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Ranganath N, Hassett LC, Saleh OMA, Yetmar ZA. Short versus prolonged duration of therapy for Pseudomonas aeruginosa bacteraemia: a systematic review and meta-analysis. J Hosp Infect 2024; 148:155-166. [PMID: 38685414 DOI: 10.1016/j.jhin.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/28/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
The optimal duration of therapy for Pseudomonas aeruginosa bloodstream infection (PSA-BSI) is unknown, with prolonged therapy frequently favored due to severity of infection, patient complexity, risk of multi-drug resistance, and high mortality. We therefore conducted a systematic review and meta-analysis of studies with head-to-head comparison of short versus prolonged therapy for PSA-BSI. A comprehensive search including Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was performed. We pooled risk ratios using DerSimonian-Laird random effects model and performed subgroup analysis of outcomes including all-cause mortality, recurrent infection, and composite of these outcomes among patients receiving short versus prolonged therapy for PSA-BSI. Heterogeneity was assessed by the I2-index. Risk of bias for cohort studies was assessed using ROBINS-I tool. Of the 908 identified studies, six were included in the systematic review and five studies with head-to-head comparison of treatment duration were assessed in the meta-analysis, totalling 1746 patients. No significant difference in propensity score-weighted composite outcome (30-day all-cause mortality or recurrent infection) was noted between patients receiving short or prolonged therapy, with a pooled RR risk ratio of 0.80 (95% CI confidence interval 0.51-1.25, P=0.32; I2 = 0%). Additionally, duration of therapy did not impact individual outcomes of 30-day all-cause mortality or recurrent/persistent infection. Our meta-analysis demonstrated that short duration of antimicrobial therapy may have similar efficacy to prolonged treatment for PSA-BSI. Future randomized trials will be necessary to definitively determine optimal management of PSA bacteraemia.
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Affiliation(s)
- N Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA.
| | - L C Hassett
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - O M A Saleh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Z A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA; Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
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Omrani AS, Abujarir SH, Ben Abid F, Shaar SH, Yilmaz M, Shaukat A, Alsamawi MS, Elgara MS, Alghazzawi MI, Shunnar KM, Zaqout A, Aldeeb YM, Alfouzan W, Almaslamani MA. Switch to oral antibiotics in Gram-negative bacteraemia: a randomized, open-label, clinical trial. Clin Microbiol Infect 2024; 30:492-498. [PMID: 37858867 DOI: 10.1016/j.cmi.2023.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVES To evaluate the safety and efficacy of switching from intravenous (IV) to oral antimicrobial therapy in patients with Enterobacterales bacteraemia, after completion of 3-5 days of microbiologically active IV therapy. METHODS A multicentre, open-label, randomized trial of adults with monomicrobial Enterobacterales bacteraemia caused by a strain susceptible to ≥1 oral beta-lactam, quinolone, or trimethoprim/sulfamethoxazole. Inclusion criteria included completion of 3-5 days of microbiologically active IV therapy, being afebrile and haemodynamically stable for ≥48 hours, and absence of an uncontrolled source of infection. Pregnancy, endocarditis, and neurological infections were exclusion criteria. Randomization, stratified by urinary source of bacteraemia, was to continue IV (IV Group) or to switch to oral therapy (Oral Group). Agents and duration of therapy were determined by the treating physicians. The primary endpoint was treatment failure, defined as death, need for additional antimicrobial therapy, microbiological relapse, or infection-related re-admission within 90 days. Non-inferiority threshold was set at 10% in the 95% CI for the difference in the proportion with treatment failure between the Oral and IV Groups in the modified intention-to-treat population. The protocol was registered at ClinicalTrials.gov (NCT04146922). RESULTS In the modified intention-to-treat population, treatment failure occurred in 21 of 82 (25.6%) in the IV Group, and 18 of 83 (21.7%) in the Oral Group (risk difference -3.7%, 95% CI -16.6% to 9.2%). The proportions of subjects with any adverse events (AE), serious AE, or AE leading to treatment discontinuation were comparable. DISCUSSION In patients with Enterobacterales bacteraemia, oral switch, after initial IV antimicrobial therapy, clinical stability, and source control, is non-inferior to continuing IV therapy.
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Affiliation(s)
- Ali S Omrani
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Qatar University College of Medicine, Doha, Qatar.
| | - Sulieman H Abujarir
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Ben Abid
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Shahd H Shaar
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar
| | - Mesut Yilmaz
- Department of Infectious Diseases and Microbiology, Istanbul Medipol University, Istanbul, Turkiye
| | - Adila Shaukat
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Al Wakra Hospital, Hamad Medical Corporation, Al Wakra, Qatar
| | - Mussad S Alsamawi
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar
| | - Mohamed S Elgara
- Division of Internal Medicine, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Islam Alghazzawi
- Division of Internal Medicine, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Khaled M Shunnar
- Division of Internal Medicine, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Zaqout
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Yasser M Aldeeb
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar
| | - Wadha Alfouzan
- Department of Microbiology, Farwania Hospital, Kuwait City, Kuwait; Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Muna A Almaslamani
- Communicable Diseases Center, Hamad Medical Corporation, Doha, Qatar; Division of Infectious Diseases, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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Grillo Perez S, Diaz-Brochero C, Garzon Herazo JR, Muñoz Velandia OM. Short-term versus usual-term antibiotic treatment for uncomplicated Staphylococcus aureus bacteremia: a systematic review and meta-analysis. Ther Adv Infect Dis 2024; 11:20499361241237615. [PMID: 38476737 PMCID: PMC10929032 DOI: 10.1177/20499361241237615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Introduction Uncomplicated Staphylococcus aureus bacteremia remains a leading cause of morbidity and mortality in hospitalized patients. Current guidelines recommend a minimum of 14 days of treatment. Objective To evaluate the efficacy and safety of short versus usual antibiotic therapy in adults with uncomplicated S. aureus bacteremia (SAB). Methods We developed a search strategy to identify systematic review and meta-analysis of non-randomized studies (NRS), comparing short versus usual or long antibiotic regimens for uncomplicated SAB in MEDLINE, Embase, and the Cochrane Register up to June 2023. The risk of bias was assessed using the ROBINS I tool. The meta-analysis was performed using Review Manager software with a random effect model. Results Six NRS with a total of 1700 patients were included. No significant differences were found when comparing short versus prolonged antibiotic therapy as defined by the authors for 90-day mortality [odds ratio (OR): 1.09; 95% confidence interval (CI): 0.82-1.46, p: 0.55; I2 = 0%] or 90-day recurrence or relapse of bacteremia [OR: 0.72; 95% CI: 0.31-1.68, p: 0.45; I2 = 26%]. Sensitivity analysis showed similar results when comparing a predefined duration of <14 days versus ⩾14 days and when excluding the only study with a high risk of bias. Conclusion Shorter-duration regimens could be considered as an alternative option for uncomplicated SAB in low-risk cases. However, based on a small number of studies with significant methodological limitations and risk of bias, the benefits and harms of shorter regimens should be analyzed with caution. Randomized clinical trials are needed to determine the best approach regarding the optimal duration of therapy.
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Affiliation(s)
- Santiago Grillo Perez
- Department of Internal Medicine, Hospital Universitario San Ignacio, Carrera 7 No 40-62, 7th Floor, Bogotá 110231, Colombia
- School of medicine, Pontifical Xavierian University, Carrera 7 No 40-62, 8th Floor, Bogotá 110231, Colombia
| | - Candida Diaz-Brochero
- Pontifical Xavierian University, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
- Infectious Diseases Unit, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Javier Ricardo Garzon Herazo
- Pontifical Xavierian University, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
- Infectious Diseases Unit, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Oscar Mauricio Muñoz Velandia
- Pontifical Xavierian University, Bogotá, Colombia
- Department of Internal Medicine, Hospital Universitario San Ignacio, Bogotá, Colombia
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Hand J, Imlay H. Antimicrobial Stewardship in Immunocompromised Patients: Current State and Future Opportunities. Infect Dis Clin North Am 2023; 37:823-851. [PMID: 37741735 DOI: 10.1016/j.idc.2023.08.002] [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: 09/25/2023]
Abstract
Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.
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Affiliation(s)
- Jonathan Hand
- Ochsner Health, New Orleans, LA, USA; University of Queensland School of Medicine, Ochsner Clinical School
| | - Hannah Imlay
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA.
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Ranganath N, Yetmar ZA, McCandless AR, Rivera CG, Lahr BD, Tande AJ, Shah AS. Evaluating antimicrobial duration for Gram-negative bacteremia in patients with neutropenia due to hematologic malignancy or hematopoietic stem cell transplantation. Transpl Infect Dis 2023; 25:e14085. [PMID: 37279240 DOI: 10.1111/tid.14085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND In the management of Gram-negative bloodstream infection (GN-BSI), short antimicrobial courses have been increasingly demonstrated to be non-inferior to prolonged therapy, with lower risk of Clostridioides difficile infection (CDI) and emergence of multi-drug resistant (MDR) organisms. However, immunocompromised hosts were excluded from these studies. We investigated outcomes of short (≤10 days), intermediate (11-14 days), and prolonged (≥15 days) antimicrobial durations for GN-BSI in neutropenic patients. METHODS A retrospective cohort study was conducted on neutropenic patients with monomicrobial GN-BSI between 2018 and 2022. The primary outcome was a composite of all-cause mortality and microbiologic relapse within 90 days after therapy completion. The secondary outcome was a composite of 90-day CDI and development of MDR-GN bacteria. Cox regression analysis with propensity score (PS) adjustment was used to compare outcomes between the three groups. RESULTS A total of 206 patients were classified into short (n = 67), intermediate (n = 81), or prolonged (n = 58) duration. Neutropenia was predominantly secondary to hematopoietic stem cell transplantation (48%) or hematologic malignancy (35%). The primary sources of infection included intra-abdominal (51%), vascular catheter (27%), and urinary (8%). Most patients received definitive therapy with cefepime or carbapenem. No significant difference in the primary composite endpoint was observed for intermediate versus short (PS-adjusted hazard ratio [aHR] 0.89; 95% confidence interval [95% CI] 0.39-2.03) or prolonged versus short therapy (PS-aHR 1.20; 95% CI 0.52-2.74). There was no significant difference in the secondary composite endpoint of CDI or MDR-GN emergence. CONCLUSION Our data suggest that short antimicrobial courses had comparable 90-day outcomes as intermediate and prolonged regimens for GN-BSI among immunocompromised patients with neutropenia.
