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Tan JH, McGrath CL, Brothers AW, Fatemi Y, Konold V, Pak D, Weissman SJ, Zerr DM, Kronman MP. Race and Antibiotic Use for Children Hospitalized With Acute Respiratory Infections. J Pediatric Infect Dis Soc 2024; 13:237-241. [PMID: 38456844 DOI: 10.1093/jpids/piae021] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/06/2024] [Indexed: 03/09/2024]
Abstract
We sought to evaluate whether children hospitalized with acute respiratory infections experienced differences in antibiotic use by race and ethnicity. We found that likelihood of broad-spectrum antibiotic receipt differed across racial and ethnic groups. Future work should confirm this finding, evaluate causes, and ensure equitable antibiotic use.
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Affiliation(s)
- Jenna H Tan
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Caitlin L McGrath
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Adam W Brothers
- Department of Pharmacy, Seattle Children's Hospital, Seattle, WA, USA
| | - Yasaman Fatemi
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Victoria Konold
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Daniel Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, WA, USA
| | - Scott J Weissman
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Danielle M Zerr
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Matthew P Kronman
- Department of Pediatrics, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
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Brothers AW, Pak DJ, Poole NM, Kronman MP, Bettinger B, Wilkes JJ, Carpenter PA, Englund JA, Weissman SJ. Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital. Clin Infect Dis 2024; 78:15-23. [PMID: 37647637 DOI: 10.1093/cid/ciad518] [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: 06/08/2023] [Revised: 08/15/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. METHODS In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. RESULTS Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. CONCLUSIONS Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.
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Affiliation(s)
- Adam W Brothers
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel J Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Nicole M Poole
- Departments of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew P Kronman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Brendan Bettinger
- Department of Clinical Analytics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jennifer J Wilkes
- Department of Pediatrics, Division of Hematology/Oncology, University of Washington, Seattle, Washington, USA
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Janet A Englund
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Scott J Weissman
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA
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Jewell M, Fuhrmeister ER, Roberts MC, Weissman SJ, Rabinowitz PM, Hawes SE. Associations between Isolation Source, Clonal Composition, and Antibiotic Resistance Genes in Escherichia coli Collected in Washington State, USA. Antibiotics (Basel) 2024; 13:103. [PMID: 38275332 PMCID: PMC10812632 DOI: 10.3390/antibiotics13010103] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Antimicrobial resistance (AMR) is a global health problem stemming from the use of antibiotics in humans, animals, and the environment. This study used whole-genome sequencing (WGS) of E. coli to explore patterns of AMR across sectors in Washington State, USA (WA). The WGS data from 1449 E. coli isolates were evaluated for isolation source (humans, animals, food, or the environment) and the presence of antibiotic resistance genes (ARGs). We performed sequence typing using PubMLST and used ResFinder to identify ARGs. We categorized isolates as being pan-susceptible, resistant, or multidrug-resistant (MDR), defined as carrying resistance genes for at least three or more antimicrobial drug classes. In total, 60% of isolates were pan-susceptible, while 18% were resistant, and 22% exhibited MDR. The proportion of resistant isolates varied significantly according to the source of the isolates (p < 0.001). The greatest resistance was detected in isolates from humans and then animals, while environmental isolates showed the least resistance. This study demonstrates the feasibility of comparing AMR across various sectors in Washington using WGS and a One Health approach. Such analysis can complement other efforts for AMR surveillance and potentially lead to targeted interventions and monitoring activities to reduce the overall burden of AMR.
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Affiliation(s)
- Mary Jewell
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA 98195, USA; (M.J.); (S.E.H.)
| | - Erica R. Fuhrmeister
- Department of Environmental and Occupational Health, School of Public Health, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA; (E.R.F.); (P.M.R.)
- Department of Civil and Environmental Engineering, University of Washington, 3760 E. Stevens Way NE, Seattle, WA 98195, USA
| | - Marilyn C. Roberts
- Department of Environmental and Occupational Health, School of Public Health, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA; (E.R.F.); (P.M.R.)
| | - Scott J. Weissman
- Division of Infectious Disease, Seattle Children’s Hospital, Seattle, WA 98105, USA;
| | - Peter M. Rabinowitz
- Department of Environmental and Occupational Health, School of Public Health, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA; (E.R.F.); (P.M.R.)
- Center for One Health Research, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA
| | - Stephen E. Hawes
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA 98195, USA; (M.J.); (S.E.H.)
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Tseng AS, Roberts MC, Weissman SJ, Rabinowitz PM. Study of heavy metal resistance genes in Escherichia coli isolates from a marine ecosystem with a history of environmental pollution (arsenic, cadmium, copper, and mercury). PLoS One 2023; 18:e0294565. [PMID: 37972039 PMCID: PMC10653420 DOI: 10.1371/journal.pone.0294565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023] Open
Abstract
We analyzed whole genome sequences of 308 Escherichia coli isolates from a marine ecosystem to determine the prevalence and relationships of heavy metal resistance genes (HMRGs) and antibiotic resistance genes (ARGs), as well as the presence of plasmid sequences. We screened all genomes for presence of 18 functional HMRGs conferring resistance to arsenic, cadmium, copper, or cadmium/mercury. In subset analyses, we examined geographic variations of HMRG carriage patterns in 224 isolates from water sources, and sought genetic linkages between HMRGs and ARGs in 25 genomes of isolates resistant to antibiotics. We found high carriage rates of HMRGs in all genomes, with 100% carrying at least one copy of 11 out of 18 HMRGs. A total of 173 (56%) of the isolates carried both HMRGs and plasmid sequences. In the 25 genomes of antibiotic-resistant isolates, 80% (n = 20) carried HMRGs, ARGs, and plasmid sequences, while 40% (n = 10) had linked HMRGs and ARGs on their assembled genomes. We found no evidence of geographic variation in HMRG frequency, nor any association between locational proximity to Superfund sites and co-carriage of HMRGs and ARGs. Our study findings indicate that HMRGs are common among E. coli in marine ecosystems, suggesting widespread heavy metal presence in water sources of a region with history of environmental pollution. Further research is needed to determine the role HMRGs play in driving antimicrobial resistance in human pathogens through genetic linkage and the value their detection in environmental bacterial genomes may offer as an indicator of environmental heavy metal pollution.
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Affiliation(s)
- Ashley S. Tseng
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Marilyn C. Roberts
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - Scott J. Weissman
- Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, Washington, United States of America
| | - Peter M. Rabinowitz
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
- Center for One Health Research, Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
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Tchesnokova V, Larson L, Basova I, Sledneva Y, Choudhury D, Solyanik T, Heng J, Bonilla TC, Pham S, Schartz EM, Madziwa LT, Holden E, Weissman SJ, Ralston JD, Sokurenko EV. Increase in the community circulation of ciprofloxacin-resistant Escherichia coli despite reduction in antibiotic prescriptions. Commun Med (Lond) 2023; 3:110. [PMID: 37567971 PMCID: PMC10421857 DOI: 10.1038/s43856-023-00337-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Community circulating gut microbiota is the main reservoir for uropathogenic Escherichia coli, including those resistant to antibiotics. Ciprofloxacin had been the primary antibiotic prescribed for urinary tract infections, but its broad use has been discouraged and steadily declined since 2015. How this change in prescriptions affected the community circulation of ciprofloxacin-resistant E. coli is unknown. METHODS We determined the frequency of isolation and other characteristics of E. coli resistant to ciprofloxacin in 515 and 1604 E. coli-positive fecal samples collected in 2015 and 2021, respectively. The samples were obtained from non-antibiotic-taking women of age 50+ receiving care in the Kaiser Permanente Washington healthcare system. RESULTS Here we show that despite a nearly three-fold drop in the prescription of ciprofloxacin between 2015 and 2021, the rates of gut carriage of ciprofloxacin-resistant E. coli increased from 14.2 % to 19.8% (P = .004). This is driven by a significant increase of isolates from the pandemic multi-drug resistant clonal group ST1193 (1.7% to 4.2%; P = .009) and isolates with relatively few ciprofloxacin-resistance determining chromosomal mutations (2.3% to 7.4%; P = .00003). Though prevalence of isolates with the plasmid-associated ciprofloxacin resistance dropped (59.0% to 30.9%; P = 2.7E-06), the isolates co-resistance to third generation cephalosporins has increased from 14.1% to 31.5% (P = .002). CONCLUSIONS Despite reduction in ciprofloxacin prescriptions, community circulation of the resistant uropathogenic E. coli increased with a rise of co-resistance to third generation cephalosporins. Thus, to reduce the rates of urinary tract infections refractory to antibiotic treatment, greater focus should be on controlling the resistant bacteria in gut microbiota.
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Affiliation(s)
- Veronika Tchesnokova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Lydia Larson
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Irina Basova
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Yulia Sledneva
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Debarati Choudhury
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Thalia Solyanik
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Jennifer Heng
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Teresa Christina Bonilla
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Sophia Pham
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA
| | - Ellen M Schartz
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Lawrence T Madziwa
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Erika Holden
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Scott J Weissman
- Department of Laboratory Medicine, Seattle Children's Hospital, 1100 Olive Way Tutor Center, Seattle, WA, 98101, USA
| | - James D Ralston
- Kaiser Permanente Washington, 2715 Naches Ave. SW, Renton, WA, 98057, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA
| | - Evgeni V Sokurenko
- Department of Microbiology, University of Washington School of Medicine, 1705 NE Pacific St., Seattle, WA, 98195, USA.
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Frisbie L, Weissman SJ, Kapoor H, D’Angeli M, Salm A, Radcliff J, Rabinowitz P. Outpatient Antibiotic Resistance Patterns of Escherichia coli Urinary Isolates Differ by Specialty Type. Microbiol Spectr 2022; 10:e0237321. [PMID: 35727039 PMCID: PMC9431218 DOI: 10.1128/spectrum.02373-21] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant E. coli infections represent a major cause of morbidity and mortality and pose a challenge to antibiotic stewardship. We analyzed a large outpatient data set of E. coli urinary isolates to determine whether resistance patterns vary between types of outpatient practices. Using deidentified data from a clinical reference laboratory over 5 years and logistic regression, we examined the association of antibiotic resistance with outpatient practice type, controlling for testing year, patient sex, and patient age. The odds of antibiotic resistance were significantly higher in urology/nephrology practices for ampicillin (odds ratio [OR] 1.36; 95% CI, 1.10 to 1.69), ciprofloxacin (OR 2.29; 95% CI, 1.77 to 2.94), trimethoprim-sulfamethoxazole (OR 1.52; 95% CI, 1.18 to 1.94), and gentamicin (OR 1.72; 95% CI, 1.16 to 2.46). Odds of resistance were also higher for ciprofloxacin in oncology practices (OR 1.54; 95% CI, 1.08 to 2.15) and "all other specialties" (OR 1.33; 95% CI, 1.13 to 1.56). In contrast, specimens from obstetrics and gynecology practices had lower odds of having resistance to ampicillin (OR 0.90; 95% CI, 0.82 to 0.99) and trimethoprim-sulfa (OR 0.83; 95% CI, 0.73 to 0.93) but higher odds of having resistance to nitrofurantoin (OR 1.33; 95% CI, 1.03 to 1.70). Other findings included lower odds of having resistance to trimethoprim-sulfa in pediatric practices (OR 0.78; 95% CI, 0.64 to 0.94) and lower odds of having resistance to gentamicin in isolates from internal medicine practices (OR 0.66; 95% CI, 0.51 to 0.84) (all P < 0.05). IMPORTANCE Patterns of antibiotic resistance in E. coli urinary isolates can vary between outpatient specialties. The use of clinical data to create practice and specialty-specific antibiograms in outpatient settings may improve antibiotic stewardship.
