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Parsons JB, Sidders AE, Velez AZ, Hanson BM, Angeles-Solano M, Ruffin F, Rowe SE, Arias CA, Fowler VG, Thaden JT, Conlon BP. In-patient evolution of a high-persister Escherichia coli strain with reduced in vivo antibiotic susceptibility. Proc Natl Acad Sci U S A 2024; 121:e2314514121. [PMID: 38190524 PMCID: PMC10801923 DOI: 10.1073/pnas.2314514121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/11/2023] [Indexed: 01/10/2024] Open
Abstract
Gram-negative bacterial bloodstream infections (GNB-BSI) are common and frequently lethal. Despite appropriate antibiotic treatment, relapse of GNB-BSI with the same bacterial strain is common and associated with poor clinical outcomes and high healthcare costs. The role of persister cells, which are sub-populations of bacteria that survive for prolonged periods in the presence of bactericidal antibiotics, in relapse of GNB-BSI is unclear. Using a cohort of patients with relapsed GNB-BSI, we aimed to determine how the pathogen evolves within the patient between the initial and subsequent episodes of GNB-BSI and how these changes impact persistence. Using Escherichia coli clinical bloodstream isolate pairs (initial and relapse isolates) from patients with relapsed GNB-BSI, we found that 4/11 (36%) of the relapse isolates displayed a significant increase in persisters cells relative to the initial bloodstream infection isolate. In the relapsed E. coli strain with the greatest increase in persisters (100-fold relative to initial isolate), we determined that the increase was due to a loss-of-function mutation in the ptsI gene encoding Enzyme I of the phosphoenolpyruvate phosphotransferase system. The ptsI mutant was equally virulent in a murine bacteremia infection model but exhibited 10-fold increased survival to antibiotic treatment. This work addresses the controversy regarding the clinical relevance of persister formation by providing compelling data that not only do high-persister mutations arise during bloodstream infection in humans but also that these mutants display increased survival to antibiotic challenge in vivo.
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Affiliation(s)
- Joshua B. Parsons
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC27710
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
| | - Ashelyn E. Sidders
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
| | - Amanda Z. Velez
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
| | | | - Michelle Angeles-Solano
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
| | - Felicia Ruffin
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC27710
| | - Sarah E. Rowe
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
| | - Cesar A. Arias
- Division of Infectious Diseases, Houston Methodist Hospital and Center for Infectious Diseases, Houston Methodist Research Institute, Houston, TX77030
- Department of Medicine, Weill Cornell Medical College, New York, NY10065
| | - Vance G. Fowler
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC27710
| | - Joshua T. Thaden
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC27710
| | - Brian P. Conlon
- Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, NC27559
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Bock A, Hanson BM, Ruffin F, Parsons JB, Park LP, Sharma-Kuinkel B, Mohnasky M, Arias CA, Fowler VG, Thaden JT. Clinical and Molecular Analyses of Recurrent Gram-Negative Bloodstream Infections. Clin Infect Dis 2023; 76:e1285-e1293. [PMID: 35929656 PMCID: PMC10169420 DOI: 10.1093/cid/ciac638] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/21/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The causes and clinical characteristics of recurrent gram-negative bacterial bloodstream infections (GNB-BSI) are poorly understood. METHODS We used a cohort of patients with GNB-BSI to identify clinical characteristics, microbiology, and risk factors associated with recurrent GNB-BSI. Bacterial genotyping (pulsed-field gel electrophoresis [PFGE] and whole-genome sequencing [WGS]) was used to determine whether episodes were due to relapse or reinfection. Multivariable logistic regression was used to identify risk factors for recurrence. RESULTS Of the 1423 patients with GNB-BSI in this study, 60 (4%) had recurrent GNB-BSI. Non-White race (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.38-4.01; P = .002), admission to a surgical service (OR, 2.18; 95% CI, 1.26-3.75; P = .005), and indwelling cardiac device (OR, 2.73; 95% CI, 1.21-5.58; P = .009) were associated with increased risk for recurrent GNB-BSI. Among the 48 patients with recurrent GNB-BSI whose paired bloodstream isolates underwent genotyping, 63% were due to relapse (30 of 48) and 38% were due to reinfection (18 of 48) based on WGS. Compared with WGS, PFGE correctly differentiated relapse and reinfection in 98% (47 of 48) of cases. Median time to relapse and reinfection was similar (113 days; interquartile range [IQR], 35-222 vs 174 days; IQR, 69-599; P = .13). Presence of a cardiac device was associated with relapse (relapse: 7 of 27, 26%; nonrelapse: 65 of 988, 7%; P = .002). CONCLUSIONS In this study, recurrent GNB-BSI was most commonly due to relapse. PFGE accurately differentiated relapse from reinfection when compared with WGS. Cardiac device was a risk factor for relapse.