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Affiliation(s)
- Nischal Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Brian D Lahr
- Division of Clinical Trials & Biostatistics, Department of Quantitative Health Sciences, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aditya S Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Corona A, De Santis V, Agarossi A, Prete A, Cattaneo D, Tomasini G, Bonetti G, Patroni A, Latronico N. Antibiotic Therapy Strategies for Treating Gram-Negative Severe Infections in the Critically Ill: A Narrative Review. Antibiotics (Basel) 2023; 12:1262. [PMID: 37627683 PMCID: PMC10451333 DOI: 10.3390/antibiotics12081262] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/04/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Not enough data exist to inform the optimal duration and type of antimicrobial therapy against GN infections in critically ill patients. METHODS Narrative review based on a literature search through PubMed and Cochrane using the following keywords: "multi-drug resistant (MDR)", "extensively drug resistant (XDR)", "pan-drug-resistant (PDR)", "difficult-to-treat (DTR) Gram-negative infection," "antibiotic duration therapy", "antibiotic combination therapy" "antibiotic monotherapy" "Gram-negative bacteremia", "Gram-negative pneumonia", and "Gram-negative intra-abdominal infection". RESULTS Current literature data suggest adopting longer (≥10-14 days) courses of synergistic combination therapy due to the high global prevalence of ESBL-producing (45-50%), MDR (35%), XDR (15-20%), PDR (5.9-6.2%), and carbapenemases (CP)/metallo-β-lactamases (MBL)-producing (12.5-20%) Gram-negative (GN) microorganisms (i.e., Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumanii). On the other hand, shorter courses (≤5-7 days) of monotherapy should be limited to treating infections caused by GN with higher (≥3 antibiotic classes) antibiotic susceptibility. A general approach should be based on (i) third or further generation cephalosporins ± quinolones/aminoglycosides in the case of MDR-GN; (ii) carbapenems ± fosfomycin/aminoglycosides for extended-spectrum β-lactamases (ESBLs); and (iii) the association of old drugs with new expanded-spectrum β-lactamase inhibitors for XDR, PDR, and CP microorganisms. Therapeutic drug monitoring (TDM) in combination with minimum inhibitory concentration (MIC), bactericidal vs. bacteriostatic antibiotics, and the presence of resistance risk predictors (linked to patient, antibiotic, and microorganism) should represent variables affecting the antimicrobial strategies for treating GN infections. CONCLUSIONS Despite the strategies of therapy described in the results, clinicians must remember that all treatment decisions are dynamic, requiring frequent reassessments depending on both the clinical and microbiological responses of the patient.
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Affiliation(s)
- Alberto Corona
- Accident, Emergency and ICU Department and Surgical Theatre, ASST Valcamonica, University of Brescia, 25043 Breno, Italy
| | | | - Andrea Agarossi
- Accident, Emergency and ICU Department, ASST Santi Paolo Carlo, 20142 Milan, Italy
| | - Anna Prete
- AUSL Romagna, Umberto I Hospital, 48022 Lugo, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Giacomina Tomasini
- Urgency and Emergency Surgery and Medicine Division ASST Valcamonica, 25123 Brescia, Italy
| | - Graziella Bonetti
- Clinical Pathology and Microbiology Laboratory, ASST Valcamonica, 25123 Brescia, Italy
| | - Andrea Patroni
- Medical Directorate, Infection Control Unit, ASST Valcamonica, 25123 Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
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Vance MK, Cretella DA, Ward LM, Vijayvargiya P, Garrigos ZE, Wingler MJB. Risk Factors for Bloodstream Infections Due to ESBL-Producing Escherichia coli, Klebsiella spp., and Proteus mirabilis. PHARMACY 2023; 11:pharmacy11020074. [PMID: 37104080 PMCID: PMC10143278 DOI: 10.3390/pharmacy11020074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023] Open
Abstract
(1) Background: Risk factors for extended-spectrum beta-lactamase (ESBL) infections could vary geographically. The purpose of this study was to identify local risk factors for ESBL production in patients with Gram-negative bacteremia. (2) Methods: This retrospective observational study included adult patients admitted from January 2019 to July 2021 and had positive blood cultures for E. coli, K. pneumoniae, K. oxytoca, and P. mirabilis. Patients with ESBL infection were matched to a non-ESBL-producing infection with the same organism. (3) Results: A total of 150 patients were included: 50 in the ESBL group and 100 in the non-ESBL group. Patients in the ESBL group had a longer length of stay (11 vs. 7 days, p < 0.001), but not increased mortality (14% vs. 15%, p = 0.87) Multivariate analysis identified the receipt of >1 antibiotic in the last 90 days as a risk factor for ESBL infection (OR = 3.448, 95% CI = 1.494-7.957; p = 0.004); (4) Conclusions: Recent antimicrobial use was identified as an independent risk factors for ESBL-producing Enterobacterales infections. Knowledge of this risk may improve empirical therapy and reduce inappropriate use.
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Affiliation(s)
- Mary Kathryn Vance
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - David A Cretella
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Lori M Ward
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Mary Joyce B Wingler
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Shorter antibiotic courses in the immunocompromised: the impossible dream? Clin Microbiol Infect 2023; 29:143-149. [PMID: 35988852 DOI: 10.1016/j.cmi.2022.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND A growing number of studies have demonstrated similar outcomes with shorter courses of antibiotics for bacterial infections. Immunocompromised patients are frequently excluded from these studies despite anticipated benefits associated with shortening antibiotic courses (including lower risks of antibiotic toxicity, Clostridioides difficile infection, drug-resistant pathogens, and microbiome alterations). OBJECTIVES To critically review the literature that assesses shorter antibiotic courses in immunocompromised patients, specifically among solid organ transplant recipients and neutropenic fever (NF) syndromes among patients on antineoplastic chemotherapy and undergoing haematopoietic cell transplant. SOURCES References were identified through searches of PubMed, Embase, MEDLINE, and clinical guidelines documents. CONTENT Among organ transplant recipients, the majority of studies assessing outcomes associated with shorter antibiotic courses have been retrospective but have demonstrated similar rates of clinically relevant endpoints. Patients with high- and low-risk NF have been well-studied, including enrolment in randomized studies, albeit with heterogeneous patient populations and outcomes assessed. Clinical improvement-guided adoption of shorter courses has been associated with fewer antibiotic days and similar rates of fever recurrence and mortality. IMPLICATIONS Similar to studies demonstrating efficacy in immunocompetent patients, shorter antibiotic courses should be considered for immunocompromised hosts with presumed bacterial infections. Organ recipients and patients with NF syndromes should be prioritized for study in randomized controlled clinical trials assessing shorter course therapy.
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Turjeman A, von Dach E, Molina J, Franceschini E, Koppel F, Yelin D, Dishon-Benattar Y, Mussini C, Rodríguez-Baño J, Cisneros JM, Huttner A, Paul M, Leibovici L, Yahav D. Duration of antibiotic treatment for Gram-negative bacteremia - Systematic review and individual participant data (IPD) meta-analysis. EClinicalMedicine 2023; 55:101750. [PMID: 36483269 PMCID: PMC9722443 DOI: 10.1016/j.eclinm.2022.101750] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We aim to compare the effect of short versus long treatment duration in Gram-negative bacteremia on all-cause mortality in pre-specified sub-groups. METHODS Individual participant data meta-analysis of randomized controlled trials (RCTs) comparing short (≤7) versus longer (>7 days) antibiotic treatment for Gram-negative bacteremia. Participants were adults (≥18 years), with Gram-negative bacteremia during hospital stay. We searched PubMed, Cochrane Central Register of Controlled Trials, and Web of Science to identify trials conducted up to May 2022. Primary outcome was 90-day all-cause mortality. Secondary outcomes were 30-day mortality, relapse of bacteremia, length of hospital stay, readmission, local or distant infection complications, adverse events, and resistance emergence.Outcomes were assessed in pre-specified subgroups: women vs men; non-urinary vs urinary source; presence vs absence of hypotension on initial presentation; immunocompromised patients versus non-immunocompromised patients, and age (above/below 65). Fixed-effect meta-analysis model was used to estimate pooled odds ratio (OR) and 95% confidence interval (CI). All three trials had low risk of bias for allocation generation and concealment. FINDINGS Three RCTs (1186 patients) were included; 1121 with enterobacterales bacteremia. No significant difference in mortality was demonstrated between 7- and 14-days treatment (90-day mortality: OR 1.08, 95% CI 0.73-1.58; 30-day mortality: 1.08, 0.62-1.91). Relapse (1.00, 0.50-1.97); length of hospital stay (P = 0.78); readmission (0.96, 0.80-1.22); and infection complications (local: 1.62 0.76-3.47; distant: 2.00, 0.18-22.08), were without significant difference, and so were adverse events or resistance emergence.No significant difference in clinical outcomes between 7 and 14 days of antibiotics was demonstrated in the subgroups of gender, age, hemodynamic status, immune status, and source of infection. INTERPRETATION For patients hemodynamically stable and afebrile at 48 h prior to discontinuation, seven days of antibiotic therapy for enterobacterales bacteremia result in similar outcomes as 14 days, in terms of mortality, relapse, length of hospital stay, complications of infection, resistance emergence, and adverse events. These results apply for any adult age group, gender, source of infection, immune status, and hemodynamic status on presentation. FUNDING There was no funding source for this study.
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Affiliation(s)
- Adi Turjeman
- Research Authority, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elodie von Dach
- Faculty of Medicine, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, Clinical Research Center, Geneva University Hospitals, Geneva, Switzerland
| | - José Molina
- Clinical Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Dana Yelin
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Yael Dishon-Benattar
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Jesús Rodríguez-Baño
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
- Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital; Department of Medicine, School of Medicine, University of Seville; and Biomedicine Institute of Seville/CSIC, Seville, Spain
| | - José Miguel Cisneros
- Clinical Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
| | - Angela Huttner
- Faculty of Medicine, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- Research Authority, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
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Chou A, Sucgang R, Hamill RJ, Zechiedrich L, Trautner BW. Mortality difference from Klebsiella aerogenes vs Enterobacter cloacae bloodstream infections. Access Microbiol 2023; 5:acmi000421. [PMID: 36919079 PMCID: PMC10008348 DOI: 10.1099/acmi.0.000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 10/17/2022] [Indexed: 03/02/2023] Open
Abstract
Members of the order Enterobacterales, including Escherichia coli , Klebsiella species and Enterobacter species, are important pathogens in healthcare-associated infections. Higher mortality has been reported from infections due to Klebsiella pneumoniae than from E. coli , but prior studies comparing Enterobacter aerogenes (recently renamed Klebsiella aerogenes ) bacteraemia and Enterobacter cloacae complex bacteraemia have yielded conflicting results regarding whether clinical outcomes differ. We found bacteraemia with K. aerogenes was independently associated with greater risk of 30-day mortality than bacteraemia with Enterobacter cloacae complex.