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Affiliation(s)
- Lauren Frisbie
- Department of Environmental and Occupational Health Sciences, Center for One Health Research (COHR), University of Washington School of Public Health, Seattle, Washington, USA
| | - Scott J. Weissman
- Infectious Diseases Department, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Hema Kapoor
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus, New Jersey, USA
| | - Marisa D’Angeli
- Washington State Department of Health, Shoreline, Washington, USA
| | - Ann Salm
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus, New Jersey, USA
| | - Jeff Radcliff
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus, New Jersey, USA
| | - Peter Rabinowitz
- Department of Environmental and Occupational Health Sciences, Center for One Health Research (COHR), University of Washington School of Public Health, Seattle, Washington, USA
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Gregory PF, Angus J, Brothers AW, Gray AN, Skeen K, Gooley T, Davis C, Kim HH, Weissman SJ, Zheng HB, Mallhi K, Baker KS. Risk Factors for Development of Pneumatosis Intestinalis after Pediatric Hematopoietic Stem Cell Transplantation: A Single-Center Case-Control Study. Transplant Cell Ther 2022; 28:785.e1-785.e7. [DOI: 10.1016/j.jtct.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
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Konold VJL, Brothers AW, Kronman M, Pak D, Bettinger B, Weissman SJ. Flushing an Offensive Term for Vancomycin Infusion Reaction From the Electronic Medical Record. Hosp Pediatr 2021; 11:e317-e321. [PMID: 34675085 DOI: 10.1542/hpeds.2021-005993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The medical establishment continues to be complicit in the degradation of native peoples of the United States through the use of the racist phrase "red man syndrome" (RMS) to describe the histamine-release syndrome that accompanies vancomycin infusion. METHODS Five months after the transition from 1 electronic health record to another at our freestanding children's hospital, our antimicrobial stewardship team reviewed all active allergy records to identify and then replace use of RMS terminology with preferred alternative "vancomycin flushing syndrome." In partnership with institutional stakeholders, we also launched an educational campaign and instituted in the electronic health record an autocorrect functionality to prevent new RMS entries. RESULTS We identified allergy records for 21 034 individual patients. Vancomycin was an allergen for 445 (2.1%) patients, and RMS-related terminology appeared in 274 (61.6%) of these records; we replaced all RMS instances with the vancomycin flushing syndrome term. During the 3-month period after the intervention, we identified allergy records for 8648 additional patients, with vancomycin as allergen in 65 (0.7%) and with RMS terminology identified and replaced in 29 (44.6%). In addition to the lower rate of RMS among allergy records after the intervention, we detected 3 instances of alternative terminology use. CONCLUSIONS Implementing an institutional-level change in terminology, even for racist language, requires education, reinforcement, and continued surveillance. To effectively replace this term, we need the support of national stakeholders to remove this language from our medical education systems, our textbooks, and our clinical lexicon.
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Affiliation(s)
| | | | | | | | - Brendan Bettinger
- Clinical Analytics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
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Vingino A, Roberts MC, Wainstein M, West J, Norman SA, Lambourn D, Lahti J, Ruiz R, D’Angeli M, Weissman SJ, Rabinowitz P. Surveillance for Antibiotic-Resistant E. coli in the Salish Sea Ecosystem. Antibiotics (Basel) 2021; 10:antibiotics10101201. [PMID: 34680782 PMCID: PMC8532818 DOI: 10.3390/antibiotics10101201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/19/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
E. coli was isolated from the Salish Sea (Puget Sound) ecosystem, including samples of marine and fresh water, and wildlife dependent on this environment. E. coli isolates were assessed for phenotypic and genotypic resistance to antibiotics. A total of 305 E. coli isolates was characterized from samples collected from: marine water obtained in four quadrants of the Salish Sea; select locations near beaches; fresh water from streams near marine beaches; and fecal samples from harbor porpoises (Phocoena phocoena), harbor seals (Phoca vitulina), river otters (Lontra canadensis), and English sole (Parophrys vetulus). Isolates were evaluated using antimicrobial susceptibility typing, whole-genome sequencing, fumC, and multilocus sequence typing. Resistance and virulence genes were identified from sequence data. Of the 305 isolates from Salish Sea samples, 20 (6.6%) of the E. coli were intermediate, and 31 (10.2%) were resistant to ≥1 class of antibiotics, with 26.9% of nonsusceptible (resistant and intermediate resistant) E. coli isolates from marine mammals and 70% from river otters. The proportion of nonsusceptible isolates from animals was significantly higher than samples taken from marine water (p < 0.0001). A total of 196 unique STs was identified including 37 extraintestinal pathogenic E. coli (ExPEC)-associated STs [ST10, ST38, ST58, ST69, ST73, ST117, ST131, and ST405]. The study suggests that animals may be potential sentinels for antibiotic-resistant and ExPEC E. coli in the Salish Sea ecosystem.
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Affiliation(s)
- Alexandria Vingino
- Department of Environmental and Occupational Health Sciences (DEOHS), University of Washington, Seattle, WA 98105, USA or (A.V.); (P.R.)
| | - Marilyn C. Roberts
- Department of Environmental and Occupational Health Sciences (DEOHS), University of Washington, Seattle, WA 98105, USA or (A.V.); (P.R.)
- Correspondence: ; Tel.: +1-206-543-8001
| | | | - James West
- Washington Department of Fish and Wildlife, P.O. Box 43200, Olympia, WA 98504, USA; (J.W.); (D.L.)
| | - Stephanie A. Norman
- Marine-Med: Marine Research Epidemiology, Veterinary Medicine, Bothell, WA 98021, USA; (S.A.N.); (M.D.)
| | - Dyanna Lambourn
- Washington Department of Fish and Wildlife, P.O. Box 43200, Olympia, WA 98504, USA; (J.W.); (D.L.)
| | - Jeffery Lahti
- Washington State Department of Health, Shoreline, WA 98105, USA; (J.L.); (R.R.)
| | - Ryan Ruiz
- Washington State Department of Health, Shoreline, WA 98105, USA; (J.L.); (R.R.)
| | - Marisa D’Angeli
- Marine-Med: Marine Research Epidemiology, Veterinary Medicine, Bothell, WA 98021, USA; (S.A.N.); (M.D.)
| | - Scott J. Weissman
- Division of Infectious Disease, Seattle Children’s Hospital, Seattle, WA 98105, USA;
| | - Peter Rabinowitz
- Department of Environmental and Occupational Health Sciences (DEOHS), University of Washington, Seattle, WA 98105, USA or (A.V.); (P.R.)
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Frisbie L, Weissman SJ, Kapoor H, D'Angeli M, Salm A, Radcliff J, Rabinowitz P. Antimicrobial Resistance Patterns of Urinary Escherichia coli Among Outpatients in Washington State, 2013-2017: Associations with Age and Sex. Clin Infect Dis 2021; 73:1066-1074. [PMID: 33768228 DOI: 10.1093/cid/ciab250] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Management of acute, uncomplicated cystitis in outpatients benefits from knowledge of drug resistance patterns in the population. However, antibiograms are often not available for the outpatient setting, and the role of host factors such as sex and age in assessing the likelihood of resistance are not well understood. We investigated whether antibiotic resistance patterns of outpatient urinary Escherichia coli (EC) isolates vary by age group and sex in a large database of antibiotic susceptibility test (AST) results from Washington State. METHODS We retrospectively analyzed AST data for outpatient urinary EC isolates in Washington State tested at a clinical reference laboratory from 2013 - 2017. In logistic regression models stratified by sex, we tested the associations of antibiotic resistance with patient age. RESULTS We found females >50 years had greater odds than females younger than 19 for resistance to amoxicillin-clavulanate (odds ratio [OR], 1.43; 95% CI, 1.22-1.69), ciprofloxacin (OR, 3.04; 95% CI, 2.48-3.74), ceftriaxone (OR, 2.58; 95% CI, 1.77-3.92), and gentamicin (OR, 1.62; 95% CI, 1.27-2.08) (all p<0.001). Compared to males younger than 19, males >50 years had greater odds of resistance to ciprofloxacin (OR, 2.59; 95% CI, 1.18-5.69) and lower odds of resistance to amoxicillin-clavulanate (OR, 0.56; 95% CI, 0.34-0.96) (all p<0.05). CONCLUSION These findings demonstrate that age and sex are associated with variability in antibiotic resistance patterns in the outpatient setting. Availability of outpatient antibiotic resistance data based on sex and age may be useful to inform empiric prescribing for outpatient UTIs and to support antibiotic stewardship efforts.
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Affiliation(s)
- Lauren Frisbie
- Department of Environmental and Occupational Health Sciences, Center for One Health Research (COHR), University of Washington School of Public Health, Seattle WA, USA
| | - Scott J Weissman
- Infectious Diseases Department, Seattle Children's Hospital, Seattle WA, USA
| | - Hema Kapoor
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus NJ, USA
| | | | - Ann Salm
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus NJ, USA
| | - Jeff Radcliff
- Infectious Diseases/Immunology, Quest Diagnostics, Secaucus NJ, USA
| | - Peter Rabinowitz
- Department of Environmental and Occupational Health Sciences, Center for One Health Research (COHR), University of Washington School of Public Health, Seattle WA, USA
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11
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Satlin MJ, Weissman SJ, Carpenter PA, Seo SK, Shelburne SA. American Society of Transplantation and Cellular Therapy Series, 1: Enterobacterales Infection Prevention and Management after Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:108-114. [PMID: 33781545 DOI: 10.1016/j.jtct.2020.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/15/2022]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for hematopoietic cell transplantation (HCT). A completely fresh approach was taken, with the goal of better serving clinical providers by publishing each stand-alone topic in the infectious diseases series in a concise format of frequently asked questions (FAQs), tables, and figures [1]. Adult and pediatric infectious diseases and HCT content experts developed and then answered FAQs, and then finalized topics with harmonized recommendations that were made by assigning a strength of recommendation ranging from A to E paired with a level of supporting evidence graded I to III. The first topic in the series focuses on potentially life-threatening infections in HCT caused by Enterobacterales, relevant infection risk factors, and practical considerations regarding prevention and treatment of these infections in the setting of emerging multidrug resistance.
