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Soman R, Veeraraghavan B, Hegde A, Varma S, Todi S, Singh RK, Nagavekar V, Rodrigues C, Swaminathan S, Ramsubramanian V, Ansari A, Chaudhry D, Pednekar A, Bhagat S, Patil S, Barkate H. Indian consensus on the managemeNt of carbapenem-resistant enterobacterales infection in critically ill patients II (ICONIC II). Expert Rev Anti Infect Ther 2024; 22:453-468. [PMID: 38790080 DOI: 10.1080/14787210.2024.2360116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The rising challenge of carbapenem-resistant Enterobacterales (CRE) infections in Indian healthcare settings calls for clear clinical guidance on the management of these infections. The Indian consensus on the management of CRE infection in critically ill patients (ICONIC-II) is a follow-up of the ICONIC-I study, which was undertaken in 2019. AREAS COVERED A modified Delphi method was used to build expert consensus on CRE management in India, involving online surveys, face-to - face expert meetings, and a literature review. A panel of 12 experts was formed to develop potential clinical consensus statements (CCSs), which were rated through two survey rounds. The CCSs were finalized in a final face-to - face discussion. The finalized CCSs were categorized as consensus, near consensus, and no consensus. EXPERT OPINION The outcomes included 46 CCSs (consensus: 40; near consensus: 3; and no consensus: 3). The expert panel discussed and achieved consensus on various strategies for managing CRE infections, emphasizing the significance of existing and emerging resistance mechanisms, prompt and tailored empiric therapy, and use of combination therapies. The consensus statements based on the collective expertise of the panel can potentially assist clinicians in the management of CRE infections that lack high-level evidence.
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Affiliation(s)
- Rajeev Soman
- Department of Infectious Diseases, Jupiter Hospital, Pune, India
| | | | - Ashit Hegde
- Department of Critical care, PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Subhash Varma
- Internal Medicine and Hematology Fortis Hospital Mohali, Mohali, India
| | - Subhash Todi
- Department of Critical Care and Emergency Medicine, AMRI Hospital, Kolkata, India
| | - R K Singh
- Department of Emergency Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vasant Nagavekar
- Department of Infectious Disease, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Camilla Rodrigues
- Department of Microbiology and Serology, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | | | - V Ramsubramanian
- Department of Infectious Diseases, Apollo Hospital, Chennai, India
| | - Abdul Ansari
- Department of Critical Care Services, Nanavati Super Speciality Hospital, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical care medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Amullya Pednekar
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sagar Bhagat
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Saiprasad Patil
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
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Han SB, Jeon K, Kim M, Park J, Yoon J, Cho YS, Hur J, Chun W, Kym D. Risk factors for in-hospital acquisition of carbapenem-resistant Enterobacterales in patients with severe burns. J Hosp Infect 2024; 149:165-171. [PMID: 38740304 DOI: 10.1016/j.jhin.2024.04.022] [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: 04/10/2024] [Accepted: 04/21/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Although patients with severe burns are prone to severe infections with antibiotic-resistant bacteria and inevitably have some risk factors for carbapenem-resistant Enterobacterales (CRE) acquisition, risk factors for CRE infection or colonization in these patients have not been investigated. AIM To identify the independent risk factors for CRE acquisition in patients with severe burns. METHODS Patients admitted to the burn intensive care unit (BICU) for acute burn care were categorized based on culture results during BICU care into the CRE group and non-CRE group, which included the carbapenem-susceptible Enterobacterales (CSE) and control groups. Clinical and microbiological factors were compared between the CRE and non-CRE groups, and between the CRE and CSE groups to identify independent risk factors for in-hospital CRE acquisition. FINDINGS Among the included 489 patients, 101 (20.7%) and 388 (79.3%) patients were classified in the CRE and non-CRE groups, respectively. The non-CRE group included 91 (18.6%) and 297 (60.7%) patients in the CSE and control groups, respectively. In multivariate analysis between the CRE and non-CRE groups, exposure to other CRE-acquired patients (P = 0.018), abbreviated burn severity index score ≥9 (P = 0.012), and mechanical ventilation (P < 0.001) were associated with CRE acquisition. In multivariate analysis between the CRE and CSE groups, exposure to other CRE-acquired patients was associated with CRE acquisition (P = 0.048). CONCLUSION Considering the limitation of controlling the burn severity in hospitalized patients, enhanced infection control measures for preventing in-hospital CRE transmission among patients with severe burns should be emphasized.
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Affiliation(s)
- S B Han
- Department of Pediatrics, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Gyeong-gi, Korea
| | - K Jeon
- Department of Laboratory Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - M Kim
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - J Park
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - J Yoon
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - Y S Cho
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - J Hur
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - W Chun
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea
| | - D Kym
- Department of Surgery and Critical Care, Burn Center, Hallym University Hangang Sacred Heart Hospital, Seoul, Korea.
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Salamanca-Rivera E, Palacios-Baena ZR, Cañada JE, Moure Z, Pérez-Vázquez M, Calvo-Montes J, Martínez-Martínez L, Cantón R, Ruiz Carrascoso G, Pitart C, Navarro F, Bou G, Mulet X, González-López JJ, Sivianes F, Delgado-Valverde M, Pascual Á, Oteo-Iglesias J, Rodríguez-Baño J. Epidemiological and clinical characterization of community, healthcare-associated and nosocomial colonization and infection due to carbapenemase-producing Klebsiella pneumoniae and Escherichia coli in Spain. Infection 2024:10.1007/s15010-024-02267-0. [PMID: 38703288 DOI: 10.1007/s15010-024-02267-0] [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: 01/26/2024] [Accepted: 04/12/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Community-acquired (CA) and healthcare-associated (HCA) infections caused by carbapenemase-producing Enterobacterales (CPE) are not well characterized. The objective was to provide detailed information about the clinical and molecular epidemiological features of nosocomial, HCA and CA infections caused by carbapenemase-producing Klebsiella pneumoniae (CP-Kp) and Escherichia coli (CP-Ec). METHODS A prospective cohort study was performed in 59 Spanish hospitals from February to March 2019, including the first 10 consecutive patients from whom CP-Kp or CP-Ec were isolated. Patients were stratified according to acquisition type. A multivariate analysis was performed to identify the impact of acquisition type in 30-day mortality. RESULTS Overall, 386 patients were included (363 [94%] with CP-Kp and 23 [6%] CP-Ec); in 296 patients (76.3%), the CPE was causing an infection. Acquisition was CA in 31 (8.0%) patients, HCA in 183 (47.4%) and nosocomial in 172 (48.3%). Among patients with a HCA acquisition, 100 (54.6%) had been previously admitted to hospital and 71 (38.8%) were nursing home residents. Urinary tract infections accounted for 19/23 (82.6%), 89/130 (68.5%) and 42/143 (29.4%) of CA, HCA and nosocomial infections, respectively. Overall, 68 infections (23%) were bacteremia (8.7%, 17.7% and 30.1% of CA, HCA and nosocomial, respectively). Mortality in infections was 28% (13%, 14.6% and 42.7% of CA, HCA and nosocomial, respectively). Nosocomial bloodstream infections were associated with increased odds for mortality (adjusted OR, 4.00; 95%CI 1.21-13.19). CONCLUSIONS HCA and CA infections caused by CPE are frequent and clinically significant. This information may be useful for a better understanding of the epidemiology of CPE.