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Affiliation(s)
- Andrew Chou
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd, Suite 01Y, Houston, Texas, USA.,Medical Care Line, Infectious Disease Section, Michael E. DeBakey VA Medical Center, Houston, Texas, 2002 Holcombe Blvd 111G/4B370, Houston, Texas, USA.,Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Margaret M. and Albert B. Alkek Department of Medicine Section of Infectious Disease, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Richard Sucgang
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Center for Health Data Science and Analytics, Houston Methodist Hospital, 6565 Fannin St, Houston, Texas, USA
| | - Richard J Hamill
- Medical Care Line, Infectious Disease Section, Michael E. DeBakey VA Medical Center, Houston, Texas, 2002 Holcombe Blvd 111G/4B370, Houston, Texas, USA.,Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Margaret M. and Albert B. Alkek Department of Medicine Section of Infectious Disease, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Lynn Zechiedrich
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Verna and Marrs McLean Department of Biochemistry and Molecular Biology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Department of Pharmacology and Chemical Biology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2450 Holcombe Blvd, Suite 01Y, Houston, Texas, USA.,Department of Molecular Virology and Microbiology, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
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11
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Vena A, Bovis F, Tutino S, Santagostino Barbone A, Mezzogori L, Ponzano M, Taramasso L, Baldi F, Dettori S, Labate L, Russo C, Giacobbe DR, Mikulska M, Dentone C, Magnasco L, Marchese A, Robba C, Ball L, Battaglini D, Pelosi P, Crea F, Di Pilato V, Di Biagio A, Bouza E, Muñoz P, Bassetti M. Short Course of Antifungal Therapy in Patients With Uncomplicated Candida Bloodstream Infection: Another Case of Less Is More in the Clinical Setting? Open Forum Infect Dis 2022; 10:ofac656. [PMID: 36655192 PMCID: PMC9835756 DOI: 10.1093/ofid/ofac656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Background The objective of this study was to compare the clinical outcomes of patients receiving a short course (SC) vs a prolonged course (PC) of antifungal therapy for uncomplicated Candida bloodstream infections (BSIs). Methods All episodes of uncomplicated Candida BSI from September 1, 2018, to August 31, 2020, were reviewed. We compared the primary (all-cause 90-day mortality) and secondary study end points (1-year recurrent Candida BSI and all-cause 1-year mortality) among patients who underwent SC (5-11 days) or PC (12-24 days) therapy using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. Results A total of 114 patients with uncomplicated Candida BSI were included: 35 (30.7%) were classified into the SC group (median [interquartile range {IQR}], 9 [7-11] days) and 79 (69.3%) into the PC group (median [IQR], 14 [14-16] days). Patients in the SC group compared with the PC group had a higher rate of hospitalization in the surgical ward (40.0% vs 19.0%; P = .02) or septic shock at the time of Candida BSI onset (11.4% vs 1.3%; P = .03). The risk of 90-day mortality was not different between the SC and PC groups (n = 8 [22.9%] vs 17 [21.5%], respectively; IPTW-adjusted subdistribution hazard ratio [sHR], 0.67; 95% CI, 0.31-1.47; P = .20). The risk for recurrent Candida BSI within 1 year of completing therapy (IPTW-adjusted sHR, 1.07; 95% CI, 0.20-5.80; P = .94) or for all-cause 1-year mortality (IPTW-adjusted HR, 0.72; 95% CI, 0.35-1.50; P = .38) did not differ between groups. Conclusions Receiving a short vs prolonged course of antifungal therapy did not affect mortality or BSI recurrence in patients with uncomplicated candidemia.
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Affiliation(s)
- Antonio Vena
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Francesca Bovis
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Stefania Tutino
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | | | - Laura Mezzogori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Marta Ponzano
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Biostatistics Unit, University of Genoa, Genoa, Italy
| | - Lucia Taramasso
- Correspondence: Lucia Taramasso, MD, PhD, Infectious Diseases Unit, Ospedale Policlinico San Martino—IRCCS, University of Genoa, L.go R. Benzi, 10–16132 Genoa, Italy ()
| | - Federico Baldi
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Silvia Dettori
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Labate
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Russo
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Chiara Dentone
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Laura Magnasco
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Anna Marchese
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Francesca Crea
- Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,Microbiology Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy
| | - Antonio Di Biagio
- Infectious Diseases Unit, Policlinico San Martino Hospital—IRCCS, Genoa, Italy,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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12
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Duration of antibiotic therapy in Gram-negative infections with a particular focus on multidrug-resistant pathogens. Curr Opin Infect Dis 2022; 35:614-620. [PMID: 35942853 DOI: 10.1097/qco.0000000000000861] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Antimicrobial overuse is a major health problem that contributes to antimicrobial resistance (AMR). Infections with Gram-negative bacilli (GNB) and multidrug-resistant organisms (MDRs) are associated with high morbidity and mortality, particularly in patients with underlying medical conditions. RECENT FINDINGS Although many recent studies have been published about the novel antibiotics in treating infections including those due to MDR-GNB, the optimal duration of treatment (DOT) remains inconclusive. Recent observation has supported that short antibiotic therapy (SAT) decreases AMR and adverse effects. This narrative review provides an overview of the most recent published studies on the duration of therapy in the treatment of GNB infections, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), intra-abdominal infections (IAIs), bloodstream infections (BSIs) and urinary tract infections (UTIs), with a particular focus on MDR-GNB. SUMMARY Studies showed different outcomes when comparing SAT to long antimicrobial therapy (LAT). No generalization can be made on all sites of infections and different GNBs. Further studies are needed to address the optimal DOT in MDR-GNB, as this group is underrepresented in recent studies.
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13
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How to manage central venous catheter-related bloodstream infections due to Gram-negative bacilli? Curr Opin Infect Dis 2022; 35:583-588. [PMID: 35852791 DOI: 10.1097/qco.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recent data evaluating the management of central venous catheter-related bloodstream infection due to Gram-negative bacilli (GNB). RECENT FINDINGS The incidence of GNB catheter-related bloodstream infection (CRBSI) has been increasing considerably in the last years, and this has raised a concern due to the high reported rate of multidrug-resistant in these infections what poses a considerable challenge for effective treatment. However, there are no specific guidelines for the management of GNB-CRBSI and optimal treatment duration has not been clearly defined. Recent studies have shown that the risk for complications is clearly different to what is stablished for Staphylococcus aureus . Therefore, a short course of antibiotic therapy might be effective once the central venous catheter (CVC) has been removed and the monitoring complications through control blood cultures or echocardiography seem to be less helpful in GNB CRBSI. SUMMARY The incidence of GNB CRBSI has been increasing considerably in the last years; this has raised a concern due to the high reported rate of MDR in these infections what poses a considerable challenge for effective treatment. However, there are no specific guidelines for the management of GNB-CRBSI and optimal treatment duration has not been clearly defined. Recent studies have shown that the risk for complications is clearly different to what is stablished for S. aureus . Therefore, a short course of antibiotic therapy might be effective once the CVC has been removed and the monitoring complications through control blood cultures or echocardiography seem to be less helpful in GNB-CRBSI.
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14
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Imlay H, Spellberg B. Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients. Transpl Infect Dis 2022; 24:e13896. [DOI: 10.1111/tid.13896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Hannah Imlay
- Department of Medicine University of Utah Salt Lake City Utah USA
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center Los Angeles California USA
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15
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Hung YP, Lee CC, Ko WC. Effects of Inappropriate Administration of Empirical Antibiotics on Mortality in Adults With Bacteraemia: Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:869822. [PMID: 35712120 PMCID: PMC9197423 DOI: 10.3389/fmed.2022.869822] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Bloodstream infections are associated with high mortality rates and contribute substantially to healthcare costs, but a consensus on the prognostic benefits of appropriate empirical antimicrobial therapy (EAT) for bacteraemia is lacking. Methods We performed a systematic search of the PubMed, Cochrane Library, and Embase databases through July 2021. Studies comparing the mortality rates of patients receiving appropriate and inappropriate EAT were considered eligible. The quality of the included studies was assessed using Joanna Briggs Institute checklists. Results We ultimately assessed 198 studies of 89,962 total patients. The pooled odds ratio (OR) for the prognostic impacts of inappropriate EAT was 2.06 (P < 0.001), and the funnel plot was symmetrically distributed. Among subgroups without between-study heterogeneity (I2 = 0%), those of patients with severe sepsis and septic shock (OR, 2.14), Pitt bacteraemia scores of ≥4 (OR, 1.88), cirrhosis (OR, 2.56), older age (OR, 1.78), and community-onset/acquired Enterobacteriaceae bacteraemia infection (OR, 2.53) indicated a significant effect of inappropriate EAT on mortality. The pooled adjusted OR of 125 studies using multivariable analyses for the effects of inappropriate EAT on mortality was 2.02 (P < 0.001), and the subgroups with low heterogeneity (I2 < 25%) exhibiting significant effects of inappropriate EAT were those of patients with vascular catheter infections (adjusted OR, 2.40), pneumonia (adjusted OR, 2.72), or Enterobacteriaceae bacteraemia (adjusted OR, 4.35). Notably, the pooled univariable and multivariable analyses were consistent in revealing the negligible impacts of inappropriate EAT on the subgroups of patients with urinary tract infections and Enterobacter bacteraemia. Conclusion Although the current evidence is insufficient to demonstrate the benefits of prompt EAT in specific bacteraemic populations, we indicated that inappropriate EAT is associated with unfavorable mortality outcomes overall and in numerous subgroups. Prospective studies designed to test these specific populations are needed to ensure reliable conclusions. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42021270274.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan City, Taiwan.,Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan.,Clinical Medicine Research Centre, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan City, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
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16
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Fattah MA, Haquin J, Macgowan A, Grier S, Chazan B, Yanovskay A, Ami RB, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodríguez-Baño J, de Cueto M, Oliver A, de Gopegui ER, Cano A, Machuca I, Gozalo-Marguello M, Martinez-Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Duration of Treatment for Pseudomonas aeruginosa Bacteremia: a Retrospective Study. Infect Dis Ther 2022; 11:1505-1519. [PMID: 35612693 PMCID: PMC9334465 DOI: 10.1007/s40121-022-00657-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION There is no consensus regarding optimal duration of antibiotic therapy for Pseudomonas aeruginosa bacteremia. We aimed to evaluate the impact of short antibiotic course. METHODS We present a retrospective multicenter study including patients with P. aeruginosa bacteremia during 2009-2015. We evaluated outcomes of patients treated with short (6-10 days) versus long (11-15 days) antibiotic courses. The primary outcome was a composite of 30-day mortality or bacteremia recurrence and/or persistence. Univariate and inverse probability treatment-weighted (IPTW) adjusted multivariate analysis for the primary outcome was performed. To avoid immortal time bias, the landmark method was used. RESULTS We included 657 patients; 273 received a short antibiotic course and 384 a long course. There was no significant difference in baseline characteristics of patients. The composite primary outcome occurred in 61/384 patients in the long-treatment group (16%) versus 32/273 in the short-treatment group (12%) (p = 0.131). Mortality accounted for 41/384 (11%) versus 25/273 (9%) of cases, respectively. Length of hospital stay was significantly shorter in the short group [median 13 days, interquartile range (IQR) 9-21 days, versus median 15 days, IQR 11-26 days, p = 0.002]. Ten patients in the long group discontinued antibiotic therapy owing to adverse events, compared with none in the short group. On univariate and multivariate analyses, duration of therapy was not associated with the primary outcome. CONCLUSIONS In this retrospective study, 6-10 days of antibiotic course for P. aeruginosa bacteremia were as effective as longer courses in terms of survival and recurrence. Shorter therapy was associated with reduced length of stay and less drug discontinuation.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- Université de Lorraine, APEMAC, 54000, Nancy, France.,Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Manal Abdel Fattah
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Justine Haquin
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Alasdair Macgowan
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Sally Grier
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Bibiana Chazan
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Anna Yanovskay
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Michal Landes
- Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Evelina Tacconelli
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Michael Buhl
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Jesús Rodríguez-Baño
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Marina de Cueto
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Enrique Ruiz de Gopegui
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | | | - Luis Martinez-Martinez
- Microbiology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Leonardo Pagani
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, 2 Sheba Road, 52621, Ramat-Gan, Israel.