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Affiliation(s)
- Michael J Satlin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York.
| | - Scott J Weissman
- Division of Infectious Diseases, Seattle Children's Hospital, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Paul A Carpenter
- Division of Infectious Diseases, Seattle Children's Hospital, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Susan K Seo
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samuel A Shelburne
- Department of Infectious Diseases, MD Anderson Cancer Center, Houston, Texas
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12
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Affiliation(s)
- Scott J Weissman
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington
| | - Barbara Stoll
- Department of Pediatrics, McGovern Medical School at UTHealth, Houston, Texas
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13
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Miles-Jay A, Weissman SJ, Adler AL, Baseman JG, Zerr DM. Whole Genome Sequencing Detects Minimal Clustering Among Escherichia coli Sequence Type 131-H30 Isolates Collected From United States Children's Hospitals. J Pediatric Infect Dis Soc 2020; 10:183-187. [PMID: 32185378 PMCID: PMC7996643 DOI: 10.1093/jpids/piaa023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/13/2019] [Accepted: 02/28/2020] [Indexed: 11/13/2022]
Abstract
We applied whole genome sequencing to identify putative transmission clusters among clinical multidrug-resistant Escherichia coli sequence type 131-H30 isolates from 4 United States children's hospitals. Of 126 isolates, 17 were involved in 8 putative transmission clusters; 4 clusters showed evidence of healthcare-associated epidemiologic linkages. Geographic clustering analyses showed weak geographic clustering.
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Affiliation(s)
- Arianna Miles-Jay
- Department of Epidemiology, University of Washington, Seattle, Washington, USA,Seattle Children’s Research Institute, Seattle, Washington, USA,Corresponding Author: Arianna Miles-Jay, PhD, MPH, University of Michigan Medical School, 1150 W Medical Center Dr, Medical Science Research Bldg I, Rm 1511, Ann Arbor, MI 48109. E-mail: . Present affiliation: Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott J Weissman
- Seattle Children’s Research Institute, Seattle, Washington, USA,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Amanda L Adler
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Janet G Baseman
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Danielle M Zerr
- Seattle Children’s Research Institute, Seattle, Washington, USA,Department of Pediatrics, University of Washington, Seattle, Washington, USA
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14
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Miles-Jay A, Weissman SJ, Adler AL, Tchesnokova V, Sokurenko EV, Baseman JG, Zerr DM. Epidemiology and Antimicrobial Resistance Characteristics of the Sequence Type 131-H30 Subclone Among Extraintestinal Escherichia coli Collected From US Children. Clin Infect Dis 2019; 66:411-419. [PMID: 29020219 DOI: 10.1093/cid/cix805] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 03/31/2017] [Accepted: 09/14/2017] [Indexed: 11/14/2022] Open
Abstract
Background Escherichia coli sequence type (ST) 131-H30 is a globally important pathogen implicated in rising rates of multidrug resistance among E. coli causing extraintestinal infections. Previous studies have focused on adults, leaving the epidemiology of H30 among children undefined. Methods We used clinical data and isolates from a case-control study of extended-spectrum cephalosporin-resistant E. coli conducted at 4 US children's hospitals to estimate the burden and identify host correlates of infection with H30. H30 isolates were identified using 2-locus genotyping; host correlates were examined using log-binomial regression models stratified by extended-spectrum cephalosporin resistance status. Results A total of 339 extended-spectrum cephalosporin-resistant and 1008 extended-spectrum cephalosporin-susceptible E. coli isolates were available for analyses. The estimated period prevalence of H30 was 5.3% among all extraintestinal E. coli isolates (95% confidence interval [CI], 4.6%-7.1%); H30 made up 43.3% (81/187) of extended-spectrum β-lactamase (ESBL)-producing isolates in this study. Host correlates of infection with H30 differed by extended-spectrum cephalosporin resistance status: Among resistant isolates, age ≤5 years was positively associated with H30 infection (relative risk [RR], 1.83 [95% CI, 1.19-2.83]); among susceptible isolates, age ≤5 years was negatively associated with H30 (RR, 0.48 [95% CI, .27-.87]), while presence of an underlying medical condition was positively associated (RR, 4.49 [95% CI, 2.43-8.31]). Conclusions ST131-H30 is less common among extraintestinal E. coli collected from children compared to reported estimates among adults, possibly reflecting infrequent fluoroquinolone use in pediatrics; however, it is similarly dominant among ESBL-producing isolates. The H30 subclone appears to disproportionately affect young children relative to other extended-spectrum cephalosporin-resistant E. coli.
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Affiliation(s)
- Arianna Miles-Jay
- Department of Epidemiology, University of Washington, Seattle.,Seattle Children's Research Institute, Seattle
| | - Scott J Weissman
- Seattle Children's Research Institute, Seattle.,Department of Pediatrics, University of Washington, Seattle
| | | | | | | | - Janet G Baseman
- Department of Epidemiology, University of Washington, Seattle
| | - Danielle M Zerr
- Seattle Children's Research Institute, Seattle.,Department of Pediatrics, University of Washington, Seattle
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15
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Courter JD, Parker SK, Thurm C, Kronman MP, Weissman SJ, Shah SS, Hersh AL, Brogan TV, Patel SJ, Smith MJ, Lee BR, Newland JG, Gerber JS. Accuracy of Administrative Data for Antimicrobial Administration in Hospitalized Children. J Pediatric Infect Dis Soc 2018; 7:261-263. [PMID: 28992185 DOI: 10.1093/jpids/pix064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/12/2017] [Indexed: 12/26/2022]
Abstract
Administrative data are often used as a proxy for medication-administration record (MAR) data. Multicenter MAR data were compared retrospectively with administrative data from January 2010 through June 2013 from the Pediatric Health Information Systems database. We found that administrative data were more concordant with bill-upon-administration than bill-upon-dispense data.
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Affiliation(s)
- Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical, Ohio
| | - Sarah K Parker
- Department of Pediatrics, Children's Hospital Colorado/University of Colorado, Aurora
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas
| | - Matthew P Kronman
- Division of Infectious Diseases, University of Washington School of Medicine
| | - Scott J Weissman
- Division of Infectious Diseases, University of Washington School of Medicine
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Ohio
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| | - Thomas V Brogan
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine
| | - Sameer J Patel
- Division of Pediatric Infectious Disease Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Michael J Smith
- Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Kentucky
| | - Brian R Lee
- Division of Infectious Diseases, Children's Mercy Hospital-Kansas City
| | - Jason G Newland
- Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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16
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Gern BH, Greninger AL, Weissman SJ, Stapp JR, Tao Y, Qin X. Continued in vitro cefazolin susceptibility in methicillin-susceptible Staphylococcus aureus. Ann Clin Microbiol Antimicrob 2018; 17:5. [PMID: 29463249 PMCID: PMC5819674 DOI: 10.1186/s12941-018-0257-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 10/12/2017] [Accepted: 02/12/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES In vitro trends of cefazolin and ceftriaxone susceptibilities from pediatric clinical isolates of methicillin-susceptible Staphylococcus aureus (MSSA) between 2011 and 2016 were analyzed for surveillance. METHODS Our laboratory continues to use agar disk diffusion for staphylococcal susceptibilities applying Clinical Laboratory Standard Institute's 2012 breakpoints. RESULTS A total of 3992 MSSA clinical isolates in the last 6 years were analyzed for their in vitro cefazolin and ceftriaxone susceptibilities. While all MSSA isolates exhibited cefazolin susceptibilities within the "susceptible" zone range, there have been a proportion of isolates with ceftriaxone susceptibilities falling in "intermediate" zones, ranging from 2.6% in 2011 to 8.3% in 2016. CONCLUSIONS Cefazolin continues to be the recommended agent for MSSA treatment at our institution, reflected by the finding that only 2% (6/321) of patients who received ceftriaxone as definitive therapy for MSSA bacteremia during the study period. We have confirmed the cefoxitin-predicted MSSA susceptibility to cefazolin, but have found concerning drifts in ceftriaxone susceptibilities by continued in vitro monitoring over the last 6 years.
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Affiliation(s)
- Benjamin H Gern
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | | | - Scott J Weissman
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Jennifer R Stapp
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Yue Tao
- Shanghai Children's Medical Center, Translational Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xuan Qin
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA. .,Seattle Children's Microbiology Laboratory, Seattle, USA. .,Department of Laboratory Medicine, University of Washington, Seattle, WA, USA.
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17
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Zerr DM, Weissman SJ, Zhou C, Kronman MP, Adler AL, Berry JE, Rayar J, Myers J, Haaland WL, Burnham CAD, Elward A, Newland J, Selvarangan R, Sullivan KV, Zaoutis T, Qin X. The Molecular and Clinical Epidemiology of Extended-Spectrum Cephalosporin- and Carbapenem-Resistant Enterobacteriaceae at 4 US Pediatric Hospitals. J Pediatric Infect Dis Soc 2017; 6:366-375. [PMID: 28339623 PMCID: PMC5907845 DOI: 10.1093/jpids/piw076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 01/21/2016] [Accepted: 11/10/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In this report, we aim to describe the epidemiology of extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections in children. METHODS ESC-R and CR Enterobacteriaceae isolates from normally sterile sites of patients aged <22 years from 4 freestanding pediatric medical centers were collected along with the associated clinical data. RESULTS The overall frequencies of ESC-R and CR isolates according to hospital over the 4-year study period ranged from 0.7% to 2.8%. Rates of ESC-R or CR Escherichia coli and Klebsiella pneumoniae varied according to hospital and ranged from 0.75 to 3.41 resistant isolates per 100 isolates (P < .001 for any differences). E coli accounted for 272 (77%) of the resistant isolates; however, a higher rate of resistance was observed in K pneumoniae isolates (1.78 vs 1.27 resistant isolates per 100 same-species isolates, respectively; P = .005). One-third of the infections caused by ESC-R or CR E coli were community-associated. In contrast, infections caused by ESC-R or CR K pneumoniae were more likely than those caused by resistant E coli to be healthcare- or hospital-associated and to occur in patients with an indwelling device (P ≤ .003 for any differences, multivariable logistic regression). Nonsusceptibility to 3 common non-β-lactam agents (ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole) occurred in 23% of the ESC-R isolates. The sequence type 131-associated fumC/fimH-type 40-30 was the most prevalent sequence type among all resistant E coli isolates (30%), and the clonal group 258-associated allele tonB79 was the most prevalent allele among all resistant K pneumoniae isolates (10%). CONCLUSIONS The epidemiology of ESC-R and CR Enterobacteriaceae varied according to hospital and species (E coli vs K pneumoniae). Both community and hospital settings should be considered in future research addressing pediatric ESC-R Enterobacteriaceae infection.