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Affiliation(s)
- Elena Salamanca-Rivera
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Zaira R Palacios-Baena
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain.
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain.
| | - Javier E Cañada
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Laboratorio de Referencia a Antibióticos E Infecciones Relacionadas Con La Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Zaira Moure
- Laboratorio de Referencia a Antibióticos E Infecciones Relacionadas Con La Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - María Pérez-Vázquez
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Laboratorio de Referencia a Antibióticos E Infecciones Relacionadas Con La Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Jorge Calvo-Montes
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Luis Martínez-Martínez
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Microbiology Unit, Department of Agricultural Chemistry, Soil Science and Microbiology, Reina Sofia University Hospital, University of Córdoba, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Rafael Cantón
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Guillermo Ruiz Carrascoso
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología Clínica, Hospital Universitario La Paz (IdiPAz), Madrid, Spain
| | - Cristina Pitart
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Clínic de Barcelona, ISGlobal Barcelona Institute for Global Health, Barcelona, Spain
| | - Ferran Navarro
- Servicio de Microbiología, Hospital de La Santa Creu I Sant Pau. Departament de Genètica I de Microbiologia Universitat Autónoma de Barcelona (UAB), Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Germán Bou
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio Microbiología, Hospital Universitario A Coruña, Instituto Investigación Biomédica A Coruña (INIBIC), A Coruña, Spain
| | - Xavier Mulet
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Microbiología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma, Spain
| | - Juan José González-López
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Servei de Microbiologia, Departament de Genetica I Microbiologia, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fran Sivianes
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain
| | - Mercedes Delgado-Valverde
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Álvaro Pascual
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Oteo-Iglesias
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Laboratorio de Referencia a Antibióticos E Infecciones Relacionadas Con La Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), CSIC, Universidad de Sevilla, Avda Dr. Fedriani, 3, 41009, Seville, Spain.
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain.
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Kwon KT, Kim Y, Kim SW, Chang HH, Hwang S, Bae S, Nam E. Antimicrobial Use and Carbapenem-Resistant Enterobacterales in Korea: A Nationwide Case-Control Study With Propensity Score Matching. J Korean Med Sci 2024; 39:e132. [PMID: 38622938 PMCID: PMC11018987 DOI: 10.3346/jkms.2024.39.e132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Nationwide research on the association between carbapenem-resistant Enterobacterales (CREs) and antibiotic use is limited. METHODS This nested case-control study analyzed Korean National Health Insurance claims data from April 2017 to April 2019. Based on the occurrence of CRE, hospitalized patients aged ≥ 18 years were classified into CRE (cases) and control groups. Propensity scores based on age, sex, modified Charlson comorbidity score, insurance type, long-term care facility, intensive care unit stay, and acquisition of vancomycin-resistant Enterococci were used to match the case and control groups (1:3). RESULTS After matching, the study included 6,476 participants (1,619 cases and 4,857 controls). Multivariable logistic regression analysis revealed that the utilization of broad-spectrum antibiotics, such as piperacillin/tazobactam (adjusted odds ratio [aOR], 2.178; 95% confidence interval [CI], 1.829-2.594), third/fourth generation cephalosporins (aOR, 1.764; 95% CI, 1.514-2.056), and carbapenems (aOR, 1.775; 95% CI, 1.454-2.165), as well as the presence of comorbidities (diabetes [aOR, 1.237; 95% CI, 1.061-1.443], hemiplegia or paraplegia [aOR, 1.370; 95% CI, 1.119-1.679], kidney disease [aOR, 1.312; 95% CI, 1.105-1.559], and liver disease [aOR, 1.431; 95% CI, 1.073-1.908]), were significantly associated with the development of CRE. Additionally, the CRE group had higher mortality (8.33 vs. 3.32 incidence rate per 100 person-months, P < 0.001) and a total cost of healthcare utilization per person-month (15,325,491 ± 23,587,378 vs. 5,263,373 ± 14,070,118 KRW, P < 0.001) than the control group. CONCLUSION The utilization of broad-spectrum antibiotics and the presence of comorbidities are associated with increasing development of CRE. This study emphasizes the importance of antimicrobial stewardship in reducing broad-spectrum antibiotic use and CRE disease burden in Korea.
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Affiliation(s)
- Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea.