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Affiliation(s)
- Andrew Bock
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Blake M Hanson
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA.,Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA.,Division of Infectious Disease, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Felicia Ruffin
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua B Parsons
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lawrence P Park
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Batu Sharma-Kuinkel
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Mohnasky
- University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Cesar A Arias
- Division of Infectious Diseases, Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA.,Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Joshua T Thaden
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Recurrent Pseudomonas aeruginosa Bacteremia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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4
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Preconceptual Priming Overrides Susceptibility to Escherichia coli Systemic Infection during Pregnancy. mBio 2021; 12:mBio.00002-21. [PMID: 33622714 PMCID: PMC8545081 DOI: 10.1128/mbio.00002-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Maternal sepsis is a leading cause of morbidity and mortality during pregnancy. Escherichia coli is a primary cause of bacteremia in women and occurs more frequently during pregnancy. Several key outstanding questions remain regarding how to identify women at highest infection risk and how to boost immunity against E. coli infection during pregnancy. Here, we show that pregnancy-induced susceptibility to E. coli systemic infection extends to rodents as a model of human infection. Mice infected during pregnancy contain >100-fold-more recoverable bacteria in target tissues than nonpregnant controls. Infection leads to near complete fetal wastage that parallels placental plus congenital fetal invasion. Susceptibility in maternal tissues positively correlates with the number of concepti, suggesting important contributions by expanded placental-fetal target tissue. Remarkably, these pregnancy-induced susceptibility phenotypes are also efficiently overturned in mice with resolved sublethal infection prior to pregnancy. Preconceptual infection primes the accumulation of E. coli-specific IgG and IgM antibodies, and adoptive transfer of serum containing these antibodies to naive recipient mice protects against fetal wastage. Together, these results suggest that the lack of E. coli immunity may help discriminate individuals at risk during pregnancy, and that overriding susceptibility to E. coli prenatal infection by preconceptual priming is a potential strategy for boosting immunity in this physiological window of vulnerability.IMPORTANCE Pregnancy makes women especially vulnerable to infection. The most common cause of bloodstream infection during pregnancy is by a bacterium called Escherichia coli This bacterium is a very common cause of bloodstream infection, not just during pregnancy but in all individuals, from newborn babies to the elderly, probably because it is always present in our intestine and can intermittently invade through this mucosal barrier. We first show that pregnancy in animals also makes them more susceptible to E. coli bloodstream infection. This is important because many of the dominant factors likely to control differences in human infection susceptibility can be property controlled for only in animals. Despite this vulnerability induced by pregnancy, we also show that animals with resolved E. coli infection are protected against reinfection during pregnancy, including having resistance to most infection-induced pregnancy complications. Protection against reinfection is mediated by antibodies that can be measured in the blood. This information may help to explain why most women do not develop E. coli infection during pregnancy, enabling new approaches for identifying those at especially high risk of infection and strategies for preventing infection during pregnancy.
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Aurora A, Le TD, Akers KS, Blyth DM, Graybill JC, Clemens MS, Chung KK, Rizzo JA. Recurrent bacteremia: A 10-year retrospective study in combat-related burn casualties. Burns 2018; 45:579-588. [PMID: 30385059 DOI: 10.1016/j.burns.2018.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/27/2018] [Accepted: 10/04/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period. METHODS Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome. RESULTS Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties. CONCLUSIONS Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival.
