1
|
Heyman G, Jonsson S, Fatsis-Kavalopoulos N, Hjort K, Nicoloff H, Furebring M, Andersson DI. Prevalence, misclassification, and clinical consequences of the heteroresistant phenotype in Escherichia coli bloodstream infections in patients in Uppsala, Sweden: a retrospective cohort study. THE LANCET. MICROBE 2025; 6:101010. [PMID: 39827894 PMCID: PMC12004506 DOI: 10.1016/j.lanmic.2024.101010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 09/16/2024] [Accepted: 09/25/2024] [Indexed: 01/22/2025]
Abstract
BACKGROUND Antibiotic heteroresistance is a common bacterial phenotype characterised by the presence of small resistant subpopulations within a susceptible population. During antibiotic exposure, these resistant subpopulations can be enriched and potentially lead to treatment failure. In this study, we examined the prevalence, misclassification, and clinical effect of heteroresistance in Escherichia coli bloodstream infections for the clinically important antibiotics cefotaxime, gentamicin, and piperacillin-tazobactam. METHODS We conducted a retrospective cohort analysis of patients (n=255) admitted to in-patient care and treated for E coli bloodstream infections within the Uppsala region in Sweden between Jan 1, 2014, and Dec 31, 2015. Patient inclusion criteria were admission to hospital on suspicion of infection, starting systemic antibiotics at the time of admission, positive blood cultures for the growth of E coli upon admission, and residency in the Uppsala health-care region at the time of admission. Exclusion criteria were growth of an additional pathogen than E coli in blood cultures taken at admission or previous inclusion of the patients in the study for another bloodstream infection. Antibiotic susceptibility of preserved blood culture isolates of E coli was assessed for cefotaxime, gentamicin, and piperacillin-tazobactam by disk diffusion and breakpoint crossing heteroresistance (BCHR) was identified using population analysis profiling. The clinical outcome parameters were obtained from patient records. The primary outcome variable was length of hospital stay due to the E coli bloodstream infection, defined as the time between admission and discharge from inpatient care as noted on the physician's notes. Secondary outcomes were time to fever resolution, admission to intermediary care unit or intensive care unit during time in hospital, switching or adding another intravenous antibiotic treatment, re-admission to hospital within 30 days of original admission, recurrent E coli infection within 30 days of admission to hospital, and all-cause mortality within 90 days of admission. FINDINGS A total of 255 participants with a corresponding E coli isolate (out of 500 screened for eligibility) met the inclusion criteria, with 135 female patients and 120 male patients. One (<1%) of 255 strains was BCHR for cefotaxime, 109 (43%) of 255 strains were BCHR for gentamicin, and 22 (9%) of 255 strains were BCHR for piperacillin-tazobactam. Clinical susceptibility testing misclassified 120 (96%) of 125 heteroresistant bacterial strains as susceptible. The BCHR phenotypes had no correlation to length of hospital stay due to the E coli bloodstream infection. However, patients with piperacillin-tazobactam BCHR strains who received piperacillin-tazobactam had 3·1 times higher odds for admittance to the intermediate care unit (95% CI 1·1-9·6, p=0·041) than the remainder of the cohort, excluding those treated with gentamicin. Similarly, those infected with gentamicin BCHR who received gentamicin showed higher odds for admittance to the intensive care unit (5·6 [1·1-42·0, p=0·043]) and mortality (7·1 [1·2-49·2, p=0·030]) than patients treated with gentamicin who were infected with non-gentamicin BCHR E coli. INTERPRETATION In a cohort of patients with E coli bloodstream infections, heteroresistance is common and frequently misidentified in routine clinical testing. Several negative effects on patient outcomes are associated with heteroresistant strains. FUNDING Wallenberg Foundation, Swedish Research Council, and US National Institutes Of Health.