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eunkyung Nam
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
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Wang Z, Shao C, Shao J, Hao Y, Jin Y. Risk factors of Carbapenem-resistant Enterobacterales intestinal colonization for subsequent infections in hematological patients: a retrospective case-control study. Front Microbiol 2024; 15:1355069. [PMID: 38680915 PMCID: PMC11045900 DOI: 10.3389/fmicb.2024.1355069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/01/2024] [Indexed: 05/01/2024] Open
Abstract
Objective Infections caused by Carbapenem-resistant Enterobacterales (CRE) have high treatment costs, high mortality and few effective therapeutic agents. This study aimed to determine the risk factors for progression from intestinal colonization to infection in hematological patients and the risk factors for 30-day mortality in infected patients. Methods A retrospective case-control study was conducted in the Department of Hematology at Shandong Provincial Hospital affiliated to Shandong First Medical University from April 2018 to April 2022. Patients who developed subsequent infections were identified as the case group by electronic medical record query of patients with a positive rectal screen for CRE colonization, and patients who did not develop subsequent infections were identified as the control group by stratified random sampling. Univariate analysis and logistic regression analysis determined risk factors for developing CRE infection and risk factors for mortality in CRE-infected patients. Results Eleven hematological patients in the study developed subsequent infections. The overall 30-day mortality rate for the 44 hematological patients in the case-control study was 11.4% (5/44). Mortality was higher in the case group than in the control group (36.5 vs. 3.0%, P = 0.0026), and septic shock was an independent risk factor for death (P = 0.024). Univariate analysis showed that risk factors for developing infections were non-steroidal immunosuppressants, serum albumin levels, and days of hospitalization. In multivariable logistic regression analysis, immunosuppressants [odds ratio (OR), 19.132; 95% confidence interval (CI), 1.349-271.420; P = 0.029] and serum albumin levels (OR, 0.817; 95% CI, 0.668-0.999; P = 0.049) were independent risk factors for developing infections. Conclusion Our findings suggest that septic shock increases mortality in CRE-infected hematological patients. Hematological patients with CRE colonization using immunosuppressive agents and reduced serum albumin are more likely to progress to CRE infection. This study may help clinicians prevent the onset of infection early and take measures to reduce mortality rates.
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Affiliation(s)
| | | | | | | | - Yan Jin
- Department of Clinical Laboratory, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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López-Cortés LE, Delgado-Valverde M, Moreno-Mellado E, Goikoetxea Aguirre J, Guio Carrión L, Blanco Vidal MJ, López Soria LM, Pérez-Rodríguez MT, Martínez Lamas L, Arnaiz de Las Revillas F, Armiñanzas C, Ruiz de Alegría-Puig C, Jiménez Aguilar P, Del Carmen Martínez-Rubio M, Sáez-Bejar C, de Las Cuevas C, Martín-Aspas A, Galán F, Yuste JR, Leiva-León J, Bou G, Capón González P, Boix-Palop L, Xercavins-Valls M, Goenaga-Sánchez MÁ, Anza DV, Castón JJ, Rufián MR, Merino E, Rodríguez JC, Loeches B, Cuervo G, Guerra Laso JM, Plata A, Pérez Cortés S, López Mato P, Sierra Monzón JL, Rosso-Fernández C, Bravo-Ferrer JM, Retamar-Gentil P, Rodríguez-Baño J. Efficacy and safety of a structured de-escalation from antipseudomonal β-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:375-385. [PMID: 38215770 DOI: 10.1016/s1473-3099(23)00686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal β-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia. METHODS An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal β-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal β-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete. FINDINGS 2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths. INTERPRETATION De-escalation from an antipseudomonal β-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting. FUNDING Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.
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Affiliation(s)
- Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain.
| | - Mercedes Delgado-Valverde
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Elisa Moreno-Mellado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | | | - Laura Guio Carrión
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - María Teresa Pérez-Rodríguez
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Vigo (CHUVI), Xerencia de Xestión Integrada de Vigo, Spain
| | - Lucía Martínez Lamas
- Grupo de Investigación de Microbiología y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), CHUVI, Vigo, Spain
| | - Francisco Arnaiz de Las Revillas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Armiñanzas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Ruiz de Alegría-Puig
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Carmen Sáez-Bejar
- Servicio de Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Andrés Martín-Aspas
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Facultad de Medicina, Hospital Universitario Puerta del Mar, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Universidad de Cádiz, Cádiz, Spain
| | - Fátima Galán
- Servicio de Microbiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - José Ramón Yuste
- Servicio de Enfermedades Infecciosas, Clínica Universitaria de Navarra, Pamplona, Spain
| | - José Leiva-León
- Servicio de Microbiología, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Germán Bou
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología-Instituto de Investigación Biomédica, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Lucía Boix-Palop
- Servicio de Enfermedades Infecciosas, Hospital Universitario Mútua de Terrassa, Barcelona, Spain
| | | | | | - Diego Vicente Anza
- Servicio de Microbiología, Hospital Universitario de Donostia, Donostia, Spain
| | - Juan José Castón
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Manuel Recio Rufián
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Juan Carlos Rodríguez
- Servicio de Microbiología, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Belén Loeches
- Unidad de Enfermedades Infecciosas, Hospital Universitario La Paz, Madrid, Spain
| | - Guillermo Cuervo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Antonio Plata
- Unidad de Enfermedades Infecciosas, Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Pablo López Mato
- Unidad de Enfermedades Infecciosas, Hospital de Ourense, Ourense, Spain
| | - José Luis Sierra Monzón
- Servicio de Enfermedades Infecciosas and Servicio de Urgencias, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | - Clara Rosso-Fernández
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitarios Virgen del Rocío y Virgen Macarena, Sevilla, Spain
| | - José María Bravo-Ferrer
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Pilar Retamar-Gentil
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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Manageiro V, Cano M, Furtado C, Iglesias C, Reis L, Vieira P, Teixeira A, Martins C, Veloso I, Machado J, Paiva JA, Caniça M. Genomic and epidemiological insight of an outbreak of carbapenemase-producing Enterobacterales in a Portuguese hospital with the emergence of the new KPC-124. J Infect Public Health 2024; 17:386-395. [PMID: 38246112 DOI: 10.1016/j.jiph.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacterales (CPE) is an increasing problem in healthcare settings. This study aimed to identify the source of a CPE outbreak that occurred in 2022, in a tertiary hospital in the North of Portugal, to identify exposed patients, and to assess the risk of becoming CPE-positive following hospital admission. METHODS A multi-disciplinary investigation was conducted including descriptive, analytical, and molecular epidemiology, environmental screening, and assessment of infection control measures. Clinical and environmental isolates were analyzed using whole-genome sequencing and phylogenetic analysis. Additionally, a prospective observational cohort study was conducted to further investigate the risk factors associated with the emergence of new cases in cohorts of CPE-negative admitted patients. RESULTS We observed the presence of multispecies KPC-, IMP-, and/or NDM-producing isolates. Genetically indistinguishable clinical and environmental isolates were found on the same room/ward. The ST45 KPC-3-producing Klebsiella pneumoniae clone was the responsible for the outbreak. During patients' treatment, we detected the emergence of resistance to ceftazidime-avibactam, associated with mutations in the blaKPC-3 gene (blaKPC-46, blaKPC-66 and blaKPC-124, the last variant never previously reported), suggesting a vertical evolutionary trajectory. Patients aged ≥ 75 years, hygiene/feeding-care dependent, and/or subjected to secretion aspiration were risk factors for CPE colonization after hospital admission. Additionally, cases with previous admission to the emergency department suggest that CPE dissemination may occur not only during hospitalization but also in the emergency department. CONCLUSION Overall, the study highlights that selection pressure with antibiotics, like ceftazidime-avibactam, is a contributing factor to the emergence of new β-lactamase variants and antibiotic resistance. It also shows that the hospital environment can be a significant source of CPE transmission, and that routine use of infection control measures and real-time molecular epidemiology investigations are essential to ensure the long-term termination of CPE outbreaks and prevent future resurgences.
