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Gatti M, Bonazzetti C, Tazza B, Pascale R, Miani B, Malosso M, Beci G, Marzolla D, Rinaldi M, Viale P, Giannella M. Impact on clinical outcome of follow-up blood cultures and risk factors for persistent bacteraemia in patients with gram-negative bloodstream infections: a systematic review with meta-analysis. Clin Microbiol Infect 2023; 29:1150-1158. [PMID: 36894053 DOI: 10.1016/j.cmi.2023.02.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 12/23/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND The clinical usefulness of follow-up blood cultures (FUBCs) in gram-negative bloodstream infections (GN-BSIs) represents a debated issue. OBJECTIVE To assess the impact on the clinical outcome of FUBCs in patients with GN-BSI and to predict risk factors for persistent bacteraemia. DATA SOURCES PubMed-MEDLINE, Scopus, and the Cochrane Library Database were independently searched until 24 June, 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, prospective, or retrospective observational studies, including patients affected by GN-BSIs. Primary endpoints were in-hospital mortality rate, and persistent blood stream infections were defined as FUBC-positive for the same pathogen isolated from index blood cultures (BCs). PARTICIPANTS Hospitalized patients with documented GN-BSIs. INTERVENTION Performance of FUBCs (defined as subsequent BCs collected at least 24 hours after index BCs). ASSESSMENT OF RISK OF BIAS Quality of included studies was independently assessed according to the Cochrane Risk of Bias Tool and the Risk Of Bias In Non-randomized Studies of Interventions. METHODS OF DATA SYNTHESIS Meta-analysis was performed by pooling odds ratio (OR) retrieved from studies providing adjustment for confounders using random-effect model with the inverse variance method. Risk factors for persistent blood stream infections were also assessed. RESULTS A total of 3747 articles were screened, and 11 observational studies (6 assessing impact on outcome (N = 4631), and 5 investigating risk factors for persistent GN-BSI (N = 2566)), conducted between 2002 and 2020 were included. The execution of FUBCs was associated with a significantly lower risk of mortality (OR, 0.58; 95% CI, 0.49-0.70; I2 = 0.0%). The presence of end-stage renal disease (OR, 2.99; 95% CI, 1.77-5.05), central venous catheter (OR, 3.30; 95% CI, 1.82-5.95), infections due to extended-spectrum β-lactamase-producing strains (OR, 2.25; 95% CI, 1.18-4.28), resistance to empirical treatment (OR, 2.70; 95% CI, 1.65-4.41), and unfavourable response at 48 hours (OR, 2.99; 95% CI, 1.44-6.24) emerged as independent risk factors for persistent bacteraemia. CONCLUSIONS The execution of FUBCs is associated with a significantly low risk of mortality in patients with GN-BSIs. Our analysis could be useful to stratify patients at a high risk of persistent bacteraemia to optimize the use of FUBCs.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Cecilia Bonazzetti
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Beatrice Tazza
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Renato Pascale
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Beatrice Miani
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Marta Malosso
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Giacomo Beci
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Domenico Marzolla
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, University of Bologna, Italy; Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy.