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Affiliation(s)
- Amit Aurora
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Kevin S Akers
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, United States
| | - John C Graybill
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Michael S Clemens
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Kevin K Chung
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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6
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Increased risk of death with recurrent Pseudomonas aeruginosa bacteremia. Diagn Microbiol Infect Dis 2017; 88:152-157. [DOI: 10.1016/j.diagmicrobio.2017.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/25/2017] [Accepted: 03/03/2017] [Indexed: 11/22/2022]
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7
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Gradel KO, Jensen US, Schønheyder HC, Østergaard C, Knudsen JD, Wehberg S, Søgaard M. Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study. BMC Infect Dis 2017; 17:122. [PMID: 28166732 PMCID: PMC5294810 DOI: 10.1186/s12879-017-2233-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/31/2017] [Indexed: 01/20/2023] Open
Abstract
Background Data on the impact of empirical antibiotic treatment (EAT) on patient outcome in a population-based setting are sparse. We assessed the association between EAT and the risk of recurrence within one year, short-term- (2–30 days) and long-term (31–365 days) mortality in a Danish cohort of bacteraemia patients. Methods A cohort study including all patients hospitalized with incident bacteraemia during 2007–2008 in the Copenhagen City and County areas and the North Denmark Region. EAT was defined as the antibiotic treatment given at the 1st notification of a positive blood culture. The definition of recurrence took account of pathogen species, site of infection, and time frame and was not restricted to homologous pathogens. The vital status was determined through the civil registration system. Association estimates between EAT and the outcomes were estimated by Cox and logistic regression models. Results In 6483 eligible patients, 712 (11%) had a recurrent episode. A total of 3778 (58%) patients received appropriate EAT, 1290 (20%) received inappropriate EAT, while EAT status was unrecorded for 1415 (22%) patients. The 2–30 day mortality was 15.1%, 17.4% and 19.2% in patients receiving appropriate EAT, inappropriate EAT, and unknown EAT, respectively. Among patients alive on day 30, the 31–365 day mortality was 22.3% in patients given appropriate EAT compared to 30.7% in those given inappropriate EAT. Inappropriate EAT was independently associated with recurrence (HR 1.25; 95% CI = 1.03–1.52) and long-term mortality (OR 1.35; 95% CI = 1.10–1.60), but not with short-term mortality (OR 0.85; 95% CI = 0.70–1.02) after bacteraemia. Conclusions Our data indicate that appropriate EAT is associated with reduced incidence of recurrence and lower long-term mortality following bacteraemia. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2233-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kim O Gradel
- Center for Clinical Epidemiology, South, OUH Odense University Hospital, Kløvervænget 30, Entrance 216, DK-5000, Odense C, Denmark. .,Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Ulrich S Jensen
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
| | - Henrik C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christian Østergaard
- Department of Clinical Microbiology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jenny D Knudsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Sonja Wehberg
- Center for Clinical Epidemiology, South, OUH Odense University Hospital, Kløvervænget 30, Entrance 216, DK-5000, Odense C, Denmark.,Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette Søgaard
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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8
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Sasaki S, Hasegawa T, Kawarazaki H, Nomura A, Uchida D, Imaizumi T, Furusho M, Nishiwaki H, Fukuma S, Shibagaki Y, Fukuhara S. Development and Validation of a Clinical Prediction Rule for Bacteremia among Maintenance Hemodialysis Patients in Outpatient Settings. PLoS One 2017; 12:e0169975. [PMID: 28081211 PMCID: PMC5231279 DOI: 10.1371/journal.pone.0169975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/25/2016] [Indexed: 12/23/2022] Open
Abstract
Background To our knowledge, no reliable clinical prediction rule (CPR) for identifying bacteremia in hemodialysis (HD) patients has been established. The aim of this study was to develop a CPR for bacteremia in maintenance HD patients visiting the outpatient department. Methods This multicenter cohort study involved consecutive maintenance HD patients who visited the outpatient clinic or emergency room of seven Japanese institutions between August 2011 and July 2013. The outcome measure was bacteremia diagnosed based on the results of blood cultures. The candidate predictors for bacteremia were extracted through a literature review. A CPR for bacteremia was developed using a coefficient-based multivariable logistic regression scoring method, and calibration was performed. The test performance was then assessed for the CPR. Results Of 507 patients eligible for the study, we analyzed the 293 with a complete dataset for candidate predictors. Of these 293 patients, 48 (16.4%) were diagnosed with bacteremia. At the conclusion of the deviation process, body temperature ≥ 38.3°C, heart rate ≥ 125 /min, C-reactive protein ≥ 10 mg/dL, alkaline phosphatase >360 IU/L, and no prior antibiotics use within the past week were retained and scored. The CPR had a good fit for the model on calibration. The AUC of the CPR was 0.76, and for score CPR ≥ 2, the sensitivity and specificity were 89.6% and 51.4%, respectively. Conclusions We established a simple CPR for bacteremia in maintenance HD patients using routinely obtained clinical information in an outpatient setting. This model may facilitate more appropriate clinical decision making.