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Affiliation(s)
- Danielle M Zerr
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington,Correspondence: D. M. Zerr, MD, MPH, Seattle Children’s Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105 ()
| | - Scott J Weissman
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | - Chuan Zhou
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | - Matthew P Kronman
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | | | | | | | - Jeff Myers
- Seattle Children’s Research Institute, Washington
| | | | - Carey-Ann D Burnham
- Departments of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri,Department of Pediatrics, St. Louis Children’s Hospital, Missouri
| | - Alexis Elward
- Department of Pediatrics, St. Louis Children’s Hospital, Missouri,Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Newland
- Department of Pediatrics, University of Missouri, Kansas City, Missouri,Children’s Mercy, Kansas City, Missouri
| | - Rangaraj Selvarangan
- Children’s Mercy, Kansas City, Missouri,Department of Pathology and Laboratory Medicine, University of Missouri, Kansas City, Missouri
| | - Kaede V Sullivan
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Children’s Hospital of Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Children’s Hospital of Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Xuan Qin
- Seattle Children’s Research Institute, Washington,Departments of Laboratory Medicine, University of Washington, Seattle
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18
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Mortensen JE, DeBurger B, Powell EA, DiFranco-Fisher J, Koeth L, Weissman SJ. Characterisation of carbapenem-resistant Enterobacteriaceae from the southwestern Ohio, northern Kentucky and southeastern Indiana region. J Glob Antimicrob Resist 2016; 7:141-144. [DOI: 10.1016/j.jgar.2016.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 01/22/2023] Open
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19
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Weissman SJ, Hansen NI, Zaterka-Baxter K, Higgins RD, Stoll BJ. Emergence of Antibiotic Resistance-Associated Clones Among Escherichia coli Recovered From Newborns With Early-Onset Sepsis and Meningitis in the United States, 2008-2009. J Pediatric Infect Dis Soc 2016; 5:269-76. [PMID: 26407251 PMCID: PMC5125450 DOI: 10.1093/jpids/piv013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 09/23/2014] [Accepted: 02/24/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Escherichia coli associated with early-onset sepsis (EOS) have historically been antibiotic-susceptible and K1-encapsulated. In the era of emerging antibiotic resistance, however, the clonal makeup of E coli associated with EOS has not been well characterized. METHODS Escherichia coli isolates were collected from 28 cases of EOS and early-onset meningitis (EOM) from April 2008 through December 2009, during a parent study conducted at National Institute of Child Health and Human Development Neonatal Research Network centers from February 2006 through December 2009. Clinical and microbiologic data were collected for the parent study. We applied polymerase chain reaction- and sequence-based molecular techniques to determine clonal, virulence-associated and antibiotic resistance-associated traits of the E coli isolates. RESULTS Among 28 E coli strains, phylogroup B2 strains predominated (68%), of which more than half were K1-encapsulated (53%). Phylogroup D strains were prominent as well (18%), but none were K1-encapsulated. Across the strain collection, the rate of ampicillin resistance was high (78%). The sole strain resistant to either extended-spectrum cephalosporins or fluoroquinolones represented ST131 H30-Rx, the multidrug-resistant subclone that has emerged worldwide in the last decade. This strain encoded extended-spectrum β-lactamase CTX-M-15 and carried an IncF plasmid of type F2:A1:B-. CONCLUSIONS In this collection of EOS/EOM-associated E coli isolates, we observed a high rate of ampicillin resistance, a low rate of fluoroquinolone resistance, and no aminoglycoside resistance, with resistance to third-generation cephalosporins appearing in only a single strain, from the worldwide emerging ST131 clone. Ongoing surveillance of antibiotic resistance among EOS isolates is warranted, to ensure that standard empiric regimens remain effective.
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Affiliation(s)
- Scott J. Weissman
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Washington
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Kristen Zaterka-Baxter
- Social, Statistical and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia,Children's Healthcare of Atlanta, Georgia,Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, Bethesda, Maryland
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20
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Kronman MP, Oron AP, Ross RK, Hersh AL, Newland JG, Goldin A, Rangel SJ, Weissman SJ, Zerr DM, Gerber JS. Extended- Versus Narrower-Spectrum Antibiotics for Appendicitis. Pediatrics 2016; 138:peds.2015-4547. [PMID: 27354453 DOI: 10.1542/peds.2015-4547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Appendicitis guidelines recommend either narrower- or extended-spectrum antibiotics for treatment of complicated appendicitis. The goal of this study was to compare the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with appendicitis. METHODS We performed a retrospective cohort study of children aged 3 to 18 years discharged between 2011 and 2013 from 23 freestanding children's hospitals with an appendicitis diagnosis and appendectomy performed. Subjects were classified as having complicated appendicitis if they had a postoperative length of stay ≥3 days, a central venous catheter placed, major or severe illness classification, or ICU admission. The exposure of interest was receipt of systemic extended-spectrum antibiotics (piperacillin ± tazobactam, ticarcillin ± clavulanate, ceftazidime, cefepime, or a carbapenem) on the day of appendectomy or the day after. The primary outcome was 30-day readmission for wound infection or repeat abdominal surgery. Multivariable logistic regression, propensity score weighting, and subgroup analyses were used to control for confounding by indication. RESULTS Of 24 984 patients, 17 654 (70.7%) had uncomplicated appendicitis and 7330 (29.3%) had complicated appendicitis. Overall, 664 (2.7%) patients experienced the primary outcome, 1.1% among uncomplicated cases and 6.4% among complicated cases (P < .001). Extended-spectrum antibiotic exposure was significantly associated with the primary outcome in complicated (adjusted odds ratio, 1.43 [95% confidence interval, 1.06 to 1.93]), but not uncomplicated, (adjusted odds ratio, 1.32 [95% confidence interval, 0.88 to 1.98]) appendicitis. These odds ratios remained consistent across additional analyses. CONCLUSIONS Extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, and
| | - Assaf P Oron
- Center for Clinical and Translational Research, and
| | - Rachael K Ross
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jason G Newland
- Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Adam Goldin
- Department of Pediatric Surgery, University of Washington, Seattle, Washington; and
| | - Shawn J Rangel
- Department of Pediatric Surgery, Harvard Medical School, Boston, Massachusetts
| | - Scott J Weissman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Global Infectious Diseases Research, Seattle Children's Hospital Research Institute, Seattle, Washington
| | - Danielle M Zerr
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, and
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Newland JG, Gerber JS, Weissman SJ, Shah SS, Turgeon C, Hedican EB, Thurm C, Hall M, Courter J, Brogan TV, Maples H, Lee BR, Hersh AL. Prevalence and Characteristics of Antimicrobial Stewardship Programs at Freestanding Children's Hospitals in the United States. Infect Control Hosp Epidemiol 2016; 35:265-71. [DOI: 10.1086/675277] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background and Objective.Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals.Methods.We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP.Results.We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1–1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst.Conclusions.Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.
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22
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Johnson JR, Thuras P, Johnston BD, Weissman SJ, Limaye AP, Riddell K, Scholes D, Tchesnokova V, Sokurenko E. The Pandemic H30 Subclone of Escherichia coli Sequence Type 131 Is Associated With Persistent Infections and Adverse Outcomes Independent From Its Multidrug Resistance and Associations With Compromised Hosts. Clin Infect Dis 2016; 62:1529-1536. [PMID: 27025834 DOI: 10.1093/cid/ciw193] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/11/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The H30 subclone within Escherichia coli sequence type 131 (ST131-H30) has emerged rapidly to become the leading antibiotic-resistant E. coli strain. Hypervirulence, multidrug resistance, and opportunism have been proposed as explanations for its epidemic success. METHODS We assessed 1133 consecutive unique E. coli clinical isolates from 5 medical centers (2010-2011) for H30 genotype, which we compared with epidemiological and clinical data extracted from medical records by blinded reviewers. Using univariable and multivariable logistic regression analysis, we explored associations of H30 with underlying host characteristics, clinical presentations, management, and outcomes, adjusting for host characteristics. RESULTS The H30 (n = 107) isolates were associated with hosts who were older, male, locally and systemically compromised, and healthcare and antibiotic exposed. With multivariable adjustment for host factors, H30 lost its numerous significant univariable associations with initial clinical presentation, but remained strongly associated with clinical persistence (odds ratio [OR], 3.47; 95% confidence interval [CI], 1.89-6.37), microbiological persistence (OR, 4.46; 95% CI, 2.38-8.38), subsequent hospital admission (OR, 2.68; 95% CI, 1.35-5.33), and subsequent new infection (OR, 1.73; 95% CI, 1.01-3.00). These host-adjusted associations remained strong even with added adjustment for resistance to the initially prescribed antibiotics, and the adverse outcome associations (subsequent hospital admission, new infection) were independent of clinical and microbiological persistence. CONCLUSIONS In addition to targeting compromised hosts and resisting multiple antibiotics, H30 isolates may have an intrinsic ability to cause highly persistent infections and later adverse outcomes. The basis for these host- and resistance-independent associations is unclear, but they should be considered when managing patients with H30 infections.