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Affiliation(s)
- Vera Manageiro
- National Reference Laboratory of Antibiotic Resistance and Healthcare Associated Infections, Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal; ECDC fellowship Programme, Public Health Microbiology path (EUPHEM), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Manuela Cano
- Department of Environmental Health, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Cristina Furtado
- Reference and Surveillance Unit, Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Carmen Iglesias
- Clinical Pathology Service, Hospital de Braga, Braga, Portugal
| | - Lígia Reis
- National Reference Laboratory of Antibiotic Resistance and Healthcare Associated Infections, Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Patrícia Vieira
- National Reference Laboratory of Antibiotic Resistance and Healthcare Associated Infections, Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal
| | - Aida Teixeira
- Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance (UL-PPCIRA), Hospital de Braga, Braga, Portugal
| | - Cláudia Martins
- Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance (UL-PPCIRA), Hospital de Braga, Braga, Portugal
| | - Isabel Veloso
- Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance (UL-PPCIRA), Hospital de Braga, Braga, Portugal
| | - Jorge Machado
- Coordination of the Department of Infectious Diseases, National Institute of Health, Lisbon, Portugal
| | - José Artur Paiva
- Intensive Care Medicine Service, Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal; Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal; Infections and Antimicrobial Resistance Prevention Programme, Directorate General of Health, Portugal
| | - Manuela Caniça
- National Reference Laboratory of Antibiotic Resistance and Healthcare Associated Infections, Department of Infectious Diseases, National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal; Centre for the Studies of Animal Science, Institute of Agrarian and Agri-Food Sciences and Technologies, University of Porto, Porto, Portugal; AL4AnimalS, Associate Laboratory for Animal and Veterinary Sciences, Portugal.
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8
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Paniagua-García M, Bravo-Ferrer JM, Pérez-Galera S, Kostyanev T, de Kraker MEA, Feifel J, Palacios-Baena ZR, Schotsman J, Cantón R, Daikos GL, Carevic B, Dragovac G, Tan LK, Raka L, Hristea A, Viale P, Akova M, Cano Á, Reguera JM, Bartoloni A, Florescu SA, Benea S, Bukarica L, Asensio Á, Korten V, Grundmann H, Goossens H, Bonten MJ, Gutiérrez-Gutiérrez B, Rodríguez-Baño J. Attributable mortality of infections caused by carbapenem-resistant Enterobacterales: results from a prospective, multinational case-control-control matched cohorts study (EURECA). Clin Microbiol Infect 2024; 30:223-230. [PMID: 38267096 DOI: 10.1016/j.cmi.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES To assess the mortality attributable to infections caused by carbapenem-resistant Enterobacterales (CRE) and to investigate the effect of clinical management on differences in observed outcomes in a multinational matched cohort study. METHODS A prospective matched-cohorts study (NCT02709408) was performed in 50 European hospitals from March 2016 to November 2018. The main outcome was 30-day mortality with an active post-discharge follow-up when applied. The CRE cohort included patients with complicated urinary tract infections, complicated intra-abdominal infections, pneumonia, or bacteraemia from other sources because of CRE. Two control cohorts were selected: patients with infection caused by carbapenem-susceptible Enterobacterales (CSE) and patients without infection. Matching criteria included type of infection for the CSE group, hospital ward of CRE detection, and duration of hospital admission up to CRE detection. Multivariable and stratified Cox regression was applied. RESULTS The cohorts included 235 patients with CRE infection, 235 patients with CSE infection, and 705 non-infected patients. The 30-day mortality (95% CI) was 23.8% (18.8-29.6), 10.6% (7.2-15.2), and 8.4% (6.5-10.6), respectively. The difference in 30-day mortality rates between patients with CRE infection when compared with patients with CSE infection was 13.2% (95% CI, 6.3-20.0), (HR, 2.57; 95% CI, 1.55-4.26; p < 0.001), and 15.4% (95% CI, 10.5-20.2) when compared with non-infected patients (HR, 3.85; 95% CI, 2.57-5.77; p < 0.001). The population attributable fraction for 30-day mortality for CRE vs. CSE was 19.28%, and for CRE vs. non-infected patients was 9.61%. After adjustment for baseline variables, the HRs for mortality were 1.87 (95% CI, 0.99-3.50; p 0.06) and 3.65 (95% CI, 2.29-5.82; p < 0.001), respectively. However, when treatment-related time-dependent variables were added, the HR of CRE vs. CSE reduced to 1.44 (95% CI, 0.78-2.67; p 0.24). DISCUSSION CRE infections are associated with significant attributable mortality and increased adjusted hazard of mortality when compared with CSE infections or patients without infection. Underlying patient characteristics and a delay in appropriate treatment play an important role in the CRE mortality.