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Affiliation(s)
- Sho Sasaki
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Public Health, Kyoto, JAPAN
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JAPAN
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, JAPAN
| | - Takeshi Hasegawa
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JAPAN
- Office for Promoting Medical Research, Showa University, Tokyo, JAPAN
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, JAPAN
- * E-mail:
| | - Hiroo Kawarazaki
- Division of Nephrology, Department of Internal Medicine, Inagi Municipal Hospital, Inagi, JAPAN
| | - Atsushi Nomura
- Department of Immunology, Juntendo University School of Medicine, Tokyo, JAPAN
- Department of Nephrology, Chubu Rosai Hospital, Nagoya, JAPAN
| | - Daisuke Uchida
- Division of Nephrology, Department of Internal Medicine, Inagi Municipal Hospital, Inagi, JAPAN
- Department of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, JAPAN
| | - Takahiro Imaizumi
- Department of Nephrology, Toyohashi Municipal Hospital, Toyohashi, JAPAN
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, JAPAN
| | | | - Hiroki Nishiwaki
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JAPAN
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, JAPAN
| | - Shingo Fukuma
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Public Health, Kyoto, JAPAN
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JAPAN
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, JAPAN
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Public Health, Kyoto, JAPAN
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, JAPAN
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Samet A, Sledzińska A, Krawczyk B, Hellmann A, Nowicki S, Kur J, Nowicki B. Leukemia and risk of recurrent Escherichia coli bacteremia: genotyping implicates E. coli translocation from the colon to the bloodstream. Eur J Clin Microbiol Infect Dis 2013; 32:1393-400. [PMID: 23649557 PMCID: PMC3824565 DOI: 10.1007/s10096-013-1886-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 04/22/2013] [Indexed: 11/24/2022]
Abstract
In patients with leukemia, the portal(s) and reasons for the persistence of an Escherichia coli recurrent bacteremia remain unclear. Adult Hematology Clinic (AHC) databases at the State Clinical Hospital in Gdańsk were reviewed to evaluate the frequency of E. coli bacteremia between 2002 and 2005. Blood and bowel E. coli strains were obtained and the genetic relatedness of the strains was analyzed. The rate of E. coli bacteremia per 1,000 admissions at the AHC was higher (85.0) than in the other clinics of the hospital (2.9), p < 0.001. A higher mortality was observed in patients with a history of E. coli versus non-E. coli bacteremia [30/95 (31 %) vs. 53/430 (12 %), p < 0.001]; 72.8 % of patients with leukemia had an unknown source of bacteremia. In 2005, 6 out of 25 (24 %) patients with leukemia had ≥2 episodes of E. coli-positive blood cultures. These gastrointestinal E. coli isolates were replaced within 3–8 weeks with a new E. coli H genotype. A recurrent episode of bacteremia was usually caused by an infection with a transient E. coli H genotype identical to that found in the subject’s bowel. Consistent with the definition of bowel/blood translocation, the bowel appeared to be a portal for E. coli in these subjects and, hence, a clear source for their recurring bacteremia.