Collapse
Affiliation(s)
- Gabriel Heyman
- Department of Infectious Diseases, Västmanland County Hospital Västerås, Västerås, Sweden; Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Västerås, Sweden
| | - Sofia Jonsson
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | | | - Karin Hjort
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Hervé Nicoloff
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Mia Furebring
- Department of Infectious Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Dan I Andersson
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
2
|
Araten AH, Brooks RS, Choi SDW, Esguerra LL, Savchyn D, Wu EJ, Leon G, Sniezek KJ, Brynildsen MP. Cephalosporin resistance, tolerance, and approaches to improve their activities. J Antibiot (Tokyo) 2024; 77:135-146. [PMID: 38114565 DOI: 10.1038/s41429-023-00687-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/23/2023] [Accepted: 11/05/2023] [Indexed: 12/21/2023]
Abstract
Cephalosporins comprise a β-lactam antibiotic class whose first members were discovered in 1945 from the fungus Cephalosporium acremonium. Their clinical use for Gram-negative bacterial infections is widespread due to their ability to traverse outer membranes through porins to gain access to the periplasm and disrupt peptidoglycan synthesis. More recent members of the cephalosporin class are administered as last resort treatments for complicated urinary tract infections, MRSA, and other multi-drug resistant pathogens, such as Neisseria gonorrhoeae. Unfortunately, there has been a global increase in cephalosporin-resistant strains, heteroresistance to this drug class has been a topic of increasing concern, and tolerance and persistence are recognized as potential causes of cephalosporin treatment failure. In this review, we summarize the cephalosporin antibiotic class from discovery to their mechanisms of action, and discuss the causes of cephalosporin treatment failure, which include resistance, tolerance, and phenomena when those qualities are exhibited by only small subpopulations of bacterial cultures (heteroresistance and persistence). Further, we discuss how recent efforts with cephalosporin conjugates and combination treatments aim to reinvigorate this antibiotic class.
Collapse
Affiliation(s)
- Alison H Araten
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Rachel S Brooks
- Department of English, Princeton University, Princeton, NJ, USA
| | - Sarah D W Choi
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Laura L Esguerra
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA
| | - Diana Savchyn
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA
| | - Emily J Wu
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA
| | - Gabrielle Leon
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA
| | - Katherine J Sniezek
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA
| | - Mark P Brynildsen
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
- Department of Chemical and Biological Engineering, Princeton University, Princeton, NJ, USA.
| |
Collapse
|
3
|
Liu D, Li G, Hong Z, Zhang C, Zhu N, Tan Y, Gao T. Prevalence of Multidrug-Resistant Organisms in Healthy Adults in Shenzhen, China. Health Secur 2023; 21:122-129. [PMID: 36867151 DOI: 10.1089/hs.2022.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Public health problems caused by the high transmission of multidrug-resistant organisms (MDROs) have attracted widespread international attention. However, studies on healthy adults in this field are scarce. In this article, we report the microbiological screening results of 180 healthy adults recruited from 1,222 participants between 2019 and 2022 in Shenzhen, China. Findings show a high MDRO carriage rate of 26.7% in those individuals who did not use any antibiotics in the past 6 months and had not been hospitalized within the past year. MDROs were mainly extended-spectrum β-lactamase-producing Escherichia coli with high resistance to cephalosporin. With the assistance of metagenomic sequencing technology, we also performed long-term observations of several participants and found that drug-resistant gene fragments were prevalent even when MDROs were not detected by drug sensitivity testing. Based on our findings, we suggest that healthcare regulators limit the medical overuse of antibiotics and enact measures to limit its nonmedical use.
Collapse
Affiliation(s)
- Ding Liu
- Ding Liu, MS, is a Senior Scientist, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| | - Guiqiu Li
- Guiqiu Li, MD, is a Clinical Laboratory Physician, Clinical laboratory medicine center, Huazhong University of Science and Technology Union, Shenzhen Hospital, Shenzhen, People's Republic of China
| | - Zhifan Hong
- Zhifan Hong is a Scientist, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| | - Cong Zhang
- Cong Zhang, MS, is a Senior Scientist, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| | - Ning Zhu
- Ning Zhu, PhD, is a Senior Manager, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| | - Yan Tan
- Yan Tan, PhD, is Chief Executive Officer, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| | - Ting Gao
- Ting Gao, PhD, is CMC Director, at Shenzhen Xbiome Biotech Ltd., Shenzhen, People's Republic of China
| |
Collapse
|
4
|
Bacterial heteroresistance: an evolving novel way to combat antibiotics. Biologia (Bratisl) 2021. [DOI: 10.1007/s11756-021-00820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
5
|
Analysis of β-lactams and Carbapenem Heteroresistance in Extra-intestinal Pathogenic Escherichia coli from Blood Samples in Iran. JOURNAL OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASES 2021. [DOI: 10.52547/jommid.9.3.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
6
|
Characterization of Integrons and Antimicrobial Resistance in Escherichia coli Sequence Type 131 Isolates. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:3826186. [PMID: 32184909 PMCID: PMC7060437 DOI: 10.1155/2020/3826186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/05/2020] [Accepted: 01/14/2020] [Indexed: 01/17/2023]
Abstract
Background Escherichia coli sequence type 131 (ST131) is an important multidrug-resistant extraintestinal pathogen, which can cause many kinds of infections. Integrons may play a crucial role in the dissemination of antibiotic resistance genes. The purpose of this study was to characterize the prevelance of integrons among E. coli ST131 strains in China. Methods Eighty-three E. coli ST131 strains in China. E. coli ST131 strains in China. Results Overall, 26.5% (22/83) of the E. coli ST131 strains in China. dfrA17-aadA5 and aac(6')-Ib-cr-cmlA5. Only one type of Pc promoter variant was detected among 22 integron-positive isolates (PcW). In vivo transfer of integron was successful for 9 of integron-positive E. coli ST131 strains in China. E. coli ST131 strains in China. Conclusions Our study showed a low prevalence of integrons was detected in E. coli ST131. Continued surveillance of this mobile genetic element should be performed to study the evolution of antibiotic resistance among E. coli ST131.E. coli ST131 strains in China. E. coli ST131 strains in China.