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17
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Zhao S, Wu Y, Dai Z, Chen Y, Zhou X, Zhao J. Risk factors for antibiotic resistance and mortality in patients with bloodstream infection of Escherichia coli. Eur J Clin Microbiol Infect Dis 2022; 41:713-721. [PMID: 35190911 DOI: 10.1007/s10096-022-04423-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/11/2022] [Indexed: 12/19/2022]
Abstract
This study aimed to investigate the risk factors for bloodstream infection (BSI) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) and related mortality. The clinical data of 388 patients with E. coli BSI were analyzed. Blood cultures were performed and the antimicrobial susceptibility profiles of the resulting isolates were determined. Four single-nucleotide polymorphisms (rs231775, rs12343816, rs16944, and rs2233406) were genotyped using real-time PCR. ESBL were detected by disk diffusion confirmatory testing. Univariate and multivariate regression analyses were applied to identify the risk factors for ESBL-producing isolates and the BSI-induced mortality. The prevalence of ESBL-producing E. coli in BSI patients was 40.98%. E. coli isolates were commonly susceptible to carbapenem and β-lactam/β-lactamase inhibitor combinations. The major ESBL genes were CTX-M-14, CTX-M-55, CTX-M-15, and CTX-M-27. The proportion of CTX-M-15 was significantly higher in patients over 70 years and those receiving stomach tube catheterization. Nosocomial infection, biliary tract infection, stomach tube catheterization, and previous cephalosporin administration were independent risk factors for ESBL-producing isolates. ESBL positivity, nosocomial infection, and cancer were independent risk factors of mortality. Two genetic polymorphisms associated with inflammation activation, rs231775 A allele and rs2233406 T allele, significantly increased the mortality risk of E. coli BSI with a risk ratio (95% CI) of 1.93 (1.05-3.55) and 4.38 (2.07-9.29), respectively. For patients with nosocomial infection, biliary tract infection, and cancer, the monitor of BSI and antibiotic susceptibility should be enhanced. The invasive procedures should be minimized. rs231775 and rs2233406 are promising prognostic markers for E. coli BSI patients.
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Affiliation(s)
- Shunjin Zhao
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Branch (Lanxi People's Hospital), Lanxi, 321100, China
| | - Yingjing Wu
- Emergency Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Branch (Lanxi People's Hospital), Lanxi, 321100, China
| | - Zhong Dai
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Branch (Lanxi People's Hospital), Lanxi, 321100, China
| | - Yijing Chen
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Branch (Lanxi People's Hospital), Lanxi, 321100, China
| | - Xiaojuan Zhou
- Bacterium Room, The Second Affiliated Hospital of Zhejiang University School of Medicine, Lanxi Branch (Lanxi People's Hospital), Lanxi, 321100, China
| | - Jun Zhao
- Department of Respiratory and Critical Care Medicine, Zhejiang Medical & Health Group Hangzhou Hospital, 1 Banshan Road, Hangzhou, 310022, China.
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18
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Abstract
The causative agents of recurrent Escherichia coli bacteremia can be genetically identical or discordant, but the differences between them remain unclear. This study aimed to explore these differences, with regard to their clinical and microbiological features. Patients were recruited from a Japanese tertiary teaching hospital based on blood culture data and the incidence of recurrent E. coli bacteremia. We compared the patients' clinical and microbiological characteristics between the two groups (those with identical or discordant E. coli bacteremia) divided by the result of enterobacterial repetitive intergenic consensus PCR. Among 70 pairs of recurrent E. coli bacteremia strains, 49 pairs (70%) were genetically identical. Patients with genetically identical or discordant E. coli bacteremia were more likely to have renal failure or neoplasms, respectively. The virulence factor (VF) scores of genetically identical E. coli strains were significantly higher than those of genetically discordant strains, with the prevalence of eight VF genes being significantly higher in genetically identical E. coli strains. No significant differences were found between the two groups regarding antimicrobial susceptibility and biofilm formation potential. This study showed that genetically identical E. coli bacteremia strains have more VF genes than genetically discordant strains in recurrent E. coli bacteremia. IMPORTANCEEscherichia coli causes bloodstream infection, although not all strains are pathogenic to humans. In some cases, this infection reoccurs, and several reports have described the clinical characteristics and/or molecular microbiology of recurrent Escherichia coli bacteremia. However, these studies focused on patients with specific characteristics, and they included cases caused by microorganisms other than Escherichia coli. Hence, little is known about the pathogenicity of Escherichia coli isolated from the recurrent one. The significance of our study is in evaluating the largest cohorts to date, as no cohort studies have been conducted on this topic.
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19
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Avni-Nachman S, Yahav D, Nesher E, Rozen-Zvi B, Rahamimov R, Mor E, Ben-Zvi H, Milo Y, Atamna A, Green H. Short versus prolonged antibiotic treatment for complicated urinary tract infection after kidney transplantation. Transpl Int 2021; 34:2686-2695. [PMID: 34668610 DOI: 10.1111/tri.14144] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/14/2021] [Accepted: 10/10/2021] [Indexed: 01/12/2023]
Abstract
There is no consensus regarding the optimal duration of antibiotic therapy for urinary tract infection (UTI) following kidney transplantation (KT). We performed a retrospective study comparing short (6-10 days) versus prolonged (11-21 days) antibiotic therapy for complicated UTI among KT recipients. Univariate and inverse probability treatment weighted (IPTW) adjusted multivariate analysis for composite primary outcome of all-cause mortality or readmissions within 30 days and relapsed UTI 180 days were performed. Overall, 214 KT recipients with complicated UTI were included; 115 short-course treatment (median 8, interquartile range [IQR] 6-9 days), 99 prolonged course (median 14, IQR 12-21 days). The composite outcome occurred in 33 (28.6%) in the short-course group and 30 (30%) in the prolonged-course group; relapsed UTI occurred in 19 (16.5%) vs. 21 (21%), respectively. Duration of antibiotic treatment was not associated with any of these outcomes. The only risk factor for mortality/readmissions in multivariate analysis was deceased donor. No differences between groups were demonstrated for length of hospital stay, rates of bacteraemia, resistance development, and serum creatinine at 30 and 90 days. In conclusion, we found no difference in clinical outcomes between KT recipients treated for complicated UTI with short-course antibiotic (6-10 days) versus longer course (11-21 days).
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Affiliation(s)
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eviatar Nesher
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Transplant Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Transplant Department, Rabin Medical Center, Petah-Tikva, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery and Transplantation, Transplant Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Haim Ben-Zvi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Yaniv Milo
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Petah-Tikva, Israel
| | - Hefziba Green
- Department of Medicine B, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
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20
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Bae M, Jeong Y, Bae S, Kim MJ, Chong YP, Kim SH, Lee SO, Choi SH, Kim YS, Jung J. Short versus prolonged courses of antimicrobial therapy for patients with uncomplicated Pseudomonas aeruginosa bloodstream infection: a retrospective study. J Antimicrob Chemother 2021; 77:223-228. [PMID: 34590681 DOI: 10.1093/jac/dkab358] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The optimal duration of antimicrobial therapy for uncomplicated Pseudomonas aeruginosa bloodstream infection (BSI) is unknown. We compared the outcomes of short and prolonged courses of antimicrobial therapy in adults with uncomplicated pseudomonal BSI. METHODS All patients with uncomplicated P. aeruginosa BSI admitted at a tertiary-care hospital from April 2010 to April 2020 were included. We compared the primary outcome (a composite of the rate of recurrent P. aeruginosa infection and mortality within 30 days after discontinuing antimicrobial therapy) among patients who underwent short (7‒11 days) and prolonged (12‒21 days) courses of antimicrobial therapy using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. RESULTS We evaluated 1477 patients with P. aeruginosa BSI; of them, 290 met the eligibility criteria who received antimicrobial agents with in vitro activity, including 97 (33%) who underwent short-course therapy [median of 9 (IQR = 8‒11) days] and 193 (67%) who underwent prolonged-course therapy [median of 15 (IQR = 14‒18) days]. We found no significant difference in the risk of recurrence or 30 day mortality between the prolonged-course and short-course groups [n = 30 (16%) versus n = 11 (11%); IPTW-adjusted HR = 0.68, 95% CI = 0.34 - 1.36, P = 0.28]. The prolonged-course therapy did not significantly reduce the risk of the recurrence of P. aeruginosa infection within 180 days compared with short-course therapy [n = 37 (19%) versus n = 12 (12%); IPTW-adjusted HR = 0.57, 95% CI = 0.29 - 1.10, P = 0.09]. CONCLUSIONS Short-course antimicrobial therapy could be as effective as prolonged-course therapy for uncomplicated P. aeruginosa BSI.
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Affiliation(s)
- Moonsuk Bae
- Division of Infectious Disease, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yunseo Jeong
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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21
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Molina J, Montero-Mateos E, Praena-Segovia J, León-Jiménez E, Natera C, López-Cortés LE, Valiente L, Rosso-Fernández CM, Herrero M, Aller-García AI, Cano Á, Gutiérrez-Gutiérrez B, Márquez-Gómez I, Álvarez-Marín R, Infante C, Roca C, Valiente-Méndez A, Pachón J, Reguera JM, Corzo-Delgado JE, Torre-Cisneros J, Rodríguez-Baño J, Cisneros JM. Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial. Clin Microbiol Infect 2021; 28:550-557. [PMID: 34508886 DOI: 10.1016/j.cmi.2021.09.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To prove that 7-day courses of antibiotics for bloodstream infections caused by members of the Enterobacterales (eBSIs) allow a reduction in patients' exposure to antibiotics while achieving clinical outcomes similar to those of 14-day schemes. METHODS A randomized trial was performed. Adult patients developing eBSI with appropriate source control were assigned to 7 or 14 days of treatment, and followed 28 days after treatment cessation; treatments could be resumed whenever necessary. The primary endpoint was days of treatment at the end of follow-up. Clinical outcomes included clinical cure, relapse of eBSI and relapse of fever. A superiority margin of 3 days was set for the primary endpoint, and a non-inferiority margin of 10% was set for clinical outcomes. Efficacy and safety were assessed together with a DOOR/RADAR (desirability of outcome ranking and response adjusted for duration of antibiotic risk) analysis. RESULTS 248 patients were assigned to 7 (n = 119) or 14 (n = 129) days of treatment. In the intention-to-treat analysis, median days of treatment at the end of follow-up were 7 and 14 days (difference 7, 95%CI 7-7). The non-inferiority margin was also met for clinical outcomes, except for relapse of fever (-0.2%, 95%CI -10.4 to 10.1). The DOOR/RADAR showed that 7-day schemes had a 77.7% probability of achieving better results than 14-day treatments. CONCLUSIONS 7-day schemes allowed a reduction in antibiotic exposure of patients with eBSI while achieving outcomes similar to those of 14-day schemes. The possibility of relapsing fever in a limited number of patients, without relevance to final outcomes, may not be excluded, but was overcome by the benefits of shortening treatments.