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Yildiz M, Habibi H, Altin FB, Corbacioglu SK, Ozger HS. The effect of follow-up blood cultures on mortality and antibiotic use in gram-negative bloodstream infections. BMC Infect Dis 2023; 23:564. [PMID: 37644383 PMCID: PMC10466735 DOI: 10.1186/s12879-023-08500-9] [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: 06/13/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Gram-negative bloodstream infections (GN-BSIs) are a significant clinical challenge. The utility of follow-up blood cultures (FUBCs) in GN-BSIs and their impact on mortality and antibiotic consumption are areas of debate. This study aimed to evaluate the effect of FUBCs on mortality and antibiotic consumption in patients with GN-BSIs. METHODS This single-center, retrospective study was conducted in aged > 18 years of patients with GN-BSIs. FUBC was defined as a blood culture performed 2-7 days after the first blood culture. Patients were grouped as FUBC and no FUBC and compared. A 1:1 match analysis was performed between the groups according to the SOFA score. The matched subgroup was compared for mortality risk factors with logistic regression models. The two groups were compared for the duration of effective antibiotic therapy and total antibiotic consumption (days of therapy per 1000 patient days (DOT/1000 PD)). RESULTS FUBC was performed in 564 (69.4%) of 812 patients. Persistent, positive and negative FUBC rates were 7.9%, 14%, and 78%, respectively. The frequency of persistent GN-BSI in patients with appropriate antibiotic therapy was 3.9%. SOFA score (OR:1.33; 95% CI, 1.23-1.44), Charlson comorbidity index score (OR:1.18; 95% CI, 1.08-1.28), hospital-acquired infections (OR:1.93; 95% CI, 1.08-3.46) and carbapenem-resistant GN-BSI (OR: 2.92; 95% CI, 1.72-4.96) were independent risk factors for mortality. No relationship was found between FUBC and mortality (p > 0.05). Duration of effective antibiotic therapy (10(4-16) vs. 15(9-20), p < 0.001) and DOT/1000 PD (1609 (1000-2178) vs. 2000 (1294-2769), p < 0.001) were longer in the FUBC group. CONCLUSION Routine FUBC should not be recommended because of the low prevalence of persistent infections in patients under appropriate antibiotic therapy and FUBC increases antibiotic consumption.
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Affiliation(s)
- Mehmet Yildiz
- Infectious Disease and Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey.
| | - Hamid Habibi
- Infectious Disease and Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey
| | - Fatma Betul Altin
- Infectious Disease and Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey
| | | | - Hasan Selcuk Ozger
- Infectious Disease and Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey
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Lipworth S, Vihta KD, Chau K, Barker L, George S, Kavanagh J, Davies T, Vaughan A, Andersson M, Jeffery K, Oakley S, Morgan M, Hopkins S, Peto TEA, Crook DW, Walker AS, Stoesser N. Ten-year longitudinal molecular epidemiology study of Escherichia coli and Klebsiella species bloodstream infections in Oxfordshire, UK. Genome Med 2021; 13:144. [PMID: 34479643 PMCID: PMC8414751 DOI: 10.1186/s13073-021-00947-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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: 01/22/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of Gram-negative bloodstream infections (BSIs), predominantly caused by Escherichia coli and Klebsiella species, continues to increase; however, the causes of this are unclear and effective interventions are therefore hard to design. Methods In this study, we sequenced 3468 unselected isolates over a decade in Oxfordshire (UK) and linked this data to routinely collected electronic healthcare records and mandatory surveillance reports. We annotated genomes for clinically relevant genes, contrasting the distribution of these within and between species, and compared incidence trends over time using stacked negative binomial regression. Results We demonstrate that the observed increases in E. coli incidence were not driven by the success of one or more sequence types (STs); instead, four STs continue to dominate a stable population structure, with no evidence of adaptation to hospital/community settings. Conversely in Klebsiella spp., most infections are caused by sporadic STs with the exception of a local drug-resistant outbreak strain (ST490). Virulence elements are highly structured by ST in E. coli but not Klebsiella spp. where they occur in a diverse spectrum of STs and equally across healthcare and community settings. Most clinically hypervirulent (i.e. community-onset) Klebsiella BSIs have no known acquired virulence loci. Finally, we demonstrate a diverse but largely genus-restricted mobilome with close associations between antimicrobial resistance (AMR) genes and insertion sequences but not typically specific plasmid replicon types, consistent with the dissemination of AMR genes being highly contingent on smaller mobile genetic elements (MGEs). Conclusions Our large genomic study highlights distinct differences in the molecular epidemiology of E. coli and Klebsiella BSIs and suggests that no single specific pathogen genetic factors (e.g. AMR/virulence genes/sequence type) are likely contributing to the increasing incidence of BSI overall, that association with AMR genes in E. coli is a contributor to the increasing number of E. coli BSIs, and that more attention should be given to AMR gene associations with non-plasmid MGEs to try and understand horizontal gene transfer networks. Supplementary Information The online version contains supplementary material available at 10.1186/s13073-021-00947-2.