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Affiliation(s)
- James R Johnson
- Veterans Affairs Medical Center
- University of Minnesota, Minneapolis
| | - Paul Thuras
- Veterans Affairs Medical Center
- University of Minnesota, Minneapolis
| | - Brian D Johnston
- Veterans Affairs Medical Center
- University of Minnesota, Minneapolis
| | | | | | - Kim Riddell
- Group Health Cooperative, Seattle, Washington
| | - Delia Scholes
- University of Washington
- Group Health Cooperative, Seattle, Washington
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Stillwell T, Green M, Barbadora K, Ferrelli JG, Roberts TL, Weissman SJ, Nowalk A. Outbreak of KPC-3 Producing Carbapenem-Resistant Klebsiella pneumoniae in a US Pediatric Hospital. J Pediatric Infect Dis Soc 2015; 4:330-8. [PMID: 26582872 DOI: 10.1093/jpids/piu080] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [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: 12/31/2013] [Accepted: 07/06/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND The increase in carbapenem-resistant Enterobacteriaceae (CRE) infections is a critical public health issue. We recently experienced the largest single-center pediatric outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) at our hospital. The objective of this study was to describe the molecular epidemiology of this outbreak before and after infection-prevention interventions. METHODS All positive cultures and associated clinical conditions were reviewed to determine whether health care-associated infections (HAIs) exist. HAIs were defined using Centers for Disease Control and Prevention guidelines. CRKP isolates were collected and screened for the presence of β-lactamase genes. Strain relatedness of CRKP isolates was determined by field-inversion gel electrophoresis (FIGE) and multilocus sequence typing (MLST). Polymerase chain reaction (PCR) amplification and sequencing of blaTEM, blaSHV, and blaKPC genes were performed on representative isolates. RESULTS During March-July 2010, 18 CRKP isolates were recovered from 15 unique patients. Six isolates were considered HAIs; all were central-line-associated bloodstream infections. All isolates testing positive by PCR for blaKPC were found to carry KPC-3 in transposon Tn4401 isotype "b." FIGE revealed 2 prevalent patterns (accounting for 10 and 3 CRKP isolates, respectively) that MLST demonstrated to consist entirely of strains from ST730; the remaining FIGE types corresponded to ST14, ST15, and ST1559 (a single-locus variant of ST730), with these alternate backgrounds appearing later in the outbreak. New CRKP cases decreased after the implementation of infection-control interventions. All isolates were ciprofloxacin sensitive. CONCLUSIONS Molecular analyses document the introduction of a KPC-3-producing CRKP clone into our hospital setting, though some isolates appear to have other mechanisms of carbapenem resistance. The transition to a polyclonal epidemiology suggests that the initial outbreak was due to nosocomial spread of a single ST730 clone, while latter isolates may have been secondary to the introduction of a blaKPC-3/Tn4401 isotype "b"-containing plasmid into other K pneumoniae strain backgrounds versus new carbapenemase-producing bacteria.
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Affiliation(s)
| | - Michael Green
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
| | - Karen Barbadora
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
| | - Juliet G Ferrelli
- Infection Control Department, University of Pittsburgh Medical Center Mercy
| | - Terri L Roberts
- Infection Control Department, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pennsylvania
| | - Scott J Weissman
- Department of Pediatrics, Seattle Children's Hospital, Washington
| | - Andrew Nowalk
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
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24
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Geyer CN, Fowler RC, Johnson JR, Johnston B, Weissman SJ, Hawkey P, Hanson ND. Evaluation of CTX-M steady-state mRNA, mRNA half-life and protein production in various STs of Escherichia coli. J Antimicrob Chemother 2015; 71:607-16. [PMID: 26612874 PMCID: PMC4743699 DOI: 10.1093/jac/dkv388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/19/2015] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES High levels of β-lactamase production can impact treatment with a β-lactam/β-lactamase inhibitor combination. Goals of this study were to: (i) compare the mRNA and protein levels of CTX-M-15- and CTX-M-14-producing Escherichia coli from 18 different STs and 10 different phylotypes; (ii) evaluate the mRNA half-lives and establish a role for chromosomal- and/or plasmid-encoded factors; and (iii) evaluate the zones of inhibition for piperacillin/tazobactam and ceftolozane/tazobactam. METHODS Disc diffusion was used to establish zone size. RNA analysis was accomplished using real-time RT-PCR and CTX-M protein levels were evaluated by immunoblotting. Clinical isolates, transformants and transconjugants were used to evaluate mRNA half-lives. RESULTS mRNA levels of CTX-M-15 were up to 165-fold higher compared with CTX-M-14. CTX-M-15 protein levels were 2-48-fold less than their respective transcript levels, while CTX-M-14 protein production was comparable to the observed transcript levels. Nineteen of 25 E. coli (76%) had extended CTX-M-15 mRNA half-lives of 5-15 min and 16 (100%) CTX-M-14 isolates had mRNA half-lives of <2-3 min. Transformants had mRNA half-lives of <2 min for both CTX-M-type transcripts, while transconjugant mRNA half-lives corresponded to the half-life of the donor. Ceftolozane/tazobactam zone sizes were ≥19 mm, while piperacillin/tazobactam zone sizes were ≥17 mm. CONCLUSIONS CTX-M-15 mRNA and protein production did not correlate. Neither E. coli ST nor phylotype influenced the variability observed for CTX-M-15 mRNA or protein produced. mRNA half-life is controlled by a plasmid-encoded factor and may influence mRNA transcript levels, but not protein levels.
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Affiliation(s)
- Chelsie N Geyer
- Department of Medical Microbiology and Immunology, Center for Research in Anti-Infectives and Biotechnology, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Randal C Fowler
- Department of Medical Microbiology and Immunology, Center for Research in Anti-Infectives and Biotechnology, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - James R Johnson
- Veterans Affairs Medical Center, Minneapolis, MN, USA University of Minnesota, Minneapolis, MN, USA
| | - Brian Johnston
- Veterans Affairs Medical Center, Minneapolis, MN, USA University of Minnesota, Minneapolis, MN, USA
| | - Scott J Weissman
- Center for Global Infectious Diseases Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Peter Hawkey
- Public Health England (PHE), West Midlands Public Health Laboratory, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK Institute of Microbiology and Infection, School of Biosciences, School of Immunity and Infection, University of Birmingham, Edgbaston Campus, Birmingham B15 2TT, UK
| | - Nancy D Hanson
- Department of Medical Microbiology and Immunology, Center for Research in Anti-Infectives and Biotechnology, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
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Olson SC, Smith S, Weissman SJ, Kronman MP. Adverse Events in Pediatric Patients Receiving Long-Term Outpatient Antimicrobials. J Pediatric Infect Dis Soc 2015; 4:119-25. [PMID: 26407410 PMCID: PMC4608493 DOI: 10.1093/jpids/piu037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [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: 01/13/2014] [Accepted: 04/05/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although long treatment courses of outpatient antimicrobials are often used in pediatric patients, few data exist regarding the frequency of adverse events (AEs) associated with these medications. METHODS We performed a retrospective cohort study of all patients seen in the Infectious Diseases clinic at a tertiary referral children's hospital from August 1, 2009 to August 1, 2011. We included patients who received ≥14 days of oral or intravenous antibiotic, antiviral, or antifungal medications. Patients receiving only prophylactic medications or human immunodeficiency virus treatment were excluded. RESULTS Three hundred thirty-five subjects met inclusion criteria, with a median age of 7.4 years at start of therapy. The cohort was predominantly male (60%), white (54%), and previously healthy (59%). A majority (88.4%) of subjects were treated for bacterial infections. β-Lactam agents were the most commonly used antimicrobial class (210 subjects; 62.7%), followed by clindamycin (86; 25.7%), rifampin (76; 22.7%), and vancomycin (62; 18.5%). Overall, 107 (31.9%) subjects experienced 151 distinct AEs. The most common individual AE noted was diarrhea (44; 29.1% of all AEs). Serious AEs developed in 42 (12.5%) subjects, including allergic reactions (15; 11.3% of all AEs), venous catheter-related complications (14; 13.0% of those with catheters), neutropenia (9; 3.0%), renal insufficiency (7; 2.5%), and hepatotoxicity (3; 1.1%). Rates of AEs were similar between those on oral and intravenous antimicrobials. CONCLUSIONS In our study population, patients on prolonged oral or intravenous outpatient antimicrobials experienced AEs frequently. These findings support the need for close monitoring of pediatric patients on prolonged antimicrobial therapy and vigilance for unwanted effects of these medications.
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Affiliation(s)
- Scott C. Olson
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle
| | - Sherilyn Smith
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Clinical and Translational Research
| | - Scott J. Weissman
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Global Infectious Disease Research, Seattle Children's Hospital Research Institute, Washington
| | - Matthew P. Kronman
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Clinical and Translational Research
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Hersh AL, De Lurgio SA, Thurm C, Lee BR, Weissman SJ, Courter JD, Brogan TV, Shah SS, Kronman MP, Gerber JS, Newland JG. Antimicrobial stewardship programs in freestanding children's hospitals. Pediatrics 2015; 135:33-9. [PMID: 25489018 DOI: 10.1542/peds.2014-2579] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [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] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Single-center evaluations of pediatric antimicrobial stewardship programs (ASPs) suggest that ASPs are effective in reducing and improving antibiotic prescribing, but studies are limited. Our objective was to compare antibiotic prescribing rates in a group of pediatric hospitals with formalized ASPs (ASP+) to a group of concurrent control hospitals without formalized stewardship programs (ASP-). METHODS We evaluated the impact of ASPs on antibiotic prescribing over time measured by days of therapy/1000 patient-days in a group of 31 freestanding children's hospitals (9 ASP+, 22 ASP-). We compared differences in average antibiotic use for all ASP+ and ASP- hospitals from 2004 to 2012 before and after release of 2007 Infectious Diseases Society of America guidelines for developing ASPs. Antibiotic use was compared for both all antibacterials and for a select subset (vancomycin, carbapenems, linezolid). For each ASP+ hospital, we determined differences in the average monthly changes in antibiotic use before and after the program was started by using interrupted time series via dynamic regression. RESULTS In aggregate, as compared with those years preceding the guidelines, there was a larger decline in average antibiotic use in ASP+ hospitals than in ASP- hospitals from 2007 to 2012, the years after the release of Infectious Diseases Society of America guidelines (11% vs 8%, P = .04). When examined individually, relative to preimplementation trends, 8 of 9 ASP+ hospitals revealed declines in antibiotic use, with an average monthly decline in days of therapy/1000 patient-days of 5.7%. For the select subset of antibiotics, the average monthly decline was 8.2%. CONCLUSIONS Formalized ASPs in children's hospitals are effective in reducing antibiotic prescribing.
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Affiliation(s)
- Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | - Stephen A De Lurgio
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas City, Kansas
| | - Brian R Lee
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Scott J Weissman
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | | | - Thomas V Brogan
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; and
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Jeffrey S Gerber
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason G Newland
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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Drekonja DM, Beekmann SE, Elliott S, Mukundan D, Polenakovik H, Rosenthal ME, Tamma PD, Polgreen PM, Weissman SJ. Challenges in the management of infections due to carbapenem-resistant Enterobacteriaceae. Infect Control Hosp Epidemiol 2014; 35:437-9. [PMID: 24602953 DOI: 10.1086/675604] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) infections are increasing and are associated with considerable morbidity and mortality. Members of the Emerging Infections Network treating CRE encountered difficulties in obtaining laboratory results and struggled with limited treatment options. In addition, many treated patients experienced an alarming degree of drug toxicity from CRE therapies.