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Affiliation(s)
- A Samet
- Laboratory of Clinical Microbiology, Gdańsk University of Medicine, Gdańsk, Poland
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Jensen US, Knudsen JD, Wehberg S, Gregson DB, Laupland KB. Risk factors for recurrence and death after bacteraemia: a population-based study. Clin Microbiol Infect 2011; 17:1148-54. [PMID: 21714830 DOI: 10.1111/j.1469-0691.2011.03587.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although most bacteraemic outcome studies have focused on mortality, a repeated episode(s) is another important outcome of bacteraemia. We sought to characterize patient factors and microbial species associated with recurrence and death from bacteraemia. Population-based surveillance for bacteraemia was conducted in a Canadian health region during 2000-2008. Episodes of bacteraemia were extracted and characterized. Transition intensities of both recurrence and death were estimated by separate multivariate Cox proportional hazards models. We identified 9713 patients with incident episodes of bacteraemia. Within 1 year: 892 (9.2%) had recurrent bacteraemia, 2401 (24.7%) had died without a recurrent episode and 330 (3.4%) had died after a recurrent episode. Independent risk factors for recurrence within 1 year (hazard ratio; 95% confidence interval) were: increasing Charlson comorbidity scores (score 1-2: 2.2; 1.8-2.7 and score 3+: 3.4; 2.8-4.2), origin of infection (nosocomial: 2.1; 1.8-2.6 and healthcare-associated: 2.4; 2.0-2.8), microorganism (polymicrobial: 1.5; 1.2-2.0 and fungal: 2.8; 1.9-4.2) and focus of infection (verified urogenital: 0.4; 0.3-0.6). Independent risk factors for death within 1 year included: a recurrent bacteraemic episode 3.6 (3.1-4.0), increasing age and different foci of infection. This study identifies patient groups at risk of having a recurrent episode and dying from these infections. It adds recurrent bacteraemia as an independent risk factor of death within 1 year and may help to target patients for prevention or changes in management.
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Affiliation(s)
- U S Jensen
- Department of Microbiological Surveillance and Research, Statens Serum Institut, Copenhagen S, Denmark.
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Recurrent gram-negative bloodstream infection: a 10-year population-based cohort study. J Infect 2010; 61:28-33. [PMID: 20378069 DOI: 10.1016/j.jinf.2010.03.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/19/2010] [Accepted: 03/26/2010] [Indexed: 10/19/2022]
Abstract
SUMMARY BACKGROUND Recurrent gram-negative bloodstream infection (BSI) has not been evaluated in a population-based setting; therefore, we performed a population-based retrospective cohort study to examine the incidence, recurrence, and mortality rates of gram-negative BSI. METHODS We identified 944 episodes of gram-negative BSI, including 98 recurrent episodes, among Olmsted County, Minnesota, residents from 1/1/1998 to 12/31/2007. Kaplan-Meier method was used to estimate the cumulative incidence rate of recurrence and 28-day all-cause mortality rate of gram-negative BSI. Cox proportional hazard regression was used to determine risk factors for recurrence. RESULTS The overall age- and gender-adjusted incidence rate of gram-negative BSI per 100,000 person-years was 84.5 (95% confidence interval [CI]: 79.1-90.0), including 75.7 (95% CI: 70.6-80.8) for first episodes and 8.8 (95% CI: 7.1-10.6) for recurrent episodes. Among 846 patients with first episodes of gram-negative BSI, the cumulative incidence rates of recurrence after 1, 5, and 10 years of the initial episode were 5.6%, 9.2%, and 14.6%, respectively, with death treated as a competing risk. Patients with Klebsiella species were more likely than those with Escherichia coli BSI to develop recurrent gram-negative BSI (hazard ratio: 2.33 [95% CI: 1.34-3.92], p=0.003). The 28-day all-cause mortality rates following the initial and second episodes of gram-negative BSI were 10.0% (95% CI: 8.0-12.0) and 11.3% (95% CI: 4.4-18.2), respectively. CONCLUSIONS Even though recurrent gram-negative BSI was relatively uncommon in the general population, up to 15% of patients with gram-negative BSI developed a recurrent episode within 10 years of the initial episode.