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Affiliation(s)
- José Molina
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Enrique Montero-Mateos
- Department of Pathology and Institute of Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Salamanca, Spain
| | - Julia Praena-Segovia
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Eva León-Jiménez
- Unit of Infectious Diseases and Microbiology, Virgen de Valme University Hospital, Seville, Spain
| | - Clara Natera
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain
| | - Luis E López-Cortés
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Lucía Valiente
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | - Clara M Rosso-Fernández
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Spanish Clinical Research Network, Virgen del Rocío University Hospital, Seville, Spain
| | - Marta Herrero
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Ana I Aller-García
- Unit of Infectious Diseases and Microbiology, Virgen de Valme University Hospital, Seville, Spain
| | - Ángela Cano
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Ignacio Márquez-Gómez
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | - Rocío Álvarez-Marín
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Carmen Infante
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Cristina Roca
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Adoración Valiente-Méndez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Jerónimo Pachón
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - José María Reguera
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | | | - Julián Torre-Cisneros
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain; Department of Medical and Surgical Sciences, University of Córdoba (UCO), Córdoba, Spain
| | - Jesús Rodríguez-Baño
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - José Miguel Cisneros
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain.
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22
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MacKinnon MC, McEwen SA, Pearl DL, Lyytikäinen O, Jacobsson G, Collignon P, Gregson DB, Valiquette L, Laupland KB. Mortality in Escherichia coli bloodstream infections: a multinational population-based cohort study. BMC Infect Dis 2021; 21:606. [PMID: 34172003 PMCID: PMC8229717 DOI: 10.1186/s12879-021-06326-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background Escherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease. Using a multinational population-based cohort of E. coli BSIs, our objectives were to evaluate 30-day case fatality risk and mortality rate, and determine factors associated with each. Methods During 2014–2018, we identified 30-day deaths from all incident E. coli BSIs from surveillance nationally in Finland, and regionally in Sweden (Skaraborg) and Canada (Calgary, Sherbrooke, western interior). We used a multivariable logistic regression model to estimate factors associated with 30-day case fatality risk. The explanatory variables considered for inclusion were year (2014–2018), region (five areas), age (< 70-years-old, ≥70-years-old), sex (female, male), third-generation cephalosporin (3GC) resistance (susceptible, resistant), and location of onset (community-onset, hospital-onset). The European Union 28-country 2018 population was used to directly age and sex standardize mortality rates. We used a multivariable Poisson model to estimate factors associated with mortality rate, and year, region, age and sex were considered for inclusion. Results From 38.7 million person-years of surveillance, we identified 2961 30-day deaths in 30,923 incident E. coli BSIs. The overall 30-day case fatality risk was 9.6% (2961/30923). Calgary, Skaraborg, and western interior had significantly increased odds of 30-day mortality compared to Finland. Hospital-onset and 3GC-resistant E. coli BSIs had significantly increased odds of mortality compared to community-onset and 3GC-susceptible. The significant association between age and odds of mortality varied with sex, and contrasts were used to interpret this interaction relationship. The overall standardized 30-day mortality rate was 8.5 deaths/100,000 person-years. Sherbrooke had a significantly lower 30-day mortality rate compared to Finland. Patients that were either ≥70-years-old or male both experienced significantly higher mortality rates than those < 70-years-old or female. Conclusions In our study populations, region, age, and sex were significantly associated with both 30-day case fatality risk and mortality rate. Additionally, 3GC resistance and location of onset were significantly associated with 30-day case fatality risk. Escherichia coli BSIs caused a considerable burden of disease from 30-day mortality. When analyzing population-based mortality data, it is important to explore mortality through two lenses, mortality rate and case fatality risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06326-x.
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Affiliation(s)
- Melissa C MacKinnon
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada.
| | - Scott A McEwen
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| | - David L Pearl
- Department of Population Medicine, University of Guelph, Guelph, Ontario, Canada
| | - Outi Lyytikäinen
- Department of Health Security, National Institute for Health and Welfare, Helsinki, Finland
| | - Gunnar Jacobsson
- Department of Infectious Diseases, Skaraborg Hospital, Skövde, Sweden.,CARe - Center for Antibiotic Resistance Research, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Peter Collignon
- Department of Infectious Disease and Microbiology, The Canberra Hospital, Garran, Australian Capital Territory, Australia.,Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - Daniel B Gregson
- Departments of Medicine, and Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary Zone, Calgary, Alberta, Canada
| | - Louis Valiquette
- Department of Microbiology-Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Kevin B Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, British Columbia, Canada.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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23
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Ruiz-Ruigómez M, Fernández-Ruiz M, San-Juan R, López-Medrano F, Orellana MÁ, Corbella L, Rodríguez-Goncer I, Hernández Jiménez P, Aguado JM. Impact of duration of antibiotic therapy in central venous catheter-related bloodstream infection due to Gram-negative bacilli. J Antimicrob Chemother 2021; 75:3049-3055. [PMID: 32591804 DOI: 10.1093/jac/dkaa244] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A progressive increase in the incidence of catheter-related bloodstream infection (CRBSI) due to Gram-negative bacilli (GNB) has been reported. Current guidelines recommend antibiotic treatment for at least 7-14 days, although the supporting evidence is limited. METHODS We performed a retrospective single-centre study including all patients with a definite diagnosis of GNB CRBSI from January 2012 to October 2018 in which the central venous catheter (CVC) was removed. The occurrence of therapeutic failure [clinical failure (persistence of symptoms and laboratory signs of infection), microbiological failure (persistent bacteraemia or relapse) and/or all-cause 30 day mortality] was compared between episodes receiving short [≤7 days (SC)] or long courses [>7 days (LC)] of appropriate antibiotic therapy following CVC removal. RESULTS We included 54 GNB CRBSI episodes with an overall rate of therapeutic failure of 27.8% (15/54). Episodes receiving SC therapy were more frequently due to MDR GNB [60.9% (14/23) versus 34.5% (10/29); P = 0.058] and had higher Pitt scores [median (IQR) 1 (0-4) versus 0 (0-2); P = 0.086]. There were no significant differences in the rate of therapeutic failure between episodes treated with SC or LC therapy [30.4% (7/23) versus 27.6% (8/29); OR 1.15; 95% CI 0.34-3.83; P = 0.822]. The use of SCs was not associated with increased odds of therapeutic failure in any of the exploratory models performed. CONCLUSIONS The administration of appropriate antibiotic therapy for ≤7 days may be as safe and effective as longer courses in episodes of GNB CRBSI once the CVC has been removed.
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Affiliation(s)
- María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - María Ángeles Orellana
- Department of Microbiology, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Pilar Hernández Jiménez
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
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24
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Hojat LS, Bessesen MT, Huang M, Reid M, Knepper BC, Miller MA, Shihadeh KC, Fugit RV, Jenkins TC. Effectiveness of Shorter Versus Longer Durations of Therapy for Common Inpatient Infections Associated With Bacteremia: A Multicenter, Propensity-Weighted Cohort Study. Clin Infect Dis 2021; 71:3071-3078. [PMID: 31858136 DOI: 10.1093/cid/ciz1197] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND National guidelines for pneumonia (PNA), urinary tract infection (UTI), and acute bacterial skin and skin structure infection (ABSSSI) do not address treatment duration for infections associated with bacteremia. We evaluated clinical outcomes of patients receiving shorter (5-9 days) versus longer (10-15 days) duration of antibiotics. METHODS This was a multicenter retrospective cohort study of inpatients with uncomplicated PNA, UTI, or ABSSSI and associated bacteremia. The primary outcome was clinical failure, a composite of rehospitalization, reinitiation of antibiotics, or all-cause mortality within 30 days of antibiotic completion. Secondary outcomes included individual components of the primary outcome, Clostridioides difficile infection, and antibiotic-related adverse effects necessitating change in therapy. A propensity score-weighted logistic regression model was used to mitigate potential bias associated with nonrandom assignment of treatment duration. RESULTS Of 408 patients included, 123 received a shorter treatment duration (median 8 days) and 285 received a longer duration (median 13 days). In the propensity-weighted analysis, the probability of the primary outcome was 13.5% in the shorter group and 11.1% in the longer group (average treatment effect, 2.4%; odds ratio [OR], 1.25; 95% confidence interval [CI], .65-2.40; P = .505). However, shorter courses were associated with higher probability of restarting antibiotics (OR, 1.62; 95% CI, 1.01-2.61; P = .046) and C. difficile infection (OR, 4.01; 95% CI, 2.21-7.59; P < .0001). CONCLUSIONS Shorter courses of antibiotic treatment for PNA, UTI, and ABSSSI with bacteremia were not associated with increased overall risk of clinical failure; however, prospective studies are needed to further evaluate the effectiveness of shorter treatment durations.
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Affiliation(s)
- Leila S Hojat
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases and HIV Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mary T Bessesen
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Infectious Diseases Section, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Misha Huang
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, University of Colorado Hospital, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Hospital, Aurora, Colorado, USA.,Department of Patient Safety and Quality, University of Colorado Hospital, Aurora, Colorado, USA
| | - Margaret Reid
- Department of Biostatistics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA
| | - Matthew A Miller
- Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA.,University of Colorado School of Pharmacy, Aurora, Colorado, USA
| | - Katherine C Shihadeh
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine, Denver Health, Denver, Colorado, USA.,Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Pharmacy, Denver Health, Denver, Colorado, USA
| | - Randolph V Fugit
- Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Infectious Diseases Section, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA.,Department of Pharmacy, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Timothy C Jenkins
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine, Denver Health, Denver, Colorado, USA.,Division of Infectious Diseases, Denver Health, Denver, Colorado, USA
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Rodríguez OL, Sousa A, Pérez-Rodríguez MT, Martínez-Lamas L, Suárez RL, Martínez CT, Pino CP, Vidal FV, Pérez-Landeiro A, Casal MC. Mortality-related factors in patients with OXA-48 carbapenemase-producing Klebsiella pneumoniae bacteremia. Medicine (Baltimore) 2021; 100:e24880. [PMID: 33832068 PMCID: PMC8036053 DOI: 10.1097/md.0000000000024880] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 02/02/2021] [Indexed: 01/05/2023] Open
Abstract
Carbapenemase-producing Enterobacterales constitute a serious public health threat; however, information on the oxacilinasa (OXA-48)-type is limited. The objective of the study was to evaluate the risk factors associated with 14-day mortality for patients with bacteremia due to OXA-48 carbapenemase-producing Klebsiella pneumoniae.We conducted a retrospective, single-center observational study of adult patients with K. pneumoniae bacteremia, classifying the strains as carbapenem-susceptible K. pneumoniae (CSKp) and carbapenem-resistant K. pneumoniae (CRKp). All of the CRKp strains were the OXA-48-type.The study included 202 cases of bacteremia: 114 due to CSKp and 88 due to CRKp. The clinical cure rate was higher for the patients with CSKp (85% vs 69% for CSKp and CRKp, respectively; P = .010), while the 14-day mortality rate was lower (13% vs 30%, P = .005). An INCREMENT-CPE score ≥7 (HR 3.05, 95% CI 1.50-6.25, P = .002) was the only independent factor associated with 14-day mortality for the patients with Klebsiella spp. bacteremia. Other factors related to 14-day mortality were a rapidly fatal prognosis (McCabe) (HR 7.1, 95% CI 2.75-18.37, P < .001), dementia (HR 5.9, 95% CI 2.0-7.43, P = .001), and a high-risk source of infection (HR 2.7, 95% CI 1.06-6.82, P = .038).The most important factors associated with 14-day mortality for the patients with K. pneumoniae bacteremia was an INCREMENT-CPE score ≥7, dementia, a McCabe score indicating a rapidly fatal prognosis and a high-risk source of infection. We found no relationship between a poorer outcome and CRKp isolation or inadequate antibiotic therapy.