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Affiliation(s)
- María Paniagua-García
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Jose M Bravo-Ferrer
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain
| | - Salvador Pérez-Galera
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Tomislav Kostyanev
- Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Research Group for Global Capacity Building, National Food Institute, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jan Feifel
- Institute of Statistics, Ulm University, Ulm, Germany
| | - Zaira R Palacios-Baena
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
| | - Joost Schotsman
- Department of Medical Microbiology and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
| | - George L Daikos
- Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Gorana Dragovac
- University of Novi Sad, Faculty of Medicine and Institute of Public Health of Vojvodina, Novi Sad, Serbia
| | | | - Lul Raka
- University of Prishtina "Hasan Prishtina" and National Institute of Public Health of Kosovo, Prishtina, Kosovo
| | - Adriana Hristea
- University of Medicine and Pharmacy 'Carol Davila' Bucharest, Romania
| | | | - Murat Akova
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
| | - Ángela Cano
- CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/ Universidad de Córdoba (Departamento de Ciencias Médicas y Quirúrgicas), Córdoba, Spain
| | - Jose María Reguera
- Servicio de Enfermedades Infecciosas, Hospital Regional Universitario de Málaga/Ibima, Málaga, Spain
| | | | | | - Serban Benea
- University of Medicine and Pharmacy 'Carol Davila' Bucharest, Romania
| | | | - Ángel Asensio
- Preventive Medicine Department, Hospital Universitario Puerta del Hierro, Madrid, Spain
| | - Volkan Korten
- Marmara University School of Medicine, Istanbul, Turkey
| | - Hajo Grundmann
- Institute for Infection Prevention and Hospital Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Herman Goossens
- Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marc J Bonten
- Institute of Statistics, Ulm University, Ulm, Germany
| | - Belén Gutiérrez-Gutiérrez
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain.
| | - Jesús Rodríguez-Baño
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena and Departamento de Medicina, Universidad de Sevilla/Instituto de Biomedicina de Sevilla/CSIC, Seville, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC). Instituto de Salud Carlos III, Madrid, Spain
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Munro C, Zilberberg MD, Shorr AF. Bloodstream Infection in the Intensive Care Unit: Evolving Epidemiology and Microbiology. Antibiotics (Basel) 2024; 13:123. [PMID: 38391509 PMCID: PMC10886070 DOI: 10.3390/antibiotics13020123] [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: 12/22/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Bloodstream infections (BSIs) arising in the intensive care unit (ICUs) present a significant challenge and we completed a narrative review of the emerging literature on this issue. Multiple reports document that these infections are associated with substantial morbidity and mortality. Also, they can be caused by a variety of pathogens. Generally classified as either community or hospital in onset, or as either primary or secondary in origin, the microbiology of ICU BSIs varies across the globe. Gram-positive pathogens predominate in certain regions such as the United States while Gram-negative organisms occur more frequently in Europe, Asia, and Latin America. The incidence of ICU BSIs climbed during the recent pandemic. BSIs complicating the care of persons suffering from Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection significantly heighten the risk for death compared to patients who develop ICU BSIs but who are not infected with SARS-CoV-2. Furthermore, rates of antimicrobial resistance are generally increasing in ICU BSIs. This fact complicates attempts to ensure that the patient receives initially appropriate antimicrobial therapy and is of particular concern in Methicillin-resistant Staphylococcus aureus, Carbapenem-resistant Enterobacterales, and Acinetobacter baumannii. Fortunately, with respect to clinical application, preventive measures exist, and recent analyses suggest that increased collaboration between infectious disease specialists and intensivists can improve patient outcomes.
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Affiliation(s)
- Carly Munro
- Medstar Washington Hospital Center, Washington, DC 20010, USA
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10
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Thomsen J, Abdulrazzaq NM, Everett DB, Menezes GA, Senok A, Ayoub Moubareck C. Carbapenem resistant Enterobacterales in the United Arab Emirates: a retrospective analysis from 2010 to 2021. Front Public Health 2023; 11:1244482. [PMID: 38145078 PMCID: PMC10745492 DOI: 10.3389/fpubh.2023.1244482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/24/2023] [Indexed: 12/26/2023] Open
Abstract
Background Carbapenem-resistant Enterobacterales (CRE) are spreading in the United Arab Emirates (UAE) where their dissemination is facilitated by international travel, trade, and tourism. The objective of this study is to describe the longitudinal changes of CRE as reported by the national AMR surveillance system of the UAE. Methods In this study, we retrospectively describe CRE isolated from 317 surveillance sites, including 87 hospitals and 230 centers/clinics from 2010 to 2021. The associated clinical, demographic, and microbiological characteristics are presented by relying on the UAE national AMR surveillance program. Data was analyzed using WHONET microbiology laboratory database software (http://www.whonet.org). Results A total of 14,593 carbapenem resistant Enterobacterales were analyzed, of which 48.1% were carbapenem resistant Klebsiella pneumoniae (CRKp), 25.1% carbapenem resistant Escherichia coli (CREc), and 26.8% represented 72 other carbapenem resistant species. Carbapenem resistant strains were mostly associated with adults and isolated from urine samples (36.9% of CRKp and 66.6% of CREc) followed by respiratory samples (26.95% for CRKp) and soft tissue samples (19.5% for CRKp). Over the studied period carbapenem resistance rates remained high, especially in K. pneumoniae, and in 2021 were equivalent to 67.6% for imipenem, 76.2% for meropenem, and 91.6% for ertapenem. Nevertheless, there was a statistically significant decreasing trend for imipenem and meropenem resistance in Klebsiella species (p < 0.01) while the decrease in ertapenem resistance was non-significant. Concerning E. coli, there was a statistically significant decreasing trend for meropenem and imipenem resistance over the 12 years, while ertapenem resistance increased significantly with 83.8% of E. coli exhibiting ertapenem resistance in 2021. Resistance rates to ceftazidime and cefotaxime remained higher than 90% (in 2021) for CRKp and cefotaxime rates increased to 90.5% in 2021 for CREc. Starting 2014, resistance to colistin and tigecycline was observed in carbapenem resistant Enterobacterales. CRE were associated with a higher mortality (RR: 6.3), admission to ICU (RR 3.9), and increased length of stay (LOS; 10 excess inpatient days per CRE case). Conclusion This study supports the need to monitor CRE in the UAE and draws attention to the significant increase of ertapenem resistance in E. coli. Future surveillance analysis should include a genetic description of carbapenem resistance to provide new strategies.