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12
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The epidemiology of recurrent Gram-negative bacteremia in a tertiary-care hospital. Diagn Microbiol Infect Dis 2010; 66:456-9. [DOI: 10.1016/j.diagmicrobio.2009.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 12/01/2009] [Accepted: 12/11/2009] [Indexed: 01/10/2023]
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Recurrent bacteraemia: A 10-year regional population-based study of clinical and microbiological risk factors. J Infect 2010; 60:191-9. [DOI: 10.1016/j.jinf.2009.12.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 12/10/2009] [Accepted: 12/10/2009] [Indexed: 11/18/2022]
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14
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López Dupla M, Martinez JA, Vidal F, Almela M, López J, Marco F, Soriano A, Richart C, Mensa J. Clinical characterization of breakthrough bacteraemia: a survey of 392 episodes. J Intern Med 2005; 258:172-80. [PMID: 16018794 DOI: 10.1111/j.1365-2796.2005.01513.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Few data are available on the clinical features of patients who develop breakthrough bacteraemia, understood as positive blood cultures despite appropriate antibiotic therapy. OBJECTIVES To determine the clinical significance and outcome of a large series of breakthrough bacteraemia. DESIGN Retrospective analysis of a prospectively collected database. SETTING Two university-affiliated hospitals in Catalonia, Spain. SUBJECTS A total of 392 individuals who suffered an episode of breakthrough bacteraemia recorded between 1997 and 2002. INTERVENTIONS Demographic characteristics, underlying diseases, origin of infection, sources of infection, microorganisms isolated, McCabe and Jackson prognostic criteria, and mortality were analysed. RESULTS Breakthrough bacteraemia was detected in 392 of 6324 (6.1%) episodes of bacteraemia. Eighty per cent of episodes were nosocomial. The most frequent source of infection in breakthrough bacteraemia was endovascular (70%). Coagulase-negative staphylococci, Staphylococcus aureus, and Pseudomonas aeruginosa were the most significant microorganisms involved. Nosocomial acquisition together with selected sources (central venous catheter, endocarditis and other endovascular foci), underlying conditions (neutropenia, polytraumatism, allogenic bone marrow and kidney transplantation), and particular microbial aetiologies (S. aureus, P. aeruginosa and polymicrobial) were independently associated with increased risk for developing breakthrough bacteraemia. Crude mortality rate was greater in patients with breakthrough bacteraemia (16% vs. 12.3%; P<0.05), and this condition was an independent predictor of death (OR 1.4, 95% CI, 1-1.9; P=0.04). CONCLUSIONS In view of a case of breakthrough bacteraemia it is mandatory to search for an endovascular focus. Empiric treatment should be directed to cover S. aureus, coagulase-negative staphylococci and nonfermentative Gram-negative bacilli. Breakthrough bacteraemia is an independent predictor of death.
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Affiliation(s)
- M López Dupla
- Servei de Medicina Interna, Hospital Universitari Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain.
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15
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Velasco E, Byington R, Martins CSA, Schirmer M, Dias LCM, Gonçalves VMSC. Bloodstream infection surveillance in a cancer centre: a prospective look at clinical microbiology aspects. Clin Microbiol Infect 2004; 10:542-9. [PMID: 15191383 DOI: 10.1111/j.1469-0691.2004.00874.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A prospective clinical and microbiological surveillance study was conducted during a 26-month period to evaluate consecutive malignancy or post-bone marrow transplant patients with positive blood cultures. The study included 859 episodes of bloodstream infection (BSI) in 719 patients. There were 6.9 BSI episodes/1000 patient-days. Overall mortality was 25%. The median age of patients was 43 years, with 71% of episodes occurring in patients aged > 18 years. Patients with underlying haematology malignancies accounted for 38.2% of the episodes. An indwelling central vein catheter was present in 61% of episodes. BSI origin was unknown in 27% of episodes, associated with other sites in 49.6%, and catheter-related in 23.4%. There were 638 concomitant infection sites, of which the most common were pulmonary (28.4%), urinary tract (14.8%), and non-surgical skin or soft tissue (9.7%). In total, 1039 microorganisms were isolated within 48 h of the first blood culture, of which Gram-negative bacilli accounted for 56%. Among Klebsiella pneumoniae and Escherichia coli isolates, 37.8% and 8.9%, respectively, produced extended-spectrum beta-lactamases. High rates of ceftazidime resistance were detected among Acinetobacter spp. (40%) and Enterobacter spp. (51.2%). E. coli and K. pneumoniae were isolated frequently from haematology patients, and Enterobacter spp. from solid tumour patients. E. coli, K. pneumoniae and Pseudomonas aeruginosa were isolated more often from neutropenic than from non-neutropenic patients. Oxacillin resistance was detected in 18.7% of Staphylococcus aureus isolates. It was concluded that continuous multidisciplinary surveillance of BSI is warranted in this high-risk group of patients in order to develop strategies for antimicrobial resistance control and treatment of infectious complications.