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Affiliation(s)
- Samuel Lipworth
- Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | | | - Kevin Chau
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Leanne Barker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sophie George
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James Kavanagh
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy Davies
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alison Vaughan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Oakley
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marcus Morgan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, Colindale, London, UK
| | - Timothy E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,John Radcliffe Hospital, Oxford, OX3 9DU, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK.,NIHR Biomedical Research Centre, Oxford, UK
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Stoma I, Littmann ER, Peled JU, Giralt S, van den Brink MRM, Pamer EG, Taur Y. Compositional flux within the intestinal microbiota and risk for bloodstream infection with gram-negative bacteria. Clin Infect Dis 2020; 73:e4627-e4635. [PMID: 31976518 DOI: 10.1093/cid/ciaa068] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Gram-negative bloodstream infections represent a significant complication facing allogeneic hematopoietic cell transplant (allo-HCT) recipients, as a result of intestinal translocation during neutropenia. In this study we sought to better understand how the composition of the intestinal microbiota is connected to risk of gram-negative bloodstream infections, expanding on our prior work in these patients. METHODS Fecal specimens were collected from recipients of allo-HCT and analyzed using 16SrRNA gene sequencing. Samples and clinical data extending from the pre-transplant conditioning period through stem cell engraftment were used in the analysis. Intestinal domination (relative abundance ≥30%) by gram-negative bacteria was used as predictor of gram-negative bloodstream infection using Cox proportional hazards modelling. Further analysis of microbiota composition was performed at the genus level. RESULTS 708 allo-HCT subjects were studied (7.5% develop gram-negative infection), with 4,768 fecal samples for analysis. Gram-negative intestinal domination was associated with subsequent bloodstream infection, which was observed overall and individually at the genus level: Escherichia, Klebsiella, Enterobacter, Pseudomonas, and Stenotrophomonas. Fluoroquinolone prophylaxis was associated with decreased bloodstream infection and intestinal colonization by gram-negative microbes. In fluoroquinolone-prophylaxed patients, Escherichia coli was more frequently observed as breakthrough, both in terms of intestinal colonization and bloodstream infections, compared with non-prophylaxed patients. Initial colonization by members of Ruminococcaceae and Bacteroidetes were associated with protection against gram-negative bloodstream infection. CONCLUSION Gram-negative intestinal colonization is highly predictive of bloodstream infection, in the setting of allo-HCT. Fluoroquinolones appear to reduce these infections by influencing gut colonization.
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Affiliation(s)
- Igor Stoma
- Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center.,Department of Infectious Diseases, Belarusian State Medical University
| | - Eric R Littmann
- Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center
| | - Jonathan U Peled
- Adult Bone Marrow Transplantation Service, Memorial Hospital, Memorial Sloan Kettering Cancer Center.,Weill Cornell Medical College
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Memorial Hospital, Memorial Sloan Kettering Cancer Center.,Weill Cornell Medical College
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplantation Service, Memorial Hospital, Memorial Sloan Kettering Cancer Center.,Weill Cornell Medical College
| | - Eric G Pamer
- Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center.,Infectious Diseases Service, Memorial Hospital, Memorial Sloan Kettering Cancer Center.,Weill Cornell Medical College
| | - Ying Taur
- Center for Microbes, Inflammation and Cancer, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center.,Infectious Diseases Service, Memorial Hospital, Memorial Sloan Kettering Cancer Center.,Weill Cornell Medical College