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Affiliation(s)
- Jens Thomsen
- Abu Dhabi Public Health Center, Abu Dhabi, United Arab Emirates
- Department of Pathology and Infectious Diseases, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | | | - Dean B. Everett
- Department of Pathology and Infectious Diseases, Khalifa University, Abu Dhabi, United Arab Emirates
- Biotechnology Research Center, Khalifa University, Abu Dhabi, United Arab Emirates
- Infection Research Unit, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Godfred Antony Menezes
- Department of Medical Microbiology and Immunology, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Abiola Senok
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- School of Dentistry, Cardiff University, Cardiff, United Kingdom
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Kedišaletše M, Phumuzile D, Angela D, Andrew W, Mae NF. Epidemiology, risk factors, and clinical outcomes of carbapenem-resistant Enterobacterales in Africa: A systematic review. J Glob Antimicrob Resist 2023; 35:297-306. [PMID: 37879456 DOI: 10.1016/j.jgar.2023.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES Carbapenem-resistant Enterobacterales (CRE) commonly cause hospital-acquired infections and hospital outbreaks worldwide, with an alarming increase in Africa, necessitating review of regional CRE epidemiological trends. METHODS A systematic review was conducted using PRISMA guidelines, searching PubMed, Scopus and Web of Science databases for studies describing CRE distribution, risk factors for CRE acquisition and clinical outcome of CRE infections in Africa. RESULTS One-hundred and sixty-nine studies were included, with the majority from North Africa (92/169, 54.4%). Most studies (136/169; 80.4%) focused only on infection, with a total of 15666 CRE isolates (97.4% clinical infection, 2.6% colonisation). The leading bacterial species included Klebsiella (72.2%), Escherichia coli (13.5%), and Enterobacter (8.3%). The most frequently detected carbapenemases were NDM (43.1%) and OXA-48-like (42.9%). Sequence types were reported in 44 studies, with ST101 and ST147 most commonly reported in K. pneumoniae, and ST410, ST167 and ST38 in E. coli. Previous antibiotic use, prior hospitalisation, surgical procedures, indwelling devices, intensive care unit admission and prolonged hospital stay, were the most frequent factors associated with CRE infection/colonisation. Crude mortality for CRE infection was 37%. CONCLUSION Although K. pneumoniae and E. coli remain the most frequent CRE in Africa, observed sequence types are not the commonly reported global 'high-risk' clones. The distribution of species and carbapenemases differs across African regions, while risk factors for CRE colonisation/infection, and patient outcomes are similar to those reported globally. There are limited data on CREs from parts of Africa, highlighting the need to strengthen epidemiologic surveillance programmes in the region.
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Affiliation(s)
- Moloto Kedišaletše
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Dube Phumuzile
- Synthetic Biology Center, NextGeneration Health, Council for Scientific and Industrial Research, Pretoria, South Africa
| | - Dramowski Angela
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Whitelaw Andrew
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Newton-Foot Mae
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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12
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Wang L, Shen W, Cai J. Mobilization of the blaKPC-14 gene among heterogenous plasmids in extensively drug-resistant hypervirulent Klebsiella pneumoniae. Front Microbiol 2023; 14:1261261. [PMID: 38033558 PMCID: PMC10684954 DOI: 10.3389/fmicb.2023.1261261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Ceftazidime/avibactam (CZA) is an effective alternative for the treatment of infections caused by KPC-producing carbapenem-resistant Klebsiella pneumoniae (CRKP). However, KPC variants with CZA resistance have been observed in clinical isolates, further limiting the treatment options of clinical use. Methods In this study, we isolated three KPC-14-producing CRKP from two patients in intensive care units without CZA therapy. The antimicrobial susceptibility was determined using the broth microdilution method. Three CRKP were subjected to whole-genome sequencing to analyze the phylogenetic relatedness and the carriage of antimicrobial resistance genes and virulence factors. Long-read sequencing was also performed to obtain the complete sequences of the plasmids. The horizontal transfer of the blaKPC-14 gene was evaluated by conjugation experiments. Results Three CRKP displayed resistance or reduced susceptibility to ceftazidime/avibactam, colistin, and tigecycline. Single-nucleotide polymorphism (SNP) analysis demonstrated the close phylogenetic distance between these strains. A highly similar IncFII/IncR plasmid encoding blaKPC-14 was shared by three CRKP, with blaKPC-14 located in an NTEKPC-Ib element with the core region of ISKpn27- blaKPC-14-ISKpn6. This structure containing blaKPC-14 was also observed in another tet(A)-carrying plasmid that belonged to an unknown Inc-type in two out of three isolates. The horizontal transferability of these integrated plasmids to Escherichia coli EC600 was confirmed by the cotransmission of tet(A) and blaKPC-14 genes, but the single transfer of blaKPC-14 on the IncFII/IncR plasmid failed. Three CRKP expressed yersiniabactin and carried a hypervirulence plasmid encoding rmpA2 and aerobactin-related genes, and were thus classified as carbapenem-resistant hypervirulent K. pneumoniae (hvKP). Discussion In this study, we reported the evolution of a mosaic plasmid encoding the blaKPC-14 gene via mobile elements in extensively drug-resistant hvKP. The blaKPC-14 gene is prone to integrate into other conjugative plasmids via the NTEKPC-Ib element, further facilitating the spread of ceftazidime/avibactam resistance.