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28
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Kronman MP, Zerr DM, Qin X, Englund J, Cornell C, Sanders JE, Myers J, Rayar J, Berry JE, Adler AL, Weissman SJ. Intestinal decontamination of multidrug-resistant Klebsiella pneumoniae after recurrent infections in an immunocompromised host. Diagn Microbiol Infect Dis 2014; 80:87-9. [PMID: 25041704 DOI: 10.1016/j.diagmicrobio.2014.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 03/08/2014] [Revised: 04/22/2014] [Accepted: 06/15/2014] [Indexed: 01/13/2023]
Abstract
Multidrug-resistant (MDR) Enterobacteriaceae infections are associated with increased morbidity. We describe a 20-year-old hematopoietic cell transplantation recipient with recurrent MDR Klebsiella pneumoniae infection, prolonged intestinal colonization, and subsequent intestinal decontamination. Further study should evaluate stool surveillance, molecular typing, and fecal microbiota transplantation for patients with intestinal MDR Enterobacteriaceae carriage.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA.
| | - Danielle M Zerr
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Xuan Qin
- Microbiology laboratory, Seattle Children's Hospital, Seattle, WA, USA; Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Janet Englund
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Cathy Cornell
- Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Jean E Sanders
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jeffrey Myers
- Center for Childhood Infections and Prematurity Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Jaipreet Rayar
- Center for Childhood Infections and Prematurity Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Jessica E Berry
- Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Amanda L Adler
- Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Scott J Weissman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Division of Infectious Diseases, University of Washington, Seattle, WA, USA
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Abstract
BACKGROUND Empirical combination antibiotic regimens consisting of a β-lactam and an aminoglycoside are frequently employed in the pediatric population. Data to demonstrate the comparative benefit of empirical β-lactam combination therapy relative to monotherapy for culture-proven Gram-negative bacteremia are lacking in the pediatric population. METHODS We conducted a retrospective cohort study of children treated for Gram-negative bacteremia at The Johns Hopkins Hospital from 2004 through 2012. We compared the estimated odds of 10-day mortality and the relative duration of bacteremia for children receiving empirical combination therapy versus empirical monotherapy using 1:1 nearest-neighbor propensity-score matching without replacement, before performing regression analysis. RESULTS We identified 226 matched pairs of patients well balanced on baseline covariates. Ten-day mortality was similar between the groups (odds ratio, 0.84; 95% confidence interval [CI], 0.28 to 1.71). Use of empirical combination therapy was not associated with a decrease in the duration of bacteremia (-0.51 days; 95% CI, -2.22 to 1.48 days). There was no survival benefit when evaluating 10-day mortality for the severely ill (pediatric risk of mortality III score ≥15) or profoundly neutropenic patients (absolute neutrophil count ≤100 cells/mL) receiving combination therapy. However, a survival benefit was observed when empirical combination therapy was prescribed for children growing multidrug-resistant Gram-negative organisms from the bloodstream (odds ratio, 0.70; 95% CI, 0.51 to 0.84). CONCLUSIONS Although there appears to be no advantage to the routine addition of an aminoglycoside to a β-lactam as empirical therapy for children who have Gram-negative bacteremia, children who have risk factors for MDRGN organisms appear to benefit from this practice.
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Affiliation(s)
- Anna C Sick
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Alison E Turnbull
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Scott J Weissman
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; and
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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30
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Little ML, Qin X, Zerr DM, Weissman SJ. Molecular epidemiology of colonizing and disease-causing Klebsiella pneumoniae in paediatric patients. J Med Microbiol 2014; 63:610-616. [PMID: 24464691 DOI: 10.1099/jmm.0.063354-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Klebsiella pneumoniae causes a range of clinical disease in paediatric patients and is of increasing concern due to growing antibiotic resistance, yet little is known about the relative distribution of commensal and pathogens throughout the population structure of K. pneumoniae. We conducted a prospective, observational study of 92 isolates from Seattle Children's Hospital, including 49 disease isolates from blood and urine (13 and 36 isolates, respectively) and 43 colonization isolates from stool. Susceptibility to 20 antimicrobials was evaluated using disc diffusion, VITEK 2 and Etest. Strain relatedness was investigated using multilocus sequence typing (MLST). Demographic and clinical characteristics were largely similar between disease and colonization cohorts, with 85.7 and 74.4 % of disease and colonization cohort patients, respectively, having an underlying medical condition; the sole exception was a relative abundance of patients with urologic or renal abnormalities in the disease cohort, consistent with the predominance of urine specimens among the disease isolates. With regard to antibiotic susceptibility properties, no significant differences were noted between the disease and colonization cohorts. Using molecular analysis, 71 unique sequence types (STs) were distinguished, with novel MLST findings evident in both cohorts; 43 (46.7 %) isolates represented novel STs, including 22 with a novel allele sequence. Thirteen STs contained multiple isolates and all seven isolates with resistance to three or more antibiotic classes were within one of four multirepresentative STs. This study demonstrates that nearly half of paediatric Klebsiella isolates represent novel STs, with clustering of multidrug resistance within specific STs. These findings expand our understanding of the intersection of bacterial population structure, human colonization ecology and multidrug resistance in K. pneumoniae.
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Affiliation(s)
- Malaika L Little
- University of Washington and Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, Seattle, WA, USA
| | - Xuan Qin
- University of Washington and Seattle Children's Research Institute, Seattle, WA, USA.,Laboratory Medicine, Seattle, WA, USA
| | - Danielle M Zerr
- University of Washington and Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, Seattle, WA, USA
| | - Scott J Weissman
- University of Washington and Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, Seattle, WA, USA
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Chattopadhyay S, Taub F, Paul S, Weissman SJ, Sokurenko EV. Microbial variome database: point mutations, adaptive or not, in bacterial core genomes. Mol Biol Evol 2013; 30:1465-70. [PMID: 23493258 DOI: 10.1093/molbev/mst048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Analysis of genetic differences (gene presence/absence and nucleotide polymorphisms) among strains of a bacterial species is crucial to understanding molecular mechanisms of bacterial pathogenesis and selecting targets for novel antibacterial therapeutics. However, lack of genome-wide association studies on large and epidemiologically well-defined strain collections from the same species makes it difficult to identify the genes under positive selection and define adaptive polymorphisms in those genes. To address this need and to overcome existing limitations, we propose to create a "microbial variome"--a species-specific resource database of genomic variations based on molecular evolutionary analysis. Here, we present prototype variome databases of Escherichia coli and Salmonella enterica subspecies enterica (http://depts.washington.edu/sokurel/variome, last accessed March 26, 2013). The prototypes currently include the point mutations data of core protein-coding genes from completely sequenced genomes of 22 E. coli and 17 S. enterica strains. These publicly available databases allow for single- and multiple-field sorting, filtering, and searching of the gene variability data and the potential adaptive significance. Such resource databases would immensely help experimental research, clinical diagnostics, epidemiology, and environmental control of human pathogens.
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Weissman SJ, Adler A, Qin X, Zerr DM. Emergence of extended-spectrum β-lactam resistance among Escherichia coli at a US academic children's hospital is clonal at the sequence type level for CTX-M-15, but not for CMY-2. Int J Antimicrob Agents 2013; 41:414-20. [PMID: 23434250 DOI: 10.1016/j.ijantimicag.2013.01.006] [Citation(s) in RCA: 25] [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] [Received: 08/20/2012] [Revised: 12/23/2012] [Accepted: 01/06/2013] [Indexed: 10/27/2022]
Abstract
Resistance to extended-spectrum β-lactams is increasing worldwide among Escherichia coli and has been linked to a small number of emergent clones (e.g. ST38, ST131 and ST405) recovered from extraintestinal infections in community and hospital settings. There are, however, limited data about the relative contributions of bacterial strains, plasmids and β-lactamase genes to extended-spectrum β-lactam resistance in paediatric infections. We performed an extensive molecular analysis of phylogenetic, virulence and antibiotic resistance-related properties of 49 previously reported serial E. coli isolates recovered during 1999-2007 at Seattle Children's Hospital (Seattle, WA). Class C enzyme CMY-2 and class A enzyme CTX-M-15 were the most prominent extended-spectrum β-lactam resistance enzymes in the collection, first appearing in this patient population in 2001 and 2003, respectively, and then steadily increasing in frequency over the remainder of the study period. Among 19 CMY-2-positive isolates, 16 distinct STs were detected (D = 98.25%, 95% CI 96-100.25%), indicating that CMY spread is non-clonal at the host strain level. In contrast, among ten CTX-M-15-positive isolates, three STs were detected (D = 37.78%, 95% CI 2.36-73.20%), of which eight represented the worldwide-disseminated ST131 lineage, consistent with clonal spread of CTX-M-15-associated resistance. fimHTR subtyping of ten ST131 isolates (including two CTX-M-negative isolates) revealed that, within ST131, carriage of allele fimHTR30 correlated with CTX-M-15 positivity, whilst carriage of non-fimHTR30 alleles correlated with carriage of non-CTX-M enzymes. Thus, spread of CMY-2 is non-clonal at the ST level, but clonal spread of CTX-M-15 may be associated with a specific fimHTR-defined sublineage of ST131.
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Affiliation(s)
- Scott J Weissman
- Center for Childhood Infections and Prematurity Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.
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Johnson JR, Tchesnokova V, Johnston B, Clabots C, Roberts PL, Billig M, Riddell K, Rogers P, Qin X, Butler-Wu S, Price LB, Aziz M, Nicolas-Chanoine MH, Debroy C, Robicsek A, Hansen G, Urban C, Platell J, Trott DJ, Zhanel G, Weissman SJ, Cookson BT, Fang FC, Limaye AP, Scholes D, Chattopadhyay S, Hooper DC, Sokurenko EV. Abrupt emergence of a single dominant multidrug-resistant strain of Escherichia coli. J Infect Dis 2013; 207:919-28. [PMID: 23288927 DOI: 10.1093/infdis/jis933] [Citation(s) in RCA: 208] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fluoroquinolone-resistant Escherichia coli are increasingly prevalent. Their clonal origins--potentially critical for control efforts--remain undefined. METHODS Antimicrobial resistance profiles and fine clonal structure were determined for 236 diverse-source historical (1967-2009) E. coli isolates representing sequence type ST131 and 853 recent (2010-2011) consecutive E. coli isolates from 5 clinical laboratories in Seattle, Washington, and Minneapolis, Minnesota. Clonal structure was resolved based on fimH sequence (fimbrial adhesin gene: H subclone assignments), multilocus sequence typing, gyrA and parC sequence (fluoroquinolone resistance-determining loci), and pulsed-field gel electrophoresis. RESULTS Of the recent fluoroquinolone-resistant clinical isolates, 52% represented a single ST131 subclonal lineage, H30, which expanded abruptly after 2000. This subclone had a unique and conserved gyrA/parC allele combination, supporting its tight clonality. Unlike other ST131 subclones, H30 was significantly associated with fluoroquinolone resistance and was the most prevalent subclone among current E. coli clinical isolates, overall (10.4%) and within every resistance category (11%-52%). CONCLUSIONS Most current fluoroquinolone-resistant E. coli clinical isolates, and the largest share of multidrug-resistant isolates, represent a highly clonal subgroup that likely originated from a single rapidly expanded and disseminated ST131 strain. Focused attention to this strain will be required to control the fluoroquinolone and multidrug-resistant E. coli epidemic.
