health Organization Collaborating Center, Switzerland
| | - Ivana Radovanovic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Biana Dubinsky-Pertzov
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Shimrit Cohen-Percia
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Yehuda Kariv
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Israel
| | - Nicolas Buchs
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Noga Fallach
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Joseph Klausner
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Israel
| | - Yehuda Carmeli
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
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8
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De Backer S, Xavier B, Vanjari L, Coppens J, Lammens C, Vemu L, Carevic B, Hryniewicz W, Jorens P, Kumar-Singh S, Lee A, Harbarth S, Schrenzel J, Tacconelli E, Goossens H, Malhotra-Kumar S. Remarkable geographical variations between India and Europe in carriage of the staphylococcal surface protein-encoding sasX/sesI and in the population structure of methicillin-resistant Staphylococcus aureus belonging to clonal complex 8. Clin Microbiol Infect 2019; 25:628.e1-628.e7. [DOI: 10.1016/j.cmi.2018.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/10/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
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9
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Zivanovic V, Gojkovic-Bukarica L, Scepanovic R, Vitorovic T, Novakovic R, Milanov N, Bukumiric Z, Carevic B, Trajkovic J, Rajkovic J, Djokic V. Differences in antimicrobial consumption, prescribing and isolation rate of multidrug resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii on surgical and medical wards. PLoS One 2017; 12:e0175689. [PMID: 28467437 PMCID: PMC5415063 DOI: 10.1371/journal.pone.0175689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/29/2017] [Indexed: 11/18/2022] Open
Abstract
In order to provide guidance data for clinically rational use of an antibiotics consuption, prescribing and prevalence of multidrug resistant (MDR) Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii were monitored on the surgical (S) and medical (M) wards of the University Hospital Center “Dr. Dragisa Misovic-Dedinje” (Belgrade, Serbia), in the study period from 2012 to 2015. Appropriateness of antimicrobial use was evaluated using the Global-Prevalence Survey method designed by the University of Antwerp. The percentages of MDR pathogens relative to the total number of isolates of K. pneumoniae and P. aeruginosa were higher on the S (86.2% and 49.1%) than on the M (63.2% and 36.9%) wards. The percentage of MDR A. baumannii was not different between S (93.7%) and M (79.5%) wards. An overall antibiotics consumption (defined daily doses/100 bed-days) during study was 369.7 and 261.5 on the S and M wards, respectively. A total of 225 prescriptions of antimicrobials were evaluated in138 adults admitted to wards on the day of the survey. The percentage of antimicrobials prescribed for prophylaxis on the M and S wards were 0% and 25%, respectively. Therapies were more frequently empiric (S, 86.8% and M, 80%). The percentages of medical errors on the S and M wards were 74.6% and 27.3%, respectively. The quality indicators for antibiotic prescribing on the S and M wards were as follows: the incorrect choice of antimicrobials (35.6% vs. 20.0%), inappropriate dose interval (70.6% vs. 16.9%) or duration of therapy (72.5% vs. 23.1%), a non-documented stop/review data (73.6% vs. 16.9%) and divergence from guidelines (71.9% vs. 23.1%). Treatment based on biomarkers was more common on the M wards as compared to the S wards. The increasing prevalence of MDR pathogens, a very high consumption and incorrect prescribing of antimicrobials need special attention, particularly on the S wards.
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Affiliation(s)
- Vladimir Zivanovic
- University Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Ljiljana Gojkovic-Bukarica
- University Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical faculty, University of Belgrade, Belgrade, Serbia
| | - Radisav Scepanovic
- University Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Teodora Vitorovic
- University Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Radmila Novakovic
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical faculty, University of Belgrade, Belgrade, Serbia
| | - Nenad Milanov
- University Hospital Center “Dr. Dragisa Misovic-Dedinje”, Belgrade, Serbia
| | - Zoran Bukumiric
- Department of Medical Statistics, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jasmina Trajkovic
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical faculty, University of Belgrade, Belgrade, Serbia
| | - Jovana Rajkovic
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical faculty, University of Belgrade, Belgrade, Serbia
| | - Vladimir Djokic
- Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical faculty, University of Belgrade, Belgrade, Serbia
- * E-mail:
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10
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Erdem H, Inan A, Altındis S, Carevic B, Askarian M, Cottle L, Beovic B, Csomos A, Metodiev K, Ahmetagic S, Harxhi A, Raka L, Grozdanovski K, Nechifor M, Alp E, Bozkurt F, Hosoglu S, Balik I, Yilmaz G, Jereb M, Moradi F, Petrov N, Kaya S, Koksal I, Aslan T, Elaldi N, Akkoyunlu Y, Moravveji SA, Csato G, Szedlak B, Akata F, Oncu S, Grgic S, Cosic G, Stefanov C, Farrokhnia M, Müller M, Luca C, Koluder N, Korten V, Platikanov V, Ivanova P, Soltanipour S, Vakili M, Farahangiz S, Afkhamzadeh A, Beeching N, Ahmed SS, Cami A, Shiraly R, Jazbec A, Mirkovic T, Leblebicioglu H, Naber K. Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study. J Infect 2013; 68:131-40. [PMID: 24269951 DOI: 10.1016/j.jinf.2013.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [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: 06/12/2013] [Revised: 10/01/2013] [Accepted: 11/01/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia. METHODS A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists. RESULTS Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%). CONCLUSION ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.