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Affiliation(s)
| | | | - Jiachang Cai
- Clinical Microbiology Laboratory, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
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Lee KH, Kim D, Hong JS, Park SY, Cho NH, Kim MN, Lee YJ, Wi Y, Lee EH, Han SH, Jeong SH, Song YG. Prevalence of carbapenemase producing Enterobacterales colonization and risk factor of clinical infection. J Infect Public Health 2023; 16:1860-1869. [PMID: 37837922 DOI: 10.1016/j.jiph.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Carbapenemase-producing Enterobacterales (CPE) are global concerns in infection control, and the number of CPE outbreaks in hospitals is increasing despite the strengthening of contact precautions. This study aimed to confirm the prevalence and transition rate of CPE infection from stool surveillance culture and to identify the acquisition pathway of CPE. METHODS This is a longitudinal review of patients with stool surveillance cultures at a tertiary center in Seoul, South Korea, from July 2018 to June 2020. Pulsed-field gel electrophoresis, multi-locus sequence typing, and whole genome sequencing were performed for carbapenemase-producing Klebsiella pneumoniae and Escherichia coli strains. RESULTS Among 1620 patients who had undergone stool CPE surveillance cultures, only 7.1% of active surveillance at the Emergency Room (ER) and 4.4% of universal surveillance in the Intensive Care Unit (ICU) were stool CPE positive. The transition rates from stool carriers to clinical CPE infections were 29.4% in the ER and 31.3% in the ICU. However, it was significantly high (55.0%) in the initial stool CPE-negative ICU patients. Among the initial stool CPE-positive patients, hypertension (61% vs. 92.3%, P = 0.004), malignancy (28.8% vs. 53.8%, P = 0.027), and mechanical ventilation (25.4% vs. 53.8%, P = 0.011) were significant risk factors for clinical CPE infection. Molecular typing revealed that sequence type (ST) 307 and ST 395 were dominant in K. pneumoniae, and ST 410 was dominant in E. coli isolates. CONCLUSIONS Active surveillance showed a higher detection rate than universal stool CPE screening, and one-third of positive stool CPE specimens ultimately developed subsquent clinical CPE infection. According to the molecular typing of the identified CPE strains, in-hospital spread prevailed over external inflow, and the transition rate to clinical CPE was particularly high in the ICU. Therefore, in order to control CPE propagation, not only active surveillance to block inflow from outside, but also continuous ICU monitoring within the hospital is necessary.
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Affiliation(s)
- Kyoung Hwa Lee
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dokyun Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Sung Hong
- Department of Companion Animal Health and Science, Silla University, Busan, Republic of Korea
| | - Soon Young Park
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nan Hyoung Cho
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Mi Na Kim
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Yun Jung Lee
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Yeonji Wi
- Department of Infection Control, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Eun Hwa Lee
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hoon Han
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Goo Song
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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López-Cubillos JF, Díaz A, Cárdenas VC, Camacho-Moreno G, Cantor E, Arcila EM, Hurtado IC, Correa AM, Tierradentro TM, Ramirez O, Portilla CA, Aponte-Barrios N, López P, Torres D, Bustos-Paz M, Bravo AM, Escobar JJ, Calle JP, Dávalos DM, López-Medina E. Carbapenem resistance in Enterobacterales bloodstream infections among children with cancer or post-haematopoietic stem cell transplant: a retrospective cohort study. J Antimicrob Chemother 2023; 78:2462-2470. [PMID: 37583091 PMCID: PMC10545507 DOI: 10.1093/jac/dkad255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/01/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Risk factors for carbapenem resistance in Enterobacterales bloodstream infections among children with cancer or post-HSCT have not been thoroughly explored. METHODS All children with cancer or post-HSCT who developed Enterobacterales bloodstream infections in two cancer referral centres in major Colombian cities between 2012 and 2021 were retrospectively examined. When the infection episode occurred, carbapenem resistance mechanisms were evaluated according to the available methods. Data were divided in a training set (80%) and a test set (20%). Three internally validated carbapenem-resistant Enterobacterales (CRE) prediction models were created: a multivariate logistic regression model, and two data mining techniques. Model performances were evaluated by calculating the average of the AUC, sensitivity, specificity and predictive values. RESULTS A total of 285 Enterobacterales bloodstream infection episodes (229 carbapenem susceptible and 56 carbapenem resistant) occurred [median (IQR) age, 9 (3.5-14) years; 57% male]. The risk of CRE was 2.1 times higher when the infection was caused by Klebsiella spp. and 5.8 times higher when a carbapenem had been used for ≥3 days in the previous month. A model including these two predictive variables had a discriminatory performance of 77% in predicting carbapenem resistance. The model had a specificity of 97% and a negative predictive value of 81%, with low sensitivity and positive predictive value. CONCLUSIONS Even in settings with high CRE prevalence, these two variables can help early identification of patients in whom CRE-active agents are unnecessary and highlight the importance of strengthening antibiotic stewardship strategies directed at preventing carbapenem overuse.
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Affiliation(s)
| | - Alejandro Díaz
- Hospital General de Medellín & Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Vicky C Cárdenas
- Department of Pediatrics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - German Camacho-Moreno
- HOMI, Fundación Hospital Pediátrico la Misericordia, Bogotá, Colombia
- Department of Pediatrics, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Erika Cantor
- Centro de Estudios en Infectología Pediátrica, CEIP, Cali, Colombia
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Eliana M Arcila
- Department of Pediatrics, Corporación Universitaria Remington, Medellín, Colombia
| | - Isabel C Hurtado
- Department of Pediatrics, Universidad del Valle, Cali, Colombia
- State Department of Health, Valle del Cauca, Colombia
| | - Adriana M Correa
- Clínica Imbanaco Grupo Quironsalud, Cali, Colombia
- Faculty of Basic Sciences, Universidad Santiago de Cali, Cali, Colombia
| | | | - Oscar Ramirez
- Clínica Imbanaco Grupo Quironsalud, Cali, Colombia
- Registro Poblacional de Cáncer de Cali, Cali, Colombia
| | - Carlos A Portilla
- Department of Pediatrics, Universidad del Valle, Cali, Colombia
- Clínica Imbanaco Grupo Quironsalud, Cali, Colombia
| | | | - Pio López
- Centro de Estudios en Infectología Pediátrica, CEIP, Cali, Colombia
- Department of Pediatrics, Universidad del Valle, Cali, Colombia
| | - Daniela Torres
- Department of Pediatrics, Universidad del Valle, Cali, Colombia
| | | | - Ana M Bravo
- Department of Pediatrics, Universidad del Cauca, Popayán, Colombia