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Affiliation(s)
- James R Johnson
- Veterans Affairs Medical Center and University of Minnesota, Minneapolis, USA.
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Newland JG, Banerjee R, Gerber JS, Hersh AL, Steinke L, Weissman SJ. Antimicrobial Stewardship in Pediatric Care: Strategies and Future Directions. Pharmacotherapy 2012; 32:735-43. [DOI: 10.1002/j.1875-9114.2012.01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jason G. Newland
- Section of Infectious Diseases; Department of Pediatrics; University of Missouri-Kansas City; Children's Mercy Hospitals & Clinics; Kansas City; Missouri
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; Mayo Clinic College of Medicine; Mayo Children's Hospital; Rochester; Minnesota
| | - Jeffrey S. Gerber
- Division of Infectious Diseases; Department of Pediatrics; University of Pennsylvania School of Medicine; Children's Hospital of Philadelphia; Philadelphia; Pennsylvania
| | - Adam L. Hersh
- Division of Infectious Diseases; Department of Pediatrics; University of Utah; Primary Children's Medical Center; Salt Lake City; Utah
| | - Leah Steinke
- Department of Pharmacy; Children's Hospital of Michigan; Detroit Medical Center; Detroit; Michigan
| | - Scott J. Weissman
- Division of Infectious Diseases; Department of Pediatrics; University of Washington Medical Center; Seattle Children's Hospital; Seattle; Washington
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Jaspan HB, Brothers AW, Campbell AJP, McGuire JK, Browd SR, Manley TJ, Pak D, Weissman SJ. Multidrug-resistant Enterococcus faecium meningitis in a toddler: characterization of the organism and successful treatment with intraventricular daptomycin and intravenous tigecycline. Pediatr Infect Dis J 2010; 29:379-81. [PMID: 20010311 PMCID: PMC4778705 DOI: 10.1097/inf.0b013e3181c806d8] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [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] [Indexed: 11/25/2022]
Abstract
A case of enterococcal meningitis in a toddler is presented. The organism was highly resistant to all drugs previously used for pediatric Gram-positive meningitis. She was successfully treated with intraventricular and intravenous daptomycin and intravenous tigecycline. The organism was characterized as a member of CC17, a notorious emerging nosocomial clone of Enterococcus faecium.
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Affiliation(s)
- Heather B. Jaspan
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA,Department of Pediatrics, University of Washington, Seattle, WA
| | - Adam W. Brothers
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA
| | - Angela J. P. Campbell
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA,Department of Pediatrics, University of Washington, Seattle, WA,Fred Hutchinson Cancer Research Institute, Seattle WA
| | - John K. McGuire
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA,Department of Pediatrics, University of Washington, Seattle, WA
| | - Samuel R. Browd
- Department of Neurological Surgery, Seattle Children's Hospital, Seattle WA
| | - Thomas J. Manley
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA,Fred Hutchinson Cancer Research Institute, Seattle WA
| | - Daniel Pak
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Scott J. Weissman
- Department of Pediatrics, Seattle Children's Hospital, Seattle WA,Department of Pediatrics, University of Washington, Seattle, WA
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Weissman SJ, Beskhlebnaya V, Chesnokova V, Chattopadhyay S, Stamm WE, Hooton TM, Sokurenko EV. Differential stability and trade-off effects of pathoadaptive mutations in the Escherichia coli FimH adhesin. Infect Immun 2007; 75:3548-55. [PMID: 17502398 PMCID: PMC1932922 DOI: 10.1128/iai.01963-06] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
FimH is the tip adhesin of mannose-specific type 1 fimbriae of Escherichia coli, which are critical to the pathogenesis of urinary tract infections. Point FimH mutations increasing monomannose (1M)-specific uroepithelial adhesion are commonly found in uropathogenic strains of E. coli. Here, we demonstrate the emergence of a mixed population of clonally identical E. coli strains in the urine of a patient with acute cystitis, where half of the isolates carried a glycine-to-arginine substitution at position 66 of the mature FimH. The R66 mutation induced an unusually strong 1M-binding phenotype and a 20-fold advantage in mouse bladder colonization. However, E. coli strains carrying FimH-R66, but not the parental FimH-G66, had disappeared from the patient's rectal and urine samples collected from 29 to 44 days later, demonstrating within-host instability of the R66 mutation. No FimH variants with R66 were identified in a large (>600 strains) sequence database of fimH-positive E. coli strains. However, several strains carrying genes encoding FimH with either S66 or C66 mutations appeared to be relatively stable in the E. coli population. Relative to FimH-R66, the FimH-S66 and FimH-C66 variants mediated only moderate increases in 1M binding but preserved the ability to enhance binding under flow-induced shear conditions. In contrast, FimH-R66 completely lost shear-enhanced binding properties, with bacterial adhesion being inhibited by shear forces and lacking a rolling mode of binding. These functional trade-offs may determine the natural populational instability of this mutation or other pathoadaptive FimH mutations that confer dramatic increases in 1M binding strength.
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Affiliation(s)
- Scott J Weissman
- Department of Microbiology, University of Washington School of Medicine, 1959 North Pacific Street, Seattle, WA 98195, USA
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Chattopadhyay S, Feldgarden M, Weissman SJ, Dykhuizen DE, van Belle G, Sokurenko EV. Haplotype diversity in "source-sink" dynamics of Escherichia coli urovirulence. J Mol Evol 2006; 64:204-14. [PMID: 17177088 DOI: 10.1007/s00239-006-0063-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 10/03/2006] [Indexed: 10/23/2022]
Abstract
FimH, the mannose-specific, type 1 fimbrial adhesin of Escherichia coli, acquires amino acid replacements adaptive in extraintestinal niches (the genitourinary tract) but detrimental in the main habitat (the large intestine). This microevolutionary dynamics is reminiscent of an ecological "source-sink" model of continuous species spread from a stable primary habitat (source) into transient secondary niches (sink), with eventual extinction of the sink-evolved populations. Here, we have adapted two ecological analytical tools-diversity indexes DS and alpha--to compare size and frequency distributions of fimH haplotypes between evolutionarily conserved FimH variants ("source" haplotypes) and FimH variants with adaptive mutations (putative "sink" haplotypes). Both indexes show two- to threefold increased diversity of the sink fimH haplotypes relative to the source haplotypes, a pattern that ran opposite to those seen with nonstructural fimbrial genes (fimC and fimI) and housekeeping loci (adk and fumC) but similar to that seen with another fimbrial adhesin of E. coli, papG-II, also implicated in extraintestinal infections. The increased diversity of the sink pool of adhesin genes is due to the increased richness of the haplotypes (the number of unique haplotypes), rather than their evenness (the extent of similarity in relative abundances). Taken together, this pattern supports a continuous emergence and extinction of the gene alleles adaptive to virulence sink habitats of E. coli, rather than a one-time change in the habitat conditions. Thus, ecological methods of species diversity analysis can be successfully adapted to characterize the emergence of microbial virulence in bacterial pathogens subject to source-sink dynamics.
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Affiliation(s)
- Sujay Chattopadhyay
- Department of Microbiology, University of Washington, Seattle, WA 98195, USA
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38
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Johnson JR, Owens KL, Clabots CR, Weissman SJ, Cannon SB. Phylogenetic relationships among clonal groups of extraintestinal pathogenic Escherichia coli as assessed by multi-locus sequence analysis. Microbes Infect 2006; 8:1702-13. [PMID: 16820314 DOI: 10.1016/j.micinf.2006.02.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 01/26/2006] [Accepted: 02/01/2006] [Indexed: 11/24/2022]
Abstract
The evolutionary origins of extraintestinal pathogenic Escherichia coli (ExPEC) remain uncertain despite these organisms' relevance to human disease. A valid understanding of ExPEC phylogeny is needed as a framework against which the observed distribution of virulence factors and clinical associations can be analyzed. Accordingly, phylogenetic relationships were defined by multi-locus sequence analysis among 44 representatives of selected ExPEC clonal groups and the E. coli Reference (ECOR) collection. Recombination, which significantly obscured the phylogenetic signal for several strains, was dealt with by excluding strains or specific sequences. Conflicting overall phylogenies, and internal phylogenies for virulence-associated phylogenetic group B2, were inferred depending on the specific dataset (i.e., how extensively purged of recombination), outgroup (Salmonella enterica and/or Escherichia fergusonii), and analysis method (neighbor joining, maximum parsimony, maximum likelihood, or Bayesian likelihood). Nonetheless, the major E. coli phylogenetic groups A, B1, and B2 were consistently well resolved, as was a major sub-component of group D and an ECOR 37-O157:H7 clade. Moreover, nine important ExPEC clonal groups within groups B2 and D, characterized by serotypes O6:K2:H1, O18:K1:H7, O6:H31, and O4:K+:H+ (from group B2), and O1:K1:H-, O7:K1:H-, O157:K+:H (non-7), O15:K52:H1, and O11/17/77:K52:H18 ("clonal group A") (from group D), were consistently well resolved, regardless of clinical background (cystitis, pyelonephritis, neonatal meningitis, sepsis, or fecal), host group, geographical origin, and virulence profile. Among the group B2-derived clonal groups the O6:K2:H1 clade appeared basal. Within group D, "clonal group A" and the O15:K52:H1 clonal group were consistently placed with ECOR 47 and ECOR 44, respectively, as nearest neighbors. These findings clarify phylogenetic relationships among key ExPEC clonal groups but also emphasize that recombination appears to obscure the oldest evolutionary relationships, despite extensive targeted sequencing and use of a wide range of analysis techniques.