Collapse
|
7
|
Mechanisms and clinical relevance of bacterial heteroresistance. Nat Rev Microbiol 2019; 17:479-496. [DOI: 10.1038/s41579-019-0218-1] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2019] [Indexed: 02/08/2023]
|
8
|
Heteroresistance to Piperacillin-Tazobactam in Clinical Isolates of Escherichia coli Sequence Type 131. Antimicrob Agents Chemother 2017; 62:AAC.01923-17. [PMID: 29061749 DOI: 10.1128/aac.01923-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
9
|
Seo YB, Lee J, Kim YK, Lee SS, Lee JA, Kim HY, Uh Y, Kim HS, Song W. Randomized controlled trial of piperacillin-tazobactam, cefepime and ertapenem for the treatment of urinary tract infection caused by extended-spectrum beta-lactamase-producing Escherichia coli. BMC Infect Dis 2017; 17:404. [PMID: 28592240 PMCID: PMC5463388 DOI: 10.1186/s12879-017-2502-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 05/30/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Due to limited therapeutic options, the spread of extended-spectrum beta-lactamases (ESBLs) have become a major public health concern. We conducted a prospective, randomized, open-label comparison of the therapeutic efficacy of piperacillin-tazobactam (PTZ), cefepime, and ertapenem in febrile nosocomial urinary tract infection with ESBL-producing Escherichia coli (ESBL-EC). METHODS This study was conducted at three university hospitals between January 2013 and August 2015. Hospitalized adult patients presenting with fever were screened for healthcare-associated urinary tract infection (HA-UTI). When ESBL-EC was solely detected and susceptible to a randomized antibiotic in vitro, the case was included in the final analysis. Participants were treated for 10-14 days with PTZ, cefepime, or ertapenem. RESULTS A total of 66 participants were evenly assigned to the PTZ and ertapenem treatment groups. After the recruitment of six participants, assignment to the cefepime treatment group was stopped because of an unexpectedly high treatment failure rate. The baseline characteristics of these participants did not differ from participants in other treatment groups. The clinical and microbiological response to PTZ treatment was estimated to be 94% and was similar to the response to ertapenem treatment. The efficacy of cefepime was 33.3%. In the cefepime group, age, Charlson comorbidity index, genotype, and minimal inhibitory concentration (MIC) did not significantly affect the success of treatment. Similarly, genotype seemed to be irrelevant with respect to clinical outcome in the PTZ group. Expired cases tended to involve septic shock with a high Charlson comorbidity index and high MIC. CONCLUSION Results from this study suggest that PTZ is effective in the treatment of urinary tract infection caused by ESBL-EC when the in vitro test indicates susceptibility. In addition, cefepime should not be used as an alternative treatment for urinary tract infection caused by ESBL-EC. TRIAL REGISTRATION The trial was registered with the Clinical Research Information Service of Korea Centers for Disease Control and Prevention. (KCT0001895).
Collapse
Affiliation(s)
- Yu Bin Seo
- Division of Infectious Diseases, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jacob Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Seung Soon Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Jeong-A Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hyo Youl Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Young Uh
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Han-Sung Kim
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Wonkeun Song
- Department of Laboratory Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Shingil-ro, Youngdeungpo-gu, Seoul, 150-950, Korea.
| |
Collapse
|