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De Angelis G, Grossi A, Menchinelli G, Boccia S, Sanguinetti M, Posteraro B. Rapid molecular tests for detection of antimicrobial resistance determinants in Gram-negative organisms from positive blood cultures: a systematic review and meta-analysis. Clin Microbiol Infect 2020; 26:271-80. [PMID: 31751768 DOI: 10.1016/j.cmi.2019.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Timely detection of antimicrobial (cephalosporin/carbapenem) resistance (AMR) determinants is crucial to the clinical management of bloodstream infections caused by Gram-negative bacteria (GNB). OBJECTIVES To review and meta-analyse the evidence for using commercially available molecular tests for the direct detection of AMR determinants in GNB-positive blood cultures (PBCs). DATA SOURCES PubMed, Scopus and ISI Web of Knowledge. STUDY ELIGIBILITY CRITERIA Clinical studies evaluating the performance of two major commercial systems, namely the Verigene® and FilmArray® systems, for rapid testing of GNB-PBCs, in comparison with the phenotypic or genotypic methods performed on GNB-PBC isolates. METHODS Literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and, for meta-analysis of sensitivity and specificity of both systems, bivariate random-effects model. RESULTS Twenty studies were identified (3310 isolates) from 2006 to 2019. Nine studies were conducted in East Asia. In 15 studies using phenotypic comparators (1930 isolates), 1014 (52.5%) isolates were Escherichia coli, and 287 (14.9%) of all the isolates displayed AMR phenotypes. In five studies using genotypic comparators (1380 isolates), 585 (42.4%) were E. coli, and 100 (7.2%) of all the isolates displayed AMR genotypes. Pooled sensitivity and specificity estimates for detection of AMR determinants by the Verigene (i.e. CTX-M, IMP, KPC, NDM, OXA and VIM) and/or FilmArray (i.e. KPC) systems were 85.3% (95% CI 79.9%-89.4%) and 99.1% (95% CI 98.2%-99.5%), respectively, across the 15 studies, and 95.5% (95% CI 89.2%-98.2%) and 99.7% (95% CI 99.1%-99.9%), respectively, across the five studies. CONCLUSIONS Our findings show that the Verigene and FilmArray systems may be a valid adjunct to the conventional microbiology (phenotypic or genotypic) methods used to identify AMR in GNBs. The FilmArray system detects only one AMR genotype, namely KPC, limiting its use. Both Verigene and FilmArray systems can miss important cephalosporin/carbapenem resistance phenotypes in a minority of cases. However, the sensitivity and specificity of both systems render them valuable clinical tools in timely identification of resistant isolates. Further studies will establish the prominence of such rapid diagnostics as standard of care in individuals with bloodstream infections.
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Shaw K, Golding S, Knight J, Chadborn T, Dempster L, Finistrella V, Hopkins S. A unique approach to the development of infection prevention and control resources for front-line health care workers. Infect Prev Pract 2019; 1:100004. [PMID: 34368670 DOI: 10.1016/j.infpip.2019.100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Despite successful efforts to reduce Meticillin Resistant Staphylococcus aureus bloodstream infections (BSI) and Clostridium difficile infection, Gram-negative BSI (GNBSI) have continued to increase in England. Public Health England (PHE) and NHS Improvement (NHSI) were tasked by the Minister for Health to lead the development of tools and resources to support healthcare workers to reduce these infections. Aim To work with commissioners and providers of healthcare to collaboratively develop resources to support whole health economies to reduce GNBSI using a combination of behavioural insights and quality improvement methods. Methods We took a unique approach to develop these tools and resources using a combination of behavioural insights, quality improvement and front-line collaboration to ensure the tools and resources were designed around the needs of those who would use them. The approach taken was a stepwise iterative process in two distinct phases: a development phase and a testing phase. Both phases used a combination of behavioural insights, human factors, quality improvement and co-production methods to engage stakeholders in co-designing resources that would support them in their work to reduce GNBSI. Findings During the development phase, feedback from workshops and stakeholder reviews indicated that tools needed to be reduced, simplified, and communicated clearly. Stakeholders wanted tools that could be used by a cross-system group and indicated that leadership was key to ensuring resources were adopted to drive improvements. The final tools were published on the NHS Improvement GNBSI hub. This electronic platform had 30,000 visits between May 2017 and October 2018.
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