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Affiliation(s)
- O. Lima Rodríguez
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
| | - A. Sousa
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
- Biomedical Research Institute Galicia Sur
| | - María Teresa Pérez-Rodríguez
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
- Biomedical Research Institute Galicia Sur
| | | | - R. Longueira Suárez
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
- Biomedical Research Institute Galicia Sur
| | - C. Taboada Martínez
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
| | - C. Portela Pino
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
| | | | | | - M. Crespo Casal
- Infectious Disease Unit, Internal Medicine Department, University Hospital Complex of Vigo
- Biomedical Research Institute Galicia Sur
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Bloodstream infections in the elderly: what is the real goal? Aging Clin Exp Res 2021; 33:1101-1112. [PMID: 31486996 DOI: 10.1007/s40520-019-01337-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Abstract
Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.
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Giannella M, Malosso P, Scudeller L, Bussini L, Rebuffi C, Gatti M, Bartoletti M, Ianniruberto S, Pancaldi L, Pascale R, Tedeschi S, Viale P, Paul M. Quality of care indicators in the MAnageMent of BlOOdstream infections caused by Enterobacteriaceae (MAMBOO-E study): state of the art and research agenda. Int J Antimicrob Agents 2021; 57:106320. [PMID: 33716177 DOI: 10.1016/j.ijantimicag.2021.106320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/27/2021] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The impact on outcome of five interventions was reviewed in order to investigate the state of the art for management of Enterobacteriaceae bloodstream infection (E-BSI). METHODS We searched for randomised controlled trials (RCTs) and observational studies published from January 2008 to March 2019 in PubMed, EMBASE and Cochrane Library. Populations consisted of patients with E-BSI. Interventions were as follows: (i) performance of imaging to assess BSI source and/or complications; (ii) follow-up blood cultures (FU-BCs); (iii) use of loading dose followed by extended/continuous infusion (E/CI) of β-lactams; (iv) duration of treatment (short- versus long-term); and (v) infectious diseases (ID) consultation. Patients without intervention were considered as controls. The main outcome was 30-day mortality. RoB 2.0 and ROBINS-I tools were used for bias assessment. RESULTS No study was eligible for interventions i, iii and v. For FU-BCs, one observational study including 901 patients with E-BSI was considered. Intervention consisted of repeating BCs within 2-7 days after index BCs. All-cause 30-day mortality was 14.2% (35/247) in the intervention group versus 14.7% (96/654) in the control group. For short treatment duration, two RCTs and six observational studies were included comprising 4473 patients with E-BSI. All-cause mortality was similar in the short and long treatment groups (OR = 1.10, 95% CI 0.83-1.44). CONCLUSION Of the assessed interventions, only short treatment duration in non-immunocompromised patients with E-BSI is supported by current data. Studies investigating the use of systematic imaging, FU-BCs, E/CI β-lactams and ID consultation in patients with E-BSI are needed.
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Affiliation(s)
- Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Pietro Malosso
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Luigia Scudeller
- Clinical Trials Team, Scientific Direction, IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Linda Bussini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Chiara Rebuffi
- Scientific documentation center - Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Stefano Ianniruberto
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Livia Pancaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy.
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Mical Paul
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Gauzit R, Castan B, Bonnet E, Bru JP, Cohen R, Diamantis S, Faye A, Hitoto H, Issa N, Lebeaux D, Lesprit P, Maulin L, Poitrenaud D, Raymond J, Strady C, Varon E, Verdon R, Vuotto F, Welker Y, Stahl JP. Anti-infectious treatment duration: The SPILF and GPIP French guidelines and recommendations. Infect Dis Now 2021; 51:114-139. [PMID: 34158156 DOI: 10.1016/j.idnow.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- R Gauzit
- Infectiologie transversale, CHU Cochin, AP-HP, 75014 Paris, France.
| | - B Castan
- Maladies infectieuses et tropicales, CHG, 24000 Périgueux, France
| | - E Bonnet
- Équipe Mobile d'Infectiologie, Hôpital Joseph-Ducuing, Clinique Pasteur, 31300 Toulouse, France
| | - J P Bru
- Maladies Infectieuses, CH Annecy-Genevois, 74374 Pringy, France
| | - R Cohen
- Unité petits nourrissons, CHI, 94000 Créteil, France
| | - S Diamantis
- Maladies Infectieuses et Tropicales, groupe hospitalier Sud Île-de-France, 77000 Melun, France
| | - A Faye
- Pédiatrie Générale et maladies infectieuses, Hôpital Robert-Debré, Université de Paris, AP-HP, 75019 Paris, France
| | - H Hitoto
- Maladies Infectieuses et Tropicales, CH, 72037 Le Mans, France
| | - N Issa
- Réanimation médicale et maladies infectieuses, Hôpital Saint-André, CHU, 33000 Bordeaux, France
| | - D Lebeaux
- Université de Paris, 75006 Paris, France; Microbiologie, Unité Mobile d'Infectiologie, HEGP, AP-HP, 75015 Paris, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, Service de Biologie Clinique, Hôpital Foch, 92150 Suresnes, France
| | - L Maulin
- Maladies Infectieuses et tropicales, CHIAP, 13616 Aix-en-Provence, France
| | - D Poitrenaud
- Unité fonctionnelle d'Infectiologie Régionale, CH Ajaccio, 20303 Ajaccio, France
| | - J Raymond
- Bactériologie, Centre Hospitalier Bicêtre, 94270 Kremlin-Bicêtre, France
| | - C Strady
- Cabinet d'infectiologie, Groupe Courlancy, 51100 Reims, France
| | - E Varon
- Laboratoire de Biologie Médicale et Centre National de Référence des Pneumocoques, CHIC, 94000 Créteil, France
| | - R Verdon
- Maladies Infectieuses et Tropicales, CHU, 14033 Caen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Univ, UNICAEN, UNIROUEN, GRAM 2.0, 14000 Caen, France
| | - F Vuotto
- Maladies Infectieuses, CHU, Hôpital Huriez, 59000 Lille, France
| | - Y Welker
- Maladies Infectieuses, CHI, 78100 Saint-Germain-en-Laye, France
| | - J P Stahl
- Infectiologie, CHU Grenoble Alpes, 38043 Grenoble, France
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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] [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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30
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Chan JD, Bryson-Cahn C, Kassamali-Escobar Z, Lynch JB, Schleyer AM. The Changing Landscape of Uncomplicated Gram-Negative Bacteremia: A Narrative Review to Guide Inpatient Management. J Hosp Med 2020; 15:746-753. [PMID: 32853137 DOI: 10.12788/jhm.3414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/19/2020] [Indexed: 11/20/2022]
Abstract
Gram-negative bacteremia secondary to focal infection such as skin and soft-tissue infection, pneumonia, pyelonephritis, or urinary tract infection is commonly encountered in hospital care. Current practice guidelines lack sufficient detail to inform evidence-based practices. Specifically, antimicrobial duration, criteria to transition from intravenous to oral step-down therapy, choice of oral antimicrobials, and reassessment of follow-up blood cultures are not addressed. The presence of bacteremia is often used as a justification for a prolonged course of antimicrobial therapy regardless of infection source or clinical response. Antimicrobials are lifesaving but not benign. Prolonged antimicrobial exposure is associated with adverse effects, increased rates of Clostridioides difficile infection, antimicrobial resistance, and longer hospital length of stay. Emerging evidence supports shorter overall duration of antimicrobial treatment and earlier transition to oral agents among patients with uncomplicated Enterobacteriaceae bacteremia who have achieved adequate source control and demonstrated clinical stability and improvement. After appropriate initial treatment with an intravenous antimicrobial, transition to highly bioavailable oral agents should be considered for total treatment duration of 7 days. Routine follow-up blood cultures are not cost-effective and may result in unnecessary healthcare resource utilization and inappropriate use of antimicrobials. Clinicians should incorporate these principles into the management of gram-negative bacteremia in the hospital.
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Affiliation(s)
- Jeannie D Chan
- Department of Pharmacy, Harborview Medical Center, UW Medicine, Seattle, Washington
- School of Pharmacy, University of Washington, Seattle, Washington
- Department of Medicine, Division of Allergy & Infectious Diseases, Harborview Medical Center, UW Medicine, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
| | - Chloe Bryson-Cahn
- Department of Medicine, Division of Allergy & Infectious Diseases, Harborview Medical Center, UW Medicine, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
| | - Zahra Kassamali-Escobar
- School of Pharmacy, University of Washington, Seattle, Washington
- Department of Pharmacy, Valley Medical Center, UW Medicine, Renton, Washington
| | - John B Lynch
- Department of Medicine, Division of Allergy & Infectious Diseases, Harborview Medical Center, UW Medicine, Seattle, Washington
- School of Medicine, University of Washington, Seattle, Washington
| | - Anneliese M Schleyer
- School of Medicine, University of Washington, Seattle, Washington
- Hospital Medicine, Department of Medicine, Division of General Internal Medicine, Harborview Medical Center, UW Medicine, Seattle, Washington
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31
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Sutton JD, Stevens VW, Chang NCN, Khader K, Timbrook TT, Spivak ES. Oral β-Lactam Antibiotics vs Fluoroquinolones or Trimethoprim-Sulfamethoxazole for Definitive Treatment of Enterobacterales Bacteremia From a Urine Source. JAMA Netw Open 2020; 3:e2020166. [PMID: 33030555 PMCID: PMC7545306 DOI: 10.1001/jamanetworkopen.2020.20166] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/30/2020] [Indexed: 12/13/2022] Open
Abstract
Importance Oral β-lactam antibiotics are traditionally not recommended to treat Enterobacterales bacteremia because of concerns over subtherapeutic serum concentrations, but there is a lack of outcomes data, specifically after initial treatment with parenteral antibiotics. Given the limited data and increasing limitations of fluoroquinolones or trimethoprim-sulfamethoxazole (TMP-SMX), oral β-lactam antibiotics may be a valuable additional treatment option. Objective To compare definitive therapy with oral β-lactam antibiotics vs fluoroquinolones or TMP-SMX for Enterobacterales bacteremia from a suspected urine source. Design, Setting, and Participants A retrospective cohort study was conducted from January 1, 2007, to September 30, 2015, at 114 Veterans Affairs hospitals among 4089 adults with Escherichia coli, Klebsiella spp, or Proteus spp bacteremia and matching urine culture results. Additional inclusion criteria were receipt of active parenteral antibiotic(s) followed by conversion to an oral antibiotic. Exclusion criteria were previous Enterobacterales bacteremia, urologic abscess, or chronic prostatitis. Data were analyzed from April 15, 2019, to July 26, 2020. Exposures Conversion of therapy to an oral β-lactam antibiotic vs fluoroquinolones or TMP-SMX after 1 to 5 days of parenteral antibiotics. Main Outcomes and Measures The main outcome was a composite of either 30-day all-cause mortality or 30-day recurrent bacteremia. Propensity-based overlap weights were used to adjust for differences between groups. Log binomial regression models were used to estimate adjusted relative risks (aRRs) and adjusted risk differences (aRDs). Results Of the 4089 eligible patients (3731 men [91.2%]; median age, 71 years [interquartile range, 63-81 years]), 955 received an oral β-lactam antibiotic, and 3134 received fluoroquinolones or TMP-SMX. The primary outcome occurred for 42 patients (4.4%) who received β-lactam antibiotics and 94 patients (3.0%) who received fluoroquinolones or TMP-SMX (aRD, 0.99% [95% CI, -0.42% to 2.40%]; aRR, 1.31 [95% CI, 0.87-1.95]). Mortality rates were 3.0% (n = 29) for patients receiving β-lactam antibiotics vs 2.6% (n = 82) for those receiving fluoroquinolones or TMP-SMX (aRD, 0.06% [95% CI, -1.13% to 1.26%]; aRR, 1.02 [95% CI, 0.67-1.56]). Recurrent bacteremia rates were 1.5% (n = 14) among those receiving β-lactam antibiotics vs 0.4% (n = 12) among those receiving fluoroquinolones or TMP-SMX (aRD, 1.03% [95% CI, 0.24%-1.82%]; aRR, 3.43 [95% CI, 0.42-27.90]). Conclusions and Relevance In this cohort study of adults with E coli, Klebsiella spp, or Proteus spp bacteremia from a suspected urine source, the relative risk of recurrent bacteremia was not significantly higher with β-lactam antibiotics compared with fluoroquinolones or TMP-SMX, and the absolute risk and risk difference were small (ie, <3%). No significant difference in mortality was observed. Oral β-lactam antibiotics may be a reasonable step-down treatment option, primarily when alternative options are limited by resistance or adverse effects. Further study is needed because statistical power was limited owing to a low number of recurrent bacteremia events.