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Affiliation(s)
- Hakan Erdem
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Asuman Inan
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Selma Altındis
- Sakarya University, Faculty of Management, Department of Health Administration, Sakarya, Turkey
| | - Biljana Carevic
- Clinical Center of Serbia (CCS), Department for Hospital Epidemiology, Belgrade, Serbia
| | - Mehrdad Askarian
- Department of Community Medicine, School of Medicine, Medicinal & Natural Products Chemistry Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Lucy Cottle
- Royal Liverpool University Hospital, United Kingdom
| | - Bojana Beovic
- University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia
| | - Akos Csomos
- Semmelweis University, Department of Anaesthesia and Intensive Care, Budapest, Hungary
| | - Krassimir Metodiev
- Medical University, Department of Preclinical and Clinical Sciences, Varna, Bulgaria
| | - Sead Ahmetagic
- University Clinical Center Tuzla, Department for Infectious Diseases, Tuzla, Bosnia and Herzegovina
| | - Arjan Harxhi
- University Hospital Center of Tirana, Service of Infectious Disease, Tirana, Albania
| | - Lul Raka
- University of Prishtina, School of Medicine & National Institute of Public Health of Kosova, Prishtina, Kosova, Serbia
| | - Krsto Grozdanovski
- University Clinic for Infectious Diseases, Department of Intensive Care, Skopje, Macedonia
| | - Mihai Nechifor
- Gr. T. Popa University of Medicine and Pharmacy, Department of Pharmacology, Iasi, Romania
| | - Emine Alp
- Erciyes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kayseri, Turkey
| | - Fatma Bozkurt
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Salih Hosoglu
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Ismail Balik
- Ankara University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Gulden Yilmaz
- Ankara University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Matjaz Jereb
- University Medical Centre, Department of Infectious Diseases, Ljubljana, Slovenia
| | - Fatemeh Moradi
- Clinical Research Center on Infectious Diseases and Tropical Medicine, Bandar Abbas, Iran
| | - Nikolay Petrov
- Military Medical Academy, Department Anaesthesiology and Intensive Care, Sofia, Bulgaria
| | - Selcuk Kaya
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Iftihar Koksal
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Turan Aslan
- Bezmi Alem University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nazif Elaldi
- Cumhuriyet University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sivas, Turkey
| | - Yasemin Akkoyunlu
- Bezmi Alem University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Seyyed Alireza Moravveji
- Kashan University of Medical Sciences, Trauma Research Center, Department of Community Medicine, Kashan, Iran
| | - Gabor Csato
- Kenézy Hospital, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Balazs Szedlak
- Borsod County Hospital and Teaching Hospital, Department of Anaesthesiology and Intensive Therapy, Miskolc, Hungary
| | - Filiz Akata
- Trakya University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Edirne, Turkey
| | - Serkan Oncu
- Adnan Menderes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Aydin, Turkey
| | - Svjetlana Grgic
- University Hospital Clinic for Infectious Diseases, Mostar, Bosnia and Herzegovina
| | - Gorana Cosic
- IPH of Vojvodina, Department of Prevention and Control of Diseases, Medical Faculty, University of Novi Sad, Serbia
| | - Chavdar Stefanov
- University Multiprofile Hospital for Active Treatment, Department of Anesthesiology and Intensive Treatment, St. Georgi, Plovdiv, Bulgaria
| | - Mehrdad Farrokhnia
- Kerman University of Medical Sciences, Department of Internal Medicine, Kerman, Iran
| | - Mária Müller
- Markhot Hospital, Department of Anaesthesiology and Intensive Care, Eger, Hungary
| | - Catalina Luca
- Gr. T. Popa University of Medicine and Pharmacy, Department of Pharmacology, Iasi, Romania
| | - Nada Koluder
- Clinic for Infectious Diseases, Sarajevo, Bosnia and Herzegovina
| | - Volkan Korten
- Marmara University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Viliyan Platikanov
- University Hospital "St. Marina", Department of Anesthesiology and ICM, Varna, Bulgaria
| | - Petja Ivanova
- University Hospital "St. Marina", Department of Anesthesiology and ICM, Varna, Bulgaria
| | - Soheil Soltanipour
- Guilan University of Medical Sciences, School of Medicine, Department of Community Medicine, Rasht, Iran
| | - Mahmood Vakili
- Shahid Sadoughi University School of Medicine, Department of Community Medicine, Yazd, Iran
| | - Saman Farahangiz
- Department of Community Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdorrahim Afkhamzadeh
- Department of Community Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Salman Shaheer Ahmed
- Erciyes University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kayseri, Turkey
| | - Alma Cami
- University Hospital of Pulmonary Disease, Intensive Care Clinic, Tirana, Albania