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Affiliation(s)
- E Velasco
- Hospital do Cancer, Instituto Nacional de Cancer, Rio de Janeiro, Brazil.
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16
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Khayr WF, CarMichael MJ, Dubanowich CS, Latif RH, Waiters L. Bacteremia in Veterans Administration Nursing Home Patients. Am J Ther 2004; 11:251-7. [PMID: 15266216 DOI: 10.1097/01.mjt.0000101828.94820.c6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to identify differences between nursing home (NH) and nonnursing home (non-NH) patients with bacteremia regarding host risk factors, exposures, microbiology, and outcome. Between October 1995 and February 1998, 134 episodes of true bacteremia were identified at the North Chicago Veterans Administration Medical Center (NCVAMC). Seventy-eight episodes of bacteremia occurred in NH patients who stayed for at least 3 months in the NH at the NCVAMC and developed bacteremia there or 48 hours after admission to the acute care hospital (ACH). Fifty-six episodes occurred in the non-NH patients who developed bacteremia in the community or 48 hours after admission to the ACH. NH patients were more likely to be older than 65 years (88% vs. 71%, P = 0.0334) and to have pressure sores (25% vs. 5%, P = 0.005), urinary incontinence (42% vs. 27%, P = 0.0471), and mental illness (62% vs. 29%, P = 0.0001) than non-NH patients. Coagulase-negative Staphylococcus and Escherichia coli were the most common causes of bacteremia occurring as frequently in both groups. Methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and enterococcal bacteremia were comparable, whereas vancomycin-resistant enterococci, ceftazidime-resistant E. coli, Klebsiella pneumoniae, and Enterobacter were rarely isolated. Twelve (15%) NH patients died within 2 weeks of acquiring bacteremia compared with 4 (7%) non-NH patients (P = 0.1176). For ACH-acquired cases, 20 NH patients were similar to 26 non-NH patients with regard to hospital stay; exposure to antibiotics, steroids, intensive care setting, surgery, tube feeding, and urinary and vascular catheters prior to bacteremia. Although NH and non-NH patients with bacteremia have different host characteristics, they have similar in-hospital exposures, distribution of infecting organisms, and outcome.
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Affiliation(s)
- Walid F Khayr
- Departments of Internal Medicine and Physician Assistant, School of Health Related Science, Finch University of Health Sciences/The Chicago Medical School, 300 Green Bay Road, North Chicago, IL 60064, USA.