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Affiliation(s)
- Jesse D. Sutton
- Department of Pharmacy, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Vanessa W. Stevens
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Nai-Chung N. Chang
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Karim Khader
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Tristan T. Timbrook
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- now at BioFire Diagnostics, Salt Lake City, Utah
| | - Emily S. Spivak
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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32
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Li X, Liu C, Mao Z, Li Q, Qi S, Zhou F. Short-course versus long-course antibiotic treatment in patients with uncomplicated gram-negative bacteremia: A systematic review and meta-analysis. J Clin Pharm Ther 2020; 46:173-180. [PMID: 32981149 PMCID: PMC7820952 DOI: 10.1111/jcpt.13277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/27/2020] [Accepted: 09/07/2020] [Indexed: 12/18/2022]
Abstract
What is known and objective Gram‐negative bacteremia remains a major health problem around the world. The optimal duration of antibiotic treatment has been poorly defined, and there are significant differences of opinion between clinicians. We conducted this systematic review and meta‐analysis to compare the clinical outcomes of short‐course and long‐course treatments in patients with uncomplicated gram‐negative bacteremia. Methods We searched public databases (PubMed, EMBASE and Cochrane Library) to identify eligible studies. The primary outcomes were all‐cause mortality and the incidence of recurrent bacteremia through day 30. We used the Cochrane risk of bias assessment tool to evaluate the risk of bias for randomized controlled trials (RCTs) and the Newcastle‐Ottawa Scale for non‐RCTs. Results and discussion Six studies involving 2689 patients were included in the systematic review and meta‐analysis. No significant difference was found between short‐course and long‐course antibiotic treatments in 30‐day mortality (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.65‐1.13; P = .26), 30‐day recurrent bacteremia (RR 1.07; 95% CI 0.68‐1.67; P = .78), 90‐day mortality (RR 0.84; 95% CI 0.57‐1.24; P = .38), 90‐day recurrent bacteremia (RR 0.98; 95% CI 0.50‐1.89; P = .94), adverse events (RR 1.14; 95% CI 0.89‐1.45; P = .30), Clostridium difficile infection (RR 0.86; 95% CI 0.40‐1.86; P = .71) or resistance development (RR 1.19; 95% CI 0.66‐2.14; P = .57). What is new and conclusion Short‐course was non‐inferior to long‐course antibiotic treatments for patients with uncomplicated gram‐negative bacteremia. Considering the drug‐related side effects and cost‐effectiveness, a shorter duration of antibiotic treatment may be preferable for this particular population. However, additional high‐quality RCTs are needed to further assess whether a shorter course of antibiotic treatment is of greater benefit for patients with uncomplicated gram‐negative bacteremia.
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Affiliation(s)
- Xiaoming Li
- Medical School of Chinese PLA, Beijing, China.,Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Chao Liu
- Medical School of Chinese PLA, Beijing, China
| | - Zhi Mao
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qinglin Li
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Shuang Qi
- Medical School of Chinese PLA, Beijing, China.,Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Feihu Zhou
- Department of Critical Care Medicine, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
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Yahav D, Franceschini E, Koppel F, Turjeman A, Babich T, Bitterman R, Neuberger A, Ghanem-Zoubi N, Santoro A, Eliakim-Raz N, Pertzov B, Steinmetz T, Stern A, Dickstein Y, Maroun E, Zayyad H, Bishara J, Alon D, Edel Y, Goldberg E, Venturelli C, Mussini C, Leibovici L, Paul M. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis 2020; 69:1091-1098. [PMID: 30535100 DOI: 10.1093/cid/ciy1054] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/07/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Gram-negative bacteremia is a major cause of morbidity and mortality in hospitalized patients. Data to guide the duration of antibiotic therapy are limited. METHODS This was a randomized, multicenter, open-label, noninferiority trial. Inpatients with gram-negative bacteremia, who were afebrile and hemodynamically stable for at least 48 hours, were randomized to receive 7 days (intervention) or 14 days (control) of covering antibiotic therapy. Patients with uncontrolled focus of infection were excluded. The primary outcome at 90 days was a composite of all-cause mortality; relapse, suppurative, or distant complications; and readmission or extended hospitalization (>14 days). The noninferiority margin was set at 10%. RESULTS We included 604 patients (306 intervention, 298 control) between January 2013 and August 2017 in 3 centers in Israel and Italy. The source of the infection was urinary in 411 of 604 patients (68%); causative pathogens were mainly Enterobacteriaceae (543/604 [90%]). A 7-day difference in the median duration of covering antibiotics was achieved. The primary outcome occurred in 140 of 306 patients (45.8%) in the 7-day group vs 144 of 298 (48.3%) in the 14-day group (risk difference, -2.6% [95% confidence interval, -10.5% to 5.3%]). No significant differences were observed in all other outcomes and adverse events, except for a shorter time to return to baseline functional status in the short-course therapy arm. CONCLUSIONS In patients hospitalized with gram-negative bacteremia achieving clinical stability before day 7, an antibiotic course of 7 days was noninferior to 14 days. Reducing antibiotic treatment for uncomplicated gram-negative bacteremia to 7 days is an important antibiotic stewardship intervention. CLINICAL TRIALS REGISTRATION NCT01737320.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Adi Turjeman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Ami Neuberger
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
| | | | - Antonella Santoro
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Noa Eliakim-Raz
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Barak Pertzov
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Tali Steinmetz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | | | - Elias Maroun
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa
| | - Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Danny Alon
- Department of Medicine B, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine C, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Claudia Venturelli
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Italy
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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Corcione S, Lupia T, Maraolo AE, Mornese Pinna S, Gentile I, De Rosa FG. Carbapenem-sparing strategy: carbapenemase, treatment, and stewardship. Curr Opin Infect Dis 2020; 32:663-673. [PMID: 31599774 DOI: 10.1097/qco.0000000000000598] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW describing the current role of carbapenems and carbapenem-sparing strategies in the setting of antimicrobial stewardship programs. RECENT FINDINGS sparing carbapenems with other drugs appears to be an interesting perspective for a variety of reasons in the current context of the multidrug-resistant (MDR) pandemic. Specific algorithms should also be precisely investigated to define better how to spare carbapenems within empiric and targeted regimens, with combination treatment or monotherapies, aiming at the best use of the new drugs and improving de-escalation as soon as possible for most of the patients. SUMMARY stewardship programs may be useful in reducing probable misuse and overuse of antibiotics, which has probably contributed to the emergence of carbapenem-resistant bacteria worldwide. The proposal of carbapenem-sparing strategies has then generated substantial scientific debate and, overall, the concept of sparing these drugs is well advocated together with judicious use of novel drugs, appropriate measures of infection control and prevention as well as in stewardship programs to curb the spread of MDR and XDR-strains in healthcare facilities.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Disease, University of Naples Federico II, Naples, Italy
| | | | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Disease, University of Naples Federico II, Naples, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
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Erickson RM, Tritle BJ, Spivak ES, Timbrook TT. Impact of an Antimicrobial Stewardship Bundle for Uncomplicated Gram-Negative Bacteremia. Open Forum Infect Dis 2019; 6:ofz490. [PMID: 32128333 PMCID: PMC7047945 DOI: 10.1093/ofid/ofz490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent studies in gram-negative bacteremia (GNB) suggest that intravenous (IV) to oral (PO) switch and short treatment durations yield similar clinical outcomes and fewer adverse events. Antimicrobial stewardship program (ASP) bundled initiatives have been associated with improved clinical outcomes for bloodstream infections. METHODS This single-center retrospective cohort evaluation included inpatient adults from 11/2014-10/2015 and 10/2017-9/2018 with GNB. The pre-ASP period was before the establishment of an ASP program. In the post period, the ASP promoted IV-to-PO switches, avoidance of repeat blood cultures, and short treatment durations for patients with uncomplicated GNB. The primary outcome was duration of antibiotic therapy. Secondary outcomes included process measures associated with the bundle and clinical outcomes. RESULTS One hundred thirty-seven patients met criteria for inclusion, with 51 patients in the pre group and 86 patients in the post group. Background characteristics were similar between groups. The median duration of therapy (interquartile range) was 14 (10-16) days in the pre group and 10 days (7-14) in the post group (P < .001). The median day of IV-to-PO switch was day 5 (4-6) in the pre group vs day 4 (3-5) in the post group (P = .046). The average total hospital cost per case decreased by 27% in the post group (P = .19). Mortality rates and bacteremia recurrence were not significantly different between groups. CONCLUSIONS An ASP bundle for uncomplicated GNB was associated with reduced durations of therapy and earlier PO switch. These findings highlight the synergistic role of ASPs in optimizing antibiotic use and promoting patient safety.
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Affiliation(s)
| | - Brandon J Tritle
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tristan T Timbrook
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
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Introduction of Selection Biases Due to Loss to Follow-Up in Infectious Disease Retrospective Outcomes Studies. Antimicrob Agents Chemother 2019. [DOI: 10.1128/aac.01681-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Reply to Hughes and Beganovic, “Introduction of Selection Biases Due to Loss to Follow-Up in Infectious Disease Retrospective Outcomes Studies”. Antimicrob Agents Chemother 2019. [DOI: 10.1128/aac.01722-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Borjan J, Gonzales-Luna AJ, Carlson TJ, Finch NA, Mitchell AP, McDaneld PM, Phe K, Foolad F. Significant Publications on Infectious Diseases Pharmacotherapy in 2018. J Pharm Pract 2019; 32:546-557. [PMID: 31327285 DOI: 10.1177/0897190019863921] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To summarize the top 10 most influential peer-reviewed infectious diseases (ID) pharmacotherapy articles published in the year 2018. SUMMARY Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were thought to have most notably contributed to ID pharmacotherapy in 2018, including those related to human immunodeficiency virus (HIV). A total of 26 articles were nominated: 22 articles pertaining to general ID pharmacotherapy and 4 articles involving HIV/AIDS. To select the most significant articles of 2018, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP) asking members to vote on their top 10 general ID publications and 1 HIV publication. Of the 462 members surveyed, 213 (46%) and 108 (23%) voted for general ID pharmacotherapy- and HIV-related articles, respectively. The top article(s) for both categories are summarized. CONCLUSION With the increased emphasis on antimicrobial stewardship initiatives and the growing problem of multidrug-resistant (MDR) organisms, the amount of ID literature centered on stewardship, appropriate treatment durations, and newly approved antimicrobial agents continues to expand, making it challenging for clinicians to stay informed on the most relevant publications. This review summarizes significant ID-related publications in 2018 with the goal of aiding clinicians in staying up to date on the most noteworthy publications in ID pharmacotherapy.