- Hospital Universitario San José, Popayán, Colombia
- Clínica Nueva, Cali, Colombia
| | | | - Juan P Calle
- Centro de Estudios en Infectología Pediátrica, CEIP, Cali, Colombia
- Departament of Pediatrics, Universidad del Quindío, Armenia, Colombia
| | - Diana M Dávalos
- Centro de Estudios en Infectología Pediátrica, CEIP, Cali, Colombia
| | - Eduardo López-Medina
- Centro de Estudios en Infectología Pediátrica, CEIP, Cali, Colombia
- Department of Pediatrics, Universidad del Valle, Cali, Colombia
- Clínica Imbanaco Grupo Quironsalud, Cali, Colombia
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15
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Lee SH, Kim CH, Lee HY, Park KH, Han SH. Epidemiology of Carbapenem-Resistant Enterobacteriaceae Bacteremia in Gyeonggi Province, Republic of Korea, between 2018 and 2021. Antibiotics (Basel) 2023; 12:1286. [PMID: 37627706 PMCID: PMC10451680 DOI: 10.3390/antibiotics12081286] [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: 06/29/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
The incidence of carbapenem-resistant Enterobacteriaceae (CRE) has been increasing since 2008, with Gyeonggi Province in South Korea being particularly vulnerable due to its large number of healthcare facilities. This study examines the trends of CRE occurrence in Gyeonggi Province over the past four years and the epidemiological characteristics of the infected patients. Patients with positive CRE blood cultures admitted to healthcare facilities in Gyeonggi Province from January 2018 to December 2021 were evaluated in this study. Risk factors for CRE-related death were analyzed using data from patients who died within 30 days of the last blood sampling. Older adults aged 70 years and above constituted the majority of patients with CRE bacteremia. Antibiotic use did not significantly affect mortality risk. Non-survivors were more common in tertiary hospitals and intensive care units and included patients with hypertension, malignant tumors, and multiple underlying diseases. Klebsiella pneumoniae was the most common CRE strain, with Klebsiella pneumoniae carbapenemase being the predominant carbapenemase. Our study suggests the endemicity of CRE in Gyeonggi Province and highlights the increasing isolation of CRE strains in South Korean long-term care hospitals within the province. Further, infection control measures and government support specific to each healthcare facility type are crucial.
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Affiliation(s)
- Seung Hye Lee
- Gyeonggi Infectious Disease Control Center, Health Bureau, Gyeonggi Provincial Government, Suwon-si 16508, Gyeonggi-do, Republic of Korea; (S.H.L.)
| | - Chan Hee Kim
- Gyeonggi Infectious Disease Control Center, Health Bureau, Gyeonggi Provincial Government, Suwon-si 16508, Gyeonggi-do, Republic of Korea; (S.H.L.)
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam-si 13620, Gyeonggi-do, Republic of Korea;
| | - Kun Hee Park
- Pyeongchang County Health and Medical Center, Pyeongchang-gun 25374, Gangwon-do, Republic of Korea;
| | - Su Ha Han
- Department of Nursing, College of Medicine, SoonChunHyang University, Cheonan-si 31151, Chungcheongnam-do, Republic of Korea
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Mancuso G, De Gaetano S, Midiri A, Zummo S, Biondo C. The Challenge of Overcoming Antibiotic Resistance in Carbapenem-Resistant Gram-Negative Bacteria: "Attack on Titan". Microorganisms 2023; 11:1912. [PMID: 37630472 PMCID: PMC10456941 DOI: 10.3390/microorganisms11081912] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
The global burden of bacterial resistance remains one of the most serious public health concerns. Infections caused by multidrug-resistant (MDR) bacteria in critically ill patients require immediate empirical treatment, which may not only be ineffective due to the resistance of MDR bacteria to multiple classes of antibiotics, but may also contribute to the selection and spread of antimicrobial resistance. Both the WHO and the ECDC consider carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA), and carbapenem-resistant Acinetobacter baumannii (CRAB) to be the highest priority. The ability to form biofilm and the acquisition of multiple drug resistance genes, in particular to carbapenems, have made these pathogens particularly difficult to treat. They are a growing cause of healthcare-associated infections and a significant threat to public health, associated with a high mortality rate. Moreover, co-colonization with these pathogens in critically ill patients was found to be a significant predictor for in-hospital mortality. Importantly, they have the potential to spread resistance using mobile genetic elements. Given the current situation, it is clear that finding new ways to combat antimicrobial resistance can no longer be delayed. The aim of this review was to evaluate the literature on how these pathogens contribute to the global burden of AMR. The review also highlights the importance of the rational use of antibiotics and the need to implement antimicrobial stewardship principles to prevent the transmission of drug-resistant organisms in healthcare settings. Finally, the review discusses the advantages and limitations of alternative therapies for the treatment of infections caused by these "titans" of antibiotic resistance.
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Affiliation(s)
- Giuseppe Mancuso
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (S.D.G.); (A.M.); (S.Z.); (C.B.)
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Frimodt-Møller N, Bjerrum L. Treating urinary tract infections in the era of antibiotic resistance. Expert Rev Anti Infect Ther 2023; 21:1301-1308. [PMID: 37922147 DOI: 10.1080/14787210.2023.2279104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/31/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are associated with 25-40% of antibiotics consumed in primary care and are, therefore, driving antibiotic resistance. The worldwide increase in antibiotic resistance especially in Escherichia coli has complicated the treatment choices for UTIs and absence of effective oral antibiotics may lead to increasing need for more effective treatments. AREAS COVERED In this review we focus on the importance of the correct diagnosis of UTI as based on proof of urinary pathogens in the urine and discuss diagnostic measures including microscopy, dipstick, and culture. Antibiotic treatment can often await diagnostic measures with pain relief such as ibuprofen. The risk of an uncomplicated UTI leading to pyelonephritis is low (1-2%) and presence of bacteria in the bladder leaves some time for the immune system to react. Three antibiotics are recommended as based on their activity, and low propensity to select for resistance, i.e. nitrofurantoin, fosfomycin, and pivmecillinam, and in general, 3-5 days of treatment will suffice. EXPERT OPINION Understanding the usual benign course of uUTIs can help reduce antibiotic treatment in many cases, e.g. starting treatment by pain relief and awaiting the course of infection without antibiotics. Better rapid tests in primary care are urgently needed to enforce such policies.
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Affiliation(s)
| | - Lars Bjerrum
- Research Unit and Section of General Practice, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
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