| | - Ramin Shiraly
- Ilam University of Medical Sciences, Department of Community Medicine, Yazd, Iran
| | - Anja Jazbec
- University Clinical Center Ljubljana, Center for Intensive Internal Medicine, Ljubljana, Slovenia
| | - Tomislav Mirkovic
- University Medical Centre Ljubljana, Department of Anestesiology and Surgical Intensive Care, Ljubljana, Slovenia
| | - Hakan Leblebicioglu
- Ondokuz Mayis University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Samsun, Turkey
| | - Kurt Naber
- Technical University of Munich, Munich, Germany
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11
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Lee AS, Cooper BS, Malhotra-Kumar S, Chalfine A, Daikos GL, Fankhauser C, Carevic B, Lemmen S, Martínez JA, Masuet-Aumatell C, Pan A, Phillips G, Rubinovitch B, Goossens H, Brun-Buisson C, Harbarth S. Comparison of strategies to reduce meticillin-resistant Staphylococcus aureus rates in surgical patients: a controlled multicentre intervention trial. BMJ Open 2013; 3:e003126. [PMID: 24056477 PMCID: PMC3780302 DOI: 10.1136/bmjopen-2013-003126] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To compare the effect of two strategies (enhanced hand hygiene vs meticillin-resistant Staphylococcus aureus (MRSA) screening and decolonisation) alone and in combination on MRSA rates in surgical wards. DESIGN Prospective, controlled, interventional cohort study, with 6-month baseline, 12-month intervention and 6-month washout phases. SETTING 33 surgical wards of 10 hospitals in nine countries in Europe and Israel. PARTICIPANTS All patients admitted to the enrolled wards for more than 24 h. INTERVENTIONS The two strategies compared were (1) enhanced hand hygiene promotion and (2) universal MRSA screening with contact precautions and decolonisation (intranasal mupirocin and chlorhexidine bathing) of MRSA carriers. Four hospitals were assigned to each intervention and two hospitals combined both strategies, using targeted MRSA screening. OUTCOME MEASURES Monthly rates of MRSA clinical cultures per 100 susceptible patients (primary outcome) and MRSA infections per 100 admissions (secondary outcome). Planned subgroup analysis for clean surgery wards was performed. RESULTS After adjusting for clustering and potential confounders, neither strategy when used alone was associated with significant changes in MRSA rates. Combining both strategies was associated with a reduction in the rate of MRSA clinical cultures of 12% per month (adjusted incidence rate ratios (aIRR) 0.88, 95% CI 0.79 to 0.98). In clean surgery wards, strategy 2 (MRSA screening, contact precautions and decolonisation) was associated with decreasing rates of MRSA clinical cultures (15% monthly decrease, aIRR 0.85, 95% CI 0.74 to 0.97) and MRSA infections (17% monthly decrease, aIRR 0.83, 95% CI 0.69 to 0.99). CONCLUSIONS In surgical wards with relatively low MRSA prevalence, a combination of enhanced standard and MRSA-specific infection control approaches was required to reduce MRSA rates. Implementation of single interventions was not effective, except in clean surgery wards where MRSA screening coupled with contact precautions and decolonisation was associated with significant reductions in MRSA clinical culture and infection rates. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT00685867.
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Affiliation(s)
- Andie S Lee
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
- Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ben S Cooper
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Oxford, UK
| | - Surbhi Malhotra-Kumar
- Department of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium
| | - Annie Chalfine
- Infection Control Unit, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - George L Daikos
- First Department of Propaedeutic Medicine, Laiko General Hospital, Athens, Greece
| | - Carolina Fankhauser
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Sebastian Lemmen
- Department of Infection Control and Infectious Diseases, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Cristina Masuet-Aumatell
- Preventive Medicine Department and Faculty of Medicine, Bellvitge Biomedical Research Institute (IDIBELL), University Hospital of Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Angelo Pan
- Infectious and Tropical Diseases Unit, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Gabby Phillips
- Infection Control Department, Ninewells Hospital, Dundee, Scotland
| | - Bina Rubinovitch
- Unit of Infection Control, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Herman Goossens
- Department of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium
| | - Christian Brun-Buisson
- Inserm U 657, Institut Pasteur, Paris; Department of Intensive Care, Hopital Henri Mondor, Universite Paris-Est Creteil, Creteil, France
| | - Stephan Harbarth
- Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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