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Affiliation(s)
- James R Johnson
- Mucosal and Vaccine Research Center, Minneapolis VA Medical Center, Infectious Diseases (111F), Minneapolis, MN 55417, USA.
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Weissman SJ, Chattopadhyay S, Aprikian P, Obata-Yasuoka M, Yarova-Yarovaya Y, Stapleton A, Ba-Thein W, Dykhuizen D, Johnson JR, Sokurenko EV. Clonal analysis reveals high rate of structural mutations in fimbrial adhesins of extraintestinal pathogenic Escherichia coli. Mol Microbiol 2006; 59:975-88. [PMID: 16420365 PMCID: PMC1380272 DOI: 10.1111/j.1365-2958.2005.04985.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Type 1 fimbriae of Escherichia coli mediate mannose-specific adhesion to host epithelial surfaces and consist of a major, antigenically variable pilin subunit, FimA, and a minor, structurally conserved adhesive subunit, FimH, located on the fimbrial tip. We have analysed the variability of fimA and fimH in strains of vaginal and other origin that belong to one of the most prominent clonal groups of extraintestinal pathogenic E. coli, comprised of O1:K1-, O2:K1- and O18:K1-based serotypes. Multiple locus sequence typing (MLST) of this group revealed that the strains have identical (at all but one nucleotide position) eight housekeeping loci around the genome and belong to the ST95 complex defined by the publicly available E. coli MLST database. Multiple highly diverse fimA alleles have been introduced into the ST95 clonal complex via horizontal transfer, at a frequency comparable to that of genes defining the major O- and H-antigens. However, no further significant FimA diversification has occurred via point mutation after the transfers. In contrast, while fimH alleles also move horizontally (along with the fimA loci), they acquire point amino acid replacements at a higher rate than either housekeeping genes or fimA. These FimH mutations enhance binding to monomannose receptors and bacterial tropism for human vaginal epithelium. A similar pattern of rapid within-clonal structural evolution of the adhesive, but not pilin, subunit is also seen, respectively, in papG and papA alleles of the di-galactose-specific P-fimbriae. Thus, while structurally diverse pilin subunits of E. coli fimbriae are under selective pressure for frequent horizontal transfer between clones, the adhesive subunits of extraintestinal E. coli are under strong positive selection (Dn/Ds > 1 for fimH and papG) for functionally adaptive amino acid replacements.
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Affiliation(s)
- Scott J. Weissman
- Division of Infectious Disease, Immunology and Rheumatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Pavel Aprikian
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Mana Obata-Yasuoka
- Department of Obstetrics/Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Yuliya Yarova-Yarovaya
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ann Stapleton
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle, WA, USA
| | - William Ba-Thein
- Department of Microbiology/Immunology, Thammasit University, Pathum-Thani, Thailand
| | - Daniel Dykhuizen
- Department of Evolutionary Biology, State University of New York, Stony Brook, NY, USA
| | - James R. Johnson
- Mucosal and Vaccine Research Center, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Evgeni V. Sokurenko
- Department of Microbiology, University of Washington, Seattle, WA, USA
- *For correspondence. E-mail ; Tel. (+1) 206 685 2162; Fax (+1) 206 543 8297
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Qin X, Weissman SJ, Chesnut MF, Zhang B, Shen L. Kirby-Bauer disc approximation to detect inducible third-generation cephalosporin resistance in Enterobacteriaceae. Ann Clin Microbiol Antimicrob 2004; 3:13. [PMID: 15256000 PMCID: PMC481081 DOI: 10.1186/1476-0711-3-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 07/15/2004] [Indexed: 11/10/2022] Open
Abstract
Resistance to beta-lactam antibiotics in enteric Gram-negative bacilli may be difficult to detect using standard methods of either Kirby-Bauer disc diffusion (KBDD) or broth dilution for minimal inhibitory concentration (MIC). This difficulty is due to genetic differences in resistance determinants, differences in levels of gene expression, and variation in spectra of enzymatic activity against the substrate beta-lactams used for susceptibility testing. We have examined 95 clinical isolates reportedly susceptible to ceftazidime and ceftriaxone, as originally determined by either KBDD or MIC methods. The organisms studied here were isolated in 2002 from two pediatric hospital centers (Seattle, USA and Shanghai, China). They belong to the inducible beta-lactamase producing Gram-negative bacilli, such as Enterobacter spp., Citrobacter spp., Serratia spp., Morganella spp., Providencia spp., and Proteus vulgaris. A Kirby-Bauer disc approximation (KBDA) method identified inducible phenotypes of third-generation cephalosporin resistance in 76% of isolates, which would otherwise be considered susceptible by standard KBDD methods.
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Affiliation(s)
- Xuan Qin
- Microbiology Laboratory, Department of Laboratories and Pathology, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
| | | | - Mary Frances Chesnut
- Microbiology Laboratory, Department of Laboratories and Pathology, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
| | - Bei Zhang
- Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
| | - Lisong Shen
- Laboratory Diagnostic Center, Xin Hua Hospital and Shanghai Children's Medical Center, Shanghai Second Medical University, Shanghai, China
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Sokurenko EV, Feldgarden M, Trintchina E, Weissman SJ, Avagyan S, Chattopadhyay S, Johnson JR, Dykhuizen DE. Selection footprint in the FimH adhesin shows pathoadaptive niche differentiation in Escherichia coli. Mol Biol Evol 2004; 21:1373-83. [PMID: 15044596 DOI: 10.1093/molbev/msh136] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Spread of biological species from primary into novel habitats leads to within-species adaptive niche differentiation and is commonly driven by acquisition of point mutations in individual genes that increase fitness in the alternative environment. However, finding footprints of adaptive niche differentiation in specific genes remains a challenge. Here we describe a novel method to analyze the footprint of pathogenicity-adaptive, or pathoadaptive, mutations in the Escherichia coli gene encoding FimH-the major, mannose-sensitive adhesin. Analysis of distribution of mutations across the nodes and branches of the FimH phylogenetic network shows (1) zonal separation of evolutionary primary structural variants of FimH and recently derived ones, (2) dramatic differences in the ratio of synonymous and nonsynonymous changes between nodes from different zones, (3) evidence for replacement hot-spots in the FimH protein, (4) differential zonal distribution of FimH variants from commensal and uropathogenic E. coli, and (5) pathoadaptive functional changes in FimH brought by the mutations. The selective footprint in fimH indicates that the pathoadaptive niche differentiation of E. coli is either in its initial stages or undergoing an evolutionary "source/sink" dynamic.
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Abstract
Single-nucleotide polymorphisms (SNPs) in structural genes can have a dramatic effect on the biology of whole organisms, from bacteria and viruses to mammals. Here, we underscore the importance of SNPs in bacterial genes that contribute to the ability of pathogens to cause disease. SNPs that confer an adaptive advantage for bacterial pathogens have been discovered in the genes encoding the FimH and Dr adhesins of Escherichia coli and, most recently, Salmonella enterica sv. Typhimurium FimH.
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Affiliation(s)
- Scott J Weissman
- Division of Infectious Disease, Children's Hospital and Regional Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105, USA
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Abstract
A previously healthy 9-year-old girl presented with a 1-week history of left neck mass and low grade fever. Surgical drainage specimens from the mass were bacterial culture-negative. Legionella micdadei infection was diagnosed by a two step PCR-nucleic acid sequencing method and supported by organism-specific serology. A backyard hot tub was suspected as the source of infection.
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Affiliation(s)
- Xuan Qin
- Department of Laboratories and Pathology, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA.
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Johnson JR, Weissman SJ, Stell AL, Trintchina E, Dykhuizen DE, Sokurenko EV. Clonal and pathotypic analysis of archetypal Escherichia coli cystitis isolate NU14. J Infect Dis 2001; 184:1556-65. [PMID: 11740731 DOI: 10.1086/323891] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2001] [Revised: 07/13/2001] [Indexed: 11/04/2022] Open
Abstract
Escherichia coli NU14, a cystitis isolate used to study the pathogenesis of cystitis and to develop a FimH (type 1 fimbrial adhesin) vaccine, was assessed for extended virulence genotype, phylogenetic background, and FimH sequence and binding phenotype(s). NU14 exhibited the same virulence genotype and was derived from the same (meningitis- and cystitis-associated) subclone of E. coli O18:K1:H7 as the archetypal neonatal bacterial meningitis (NBM) isolate RS218. NU14 also displayed the same Ser62Ala FimH polymorphism as did NBM isolates RS218 and IHE3034-conferring both collagen binding and a distinct monomannose binding capability (which characterizes uropathogenic but not commensal E. coli and dramatically increases adherence to uroepithelial cells). These findings establish that strain NU14 exhibits numerous urovirulence-associated traits and derives from the single most prevalent clonal group in acute cystitis. They provide further evidence of clonal and pathotypic similarities between cystitis and NBM isolates of E. coli O18:K1:H7.
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Affiliation(s)
- J R Johnson
- Veterans Affairs Medical Center and Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55417, USA.
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Badger JL, Wass CA, Weissman SJ, Kim KS. Application of signature-tagged mutagenesis for identification of escherichia coli K1 genes that contribute to invasion of human brain microvascular endothelial cells. Infect Immun 2000; 68:5056-61. [PMID: 10948125 PMCID: PMC101737 DOI: 10.1128/iai.68.9.5056-5061.2000] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Escherichia coli K1 is the leading cause of gram-negative bacterial meningitis in neonates. It is principally due to our limited understanding of the pathogenesis of this disease that the morbidity and mortality rates remain unacceptably high. To identify genes required for E. coli K1 penetration of the blood-brain barrier (BBB), we used the negative selection strategy of signature-tagged transposon mutagenesis (STM) to screen mutants for loss or decreased invasion of human brain microvascular endothelial cells (HBMEC) which comprise the BBB. A total of 3,360 insertion mutants of E. coli K1 were screened, and potential HBMEC invasion mutants were subjected to a secondary invasion screen. Those mutants that failed to pass the serial invasion screens were then tested individually. Seven prototrophic mutants were found to exhibit significantly decreased invasive ability in HBMEC. We identified traJ and five previously uncharacterized loci whose gene products are necessary for HBMEC invasion by E. coli K1. In addition, cnf1, a gene previously shown to play a role in bacterial invasion, was identified. More importantly, a traJ mutant was attenuated in penetration of the BBB in the neonatal rat model of experimental hematogenous meningitis. This is the first in vivo demonstration that traJ is involved in the pathogenesis of E. coli K1 meningitis.
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Affiliation(s)
- J L Badger
- Division of Infectious Diseases, Childrens Hospital Los Angeles, Los Angeles, California 90027, USA
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