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Affiliation(s)
- Jovan Borjan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Travis J Carlson
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Natalie A Finch
- Department of Pharmacy, Ben Taub General Hospital, Harris Health System, Houston, TX, USA
| | - Ardath P Mitchell
- Department of Pharmacy, Memorial Hermann Katy Hospital, Katy, TX, USA
| | - Patrick M McDaneld
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kady Phe
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Karakonstantis S. Re: ‘Treatment duration for Escherichia coli bloodstream infection and outcomes’ by Giannella et al. Clin Microbiol Infect 2019; 25:640. [DOI: 10.1016/j.cmi.2018.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 10/28/2022]
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‘Treatment duration for Escherichia coli bloodstream infection and outcomes’ – Author's reply. Clin Microbiol Infect 2019; 25:641-642. [DOI: 10.1016/j.cmi.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/08/2018] [Accepted: 12/02/2018] [Indexed: 11/18/2022]
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Tansarli GS, Andreatos N, Pliakos EE, Mylonakis E. A Systematic Review and Meta-analysis of Antibiotic Treatment Duration for Bacteremia Due to Enterobacteriaceae. Antimicrob Agents Chemother 2019; 63:e02495-18. [PMID: 30803971 PMCID: PMC6496097 DOI: 10.1128/aac.02495-18] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/14/2019] [Indexed: 11/20/2022] Open
Abstract
The duration of antibiotic therapy for bacteremia due to Enterobacteriaceae is not well defined. We sought to evaluate the clinical outcomes with shorter- versus longer-course treatment. We performed a systematic search of the PubMed and EMBASE databases through May 2018. Studies presenting comparative outcomes between patients receiving antibiotic treatment for ≤10 days ("short-course") and those treated for >10 days ("long-course") were considered eligible. Four retrospective cohort studies and one randomized controlled trial comprising 2,865 patients met the inclusion criteria. The short- and long-course antibiotic treatments did not differ in 30-day all-cause mortality (1,374 patients; risk ratio [RR] = 0.99; 95% confidence interval [CI], 0.69 to 1.43), 90-day all-cause mortality (1,750 patients; RR = 1.16; 95% CI, 0.81 to 1.66), clinical cure (1,080 patients; RR = 1.02; 95% CI, 0.96 to 1.08), or relapse at 90 days (1,750 patients; RR = 1.08; 95% CI, 0.69 to 1.67). In patients with bacteremia due to Enterobacteriaceae, the short- and long-course antibiotic treatments did not differ significantly in terms of clinical outcomes. Further well-designed studies are needed before treatment for 10 days or less is adopted in clinical practice.
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Affiliation(s)
- Giannoula S Tansarli
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nikolaos Andreatos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Elina E Pliakos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Sousa A, Pérez-Rodríguez MT, Suárez M, Val N, Martínez-Lamas L, Nodar A, Longueira R, Crespo M. Short- versus long-course therapy in gram-negative bacilli bloodstream infections. Eur J Clin Microbiol Infect Dis 2019; 38:851-857. [PMID: 30680566 DOI: 10.1007/s10096-019-03467-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
Bacteremia due to gram-negative bacilli (GNB) is one of the most frequent causes of admission and prolongation of hospital stay. Nevertheless, optimal duration of antibiotic treatment is not clearly established. We designed an observational, prospective study of a cohort of adult patients with uncomplicated GNB bacteremia. They were classified according to the duration of treatment in short (7-10 days) or long (> 10 days) course. Mortality and bacteremia recurrence rate were evaluated, and propensity score for receiving short-course treatment was calculated. A total of 395 patients met eligibility criteria including 232 and 163 who received long- and short-course therapy, respectively. Median age was 71 years, 215 (54.4% male) and 51% had a urinary source. Thirty-day mortality was 12%. In multivariate analysis by logistic regression stratified according to propensity score quartile for receiving short-course therapy showed no association of duration of treatment with 30-day mortality or 90-day recurrence rate. Based on the results observed in our cohort, short-course therapy could be as safe and effective as longer courses.
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Affiliation(s)
- Adrian Sousa
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain.
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain.
| | - María Teresa Pérez-Rodríguez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
| | - Milagros Suárez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
| | - Nuria Val
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
| | - Lucía Martínez-Lamas
- Microbiology Department, Hospital Álvaro Cunqueiro, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Andrés Nodar
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
| | - Rebeca Longueira
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
| | - Manuel Crespo
- Infectious Diseases Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro-Complejo Hospitalario Universitario de Vigo, IIS Galicia Sur, Estrada Clara Campoamor 341, 36212, Vigo, Pontevedra, Spain
- Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), Hospital Álvaro Cunqueiro Bloque Técnico, Estrada Clara Campoamor 341, 36312, Vigo, Spain
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Giannella M, Pascale R, Ferraro G, Toschi A, Pancaldi L, Furii F, Bartoletti M, Tedeschi S, Ambretti S, Lewis RE, Viale P. Risk factors for treatment failure in patients receiving β-lactam/β-lactamase inhibitor combinations for Enterobacteriaceae bloodstream infection: A retrospective, single-centre, cohort study. Int J Antimicrob Agents 2019; 53:574-581. [PMID: 30639527 DOI: 10.1016/j.ijantimicag.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/29/2018] [Accepted: 01/06/2019] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate risk factors for treatment failure in patients receiving in vitro-active therapy with β-lactam/β-lactamase inhibitor (BL/BLI) for Enterobacteriaceae bloodstream infection (E-BSI). This was a retrospective, single-centre study of patients diagnosed with E-BSI at an Italian centre over a 4-year period. Exclusion criteria were age <18 years, clinical data unavailable, polymicrobial BSI, failure to receive in vitro-active therapy and death within 72 h from drawing the index blood culture. Patients who received BL/BLI as appropriate empirical and/or definitive therapy for ≥50% of the total treatment duration were selected. The primary endpoint was all-cause 30-day mortality. The secondary endpoint was 90-day relapse. Of 1319 eligible patients, 835 were selected. A total of 714 received BL/BLI as appropriate empirical therapy, of whom 522 remained on BL/BLI as definitive therapy and 192 shifted to another antibiotic for <50% of the treatment duration; 121 received BL/BLI as definitive therapy only. Non-susceptibility to extended-spectrum cephalosporins (NS-ESCs) was detected in 207 episodes (24.8%). All-cause 30-day mortality was 6.8%. In multivariate analysis adjusted for NS-ESC, independent predictors of mortality were Charlson comorbidity index, septic shock, Proteus spp. and CVC-related BSI, whilst urinary source was a protective factor. The 90-day relapse rate was 4.2%. Immunosuppression was the main independent predictor for relapse. BL/BLI was the most common antibiotic administered to patients with E-BSI in this cohort. Among patients appropriately treated with BL/BLI, failure rates were low and were primarily associated with underlying diseases, clinical severity at BSI onset and infection source.
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Affiliation(s)
- Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy.
| | - Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Giuseppe Ferraro
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Alice Toschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Livia Pancaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Francesca Furii
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Simone Ambretti
- Operative Unit of Clinical Microbiology, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Russell Edward Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Via Massarenti 11, 40137 Bologna, Italy
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Xu M, Fu Y, Kong H, Chen X, Chen Y, Li L, Yang Q. Bloodstream infections caused by Klebsiella pneumoniae: prevalence of bla KPC, virulence factors and their impacts on clinical outcome. BMC Infect Dis 2018; 18:358. [PMID: 30064360 PMCID: PMC6069789 DOI: 10.1186/s12879-018-3263-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 07/20/2018] [Indexed: 12/03/2022] Open
Abstract
Background Klebsiella pneumoniae bloodstream infections (BSIs) occur with significant prevalence and high mortality worldwide. Antimicrobial resistance and virulence are two main factors participating in the pathogenicity of K. pneumoniae. Here we investigated the prevalence of blaKPC and virulence factors in K. pneumoniae isolated from patients with BSIs and their association with clinical outcome. Methods The clinical data of 285 K. pneumoniae BSI cases diagnosed from January 2013 to December 2015 in a Chinese university hospital were retrospectively evaluated. The “string test” was performed to identify hypermucoviscous K. pneumoniae (HMKP). blaKPC, rmpA, magA and serotype-specific genes were detected by PCR amplification. Finally, a Cox proportional hazards model was employed to determine the predictors of 14-day mortality. Results Of these isolates, the prevalence of blaKPC and rmpA were 33.3% (95/285) and 31.6% (90/285) respectively. 69 isolates (24.2%, 69/285) were HMKP. rmpA was strongly associated with HM phenotype. The KPC-producing KP and HMKP were almost non-overlapping and only three HMKP isolates harbored blaKPC. K1 (28, 40.6%) and K2 (22, 31.9%) were the most common serotypes in HMKP. 44.9% of HMKP BSIs had origin of biliary tract infection or liver abscess. The 14-day mortality was 100% in blaKPC+/HM+ subgroup (3/3), followed by blaKPC+/HM− (39/92, 42.4%), blaKPC−/HM+ (5/66, 7.6%) and blaKPC−/HM− (7/124, 5.6%). The 14-day cumulative survival was significantly different between blaKPC+ and blaKPC− subgroup (Log-rank p < 0.001) but almost equal between blaKPC−/HM+ and blaKPC−/HM− subgroup (Log-rank p = 0.578) under the condition of comparable illness severity between blaKPC−/HM+ and blaKPC−/HM− subgroup. Independent risk factors for 14-day mortality were Pitt bacteremia score (HR 1.24, CI 95% 1.13–1.36, p < 0.001), Charlson comorbidity index (HR 1.24, CI 95% 1.09–1.41, p = 0.001), septic shock (HR 2.61, CI 95% 1.28–5.35, p = 0.009) and blaKPC (HR 2.20, CI 95% 1.06–4.54, p = 0.034). Conclusions Most of HMKP were antibiotic-susceptible and people infected received appropriate antimicrobial therapy, which may explain the favorable outcome of HMKP BSIs. The KPC-producing HMKP BSIs were scarce but life-threatening. blaKPC was valuable in predicting 14-day mortality. Electronic supplementary material The online version of this article (10.1186/s12879-018-3263-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Min Xu
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Center of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yiqi Fu
- Department of Respiratory Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haishen Kong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Chen
- Key Laboratory of Clinical In Vitro Diagnostic Techniques of Zhejiang Province, Center of Clinical Laboratory, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qing Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
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