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17
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Khayr WF, CarMichael MJ, Dubanowich CS, Latif RH. Epidemiology of bacteremia in the geriatric population. Am J Ther 2003; 10:127-31. [PMID: 12629591 DOI: 10.1097/00045391-200303000-00008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Walid F Khayr
- Finch University of Health Sciences/The Chicago Medical School, School of Health Related Sciences, Physician Assistant Department, 3001 Green Bay Road North, Chicago, IL 60064, USA
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18
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Olesen B, Kolmos HJ, Orskov F, Orskov I. Escherichia coli bacteraemia in patients with and without haematological malignancies: a study of strain characters and recurrent episodes. J Infect 1998; 36:93-100. [PMID: 9515676 DOI: 10.1016/s0163-4453(98)93378-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We compared serotypes, virulence factors and susceptibility to antibiotics of Escherichia coli strains isolated from 282 patients with bacteraemia. Thirty-five of these were neutropenic patients with haematological malignancy and 247 were patients with a normal or raised total white blood cell count and no haematological malignancy. Strains isolated from recurrent bacteraemia were also bio- and ribotyped. Overall, no significant difference was found between O serogroups, K antigens, serum sensitivity, production of haemolysin, expression of P-fimbriae and patterns of antibiotic susceptibility in the two groups of strains. The haematological patients more often than the non-haematological patients had an unknown focus of infection, recurrent bacteraemia, shorter intervals between recurrences and recurrences caused by identical strains. Despite a well-defined focus, six of eight non-haematological patients had recurrences with a strain different from the strain isolated in a previous episode. A possible connection between shorter intervals and recurrence with identical strains is discussed. We suggest that strains from recurrent E. coli bacteraemia are sent to a reference laboratory for serotyping and possibly ribotyping.
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Affiliation(s)
- B Olesen
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Denmark
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19
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Brauner A, Kaijser B, Kühn I. Recurrent Escherichia coli bacteraemia--clinical characteristics and bacterial properties. J Infect 1994; 28:49-57. [PMID: 8163833 DOI: 10.1016/s0163-4453(94)94130-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of the present study was to determine if recurrent bacteraemia due to Escherichia coli might be caused by the same strain in spite of apparently adequate antimicrobial therapy. Eleven patients who, altogether, experienced 24 episodes of E. coli bacteraemia were studied. All had underlying diseases; five biliary-intestinal disease, four were severely immunocompromised and two had urinary tract disorders. During the first bacteraemic episode, nine patients were treated with various combinations of drugs which included gentamicin and two with co-trimoxazole alone. Antibiotic treatment was continued for at least 12 days in each case and all patients were clinically cured. All isolates of E. coli were characterized by biochemical fingerprinting, O and K serotyping, the presence of cell-surface hydrophobicity and production of aerobactin. In two patients, the recurrent infections were due to strains different from those causing the previous episodes. In nine patients who, altogether, had 19 episodes of bacteraemia, the strain of E. coli isolated during the first and all later episodes were identical, according to all tests performed. We suggest that in such circumstances, the infecting strain may remain in the patients' environment and after recolonising the faecal flora may give rise to further infections. It may be, however, that if necessary steps are not taken, the original bacterial focus remains within the same patient so leading to emergence of the infecting strain which may then cause further episodes of bacteraemia.
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Affiliation(s)
- A Brauner
- Department of Clinical Bacteriology, Stockholm County Council Central Microbiological Laboratory and Karolinska Hospital, Sweden
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21
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Mylotte JM, White D, McDermott C, Hodan C. Nosocomial Bloodstream Infection at a Veterans Hospital; 1979 to 1987. Infect Control Hosp Epidemiol 1989. [DOI: 10.2307/30146835] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Positive blood cultures can be classified according to their veracity (true-positive or false-positive culture), clinical severity (inconsequential or life threatening), place of origin (community acquired or nosocomial), source (primary or secondary), duration (transient, intermittent, or continuous), pattern of occurrence (single episode, persistent, or recurrent), or intensity (high or low grade). In general, however, positive blood cultures identify a patient population at high risk of death. In my studies, patients with positive blood cultures were 12 times more likely to die during hospitalization than patients without positive blood cultures. Many bacteremias and fungemias occur in complicated clinical settings, and it appears that only about one-half of the deaths among affected patients are due directly to infection. Hence, it is appropriate to speak of "crude mortality" and "attributable mortality." Among hospitalized patients, recent trends include rising incidences of Staphylococcus aureus and coagulase-negative staphylococcal and enterococcal bacteremias and a dramatic increase in the incidence of fungemias. The diagnostic and therapeutic implications of blood cultures positive for specific microorganisms continue to evolve and are the subject of a large and growing medical literature.
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Affiliation(s)
- C S Bryan
- Department of Medicine, University of South Carolina School of Medicine, Columbia 29203
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