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Decrease in vancomycin-resistant Enterococcus colonization associated with a reduction in carbapenem use as empiric therapy for febrile neutropenia in patients with acute leukemia. Infect Control Hosp Epidemiol 2019; 40:774-779. [PMID: 31046849 DOI: 10.1017/ice.2019.93] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare the effects of empiric carbapenems versus cycling cefepime and piperacillin/tazobactam on the rates of vancomycin-resistant Enterococcus (VRE) colonization, bloodstream infections, and outcomes of patients admitted with acute leukemia. DESIGN Retrospective clinical study with VRE molecular strain typing and gastrointestinal microbiome comparison. SETTING A regional referral center for acute leukemia. PATIENTS 342 consecutive patients admitted with newly diagnosed acute leukemia. METHODS In September 2015, we changed our empiric antibiotic of choice for neutropenic fever from a carbapenem to the cycling regimen. We studied 214 consecutive patients during the carbapenem period and 128 during the cycling period. Surveillance for VRE stool colonization was conducted weekly. Representative stool samples were analyzed for VRE MLST types and changes in the composition and diversity of the fecal microbiota. RESULTS The change in empiric antibiotics was associated with a significant decrease in VRE colonization (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.27-0.66), a switch in the dominant VRE MLST types on the unit, and some modifications in the gastrointestinal microbiome. There were no differences in total gram-positive or gram-negative BSIs. During the carbapenem period, we observed higher absolute numbers of Candida spp and fewer ESBL BSIs, but these did not reach statistical significance. Patients during the carbapenem period had longer lengths of stay and durations of severe neutropenia and 10% higher hospital cost. CONCLUSIONS Carbapenem-sparing empiric antibiotic regimens may have advantages related to VRE ecology, gastrointestinal dysbiosis, duration of neutropenia, cost and length of stay.
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Belga S, Chiang D, Kabbani D, Abraldes JG, Cervera C. The direct and indirect effects of vancomycin-resistant enterococci colonization in liver transplant candidates and recipients. Expert Rev Anti Infect Ther 2019; 17:363-373. [PMID: 30977692 DOI: 10.1080/14787210.2019.1607297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Vancomycin-resistant enterococci (VRE) colonization and subsequent infection results in increased morbidity, mortality and use of health-care resources. The burden of VRE colonization in liver transplant candidates and recipients is significant. VRE colonization is a marker of gut dysbiosis and its impact on the microbiota-liver axis, may negatively affect graft function and result in negative outcomes pre- and post-transplantation. Areas covered: In this article we describe the epidemiology of VRE colonization, risk factors for VRE infection, health-care costs associated with VRE, with a focus on the impact of VRE colonization on liver transplant recipients' fecal microbiota, the therapeutic strategies for VRE decolonization and proposed pathophysiologic mechanisms of VRE colonization in liver transplant recipients. Expert opinion: VRE colonization results in a significant loss of bacterial microbiome diversity. This may have metabolic consequences, with low production of short-chain fatty acids which may, in turn, result in immune dysregulation. As antibiotics have failed to decolonize the gut, alternative strategies such as fecal microbiota transplantation (FMT), stimulation of intestinal antimicrobial peptides and phage therapy warrants future studies.
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Affiliation(s)
- Sara Belga
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Diana Chiang
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Dima Kabbani
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
| | - Juan G Abraldes
- b Department of Medicine, Division of Gastroenterology and Hepatology , University of Alberta , Edmonton , Alberta , Canada
| | - Carlos Cervera
- a Department of Medicine, Division of Infectious Diseases , University of Alberta , Edmonton , Alberta , Canada
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3
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Kramer TS, Remschmidt C, Werner S, Behnke M, Schwab F, Werner G, Gastmeier P, Leistner R. The importance of adjusting for enterococcus species when assessing the burden of vancomycin resistance: a cohort study including over 1000 cases of enterococcal bloodstream infections. Antimicrob Resist Infect Control 2018; 7:133. [PMID: 30459945 PMCID: PMC6234683 DOI: 10.1186/s13756-018-0419-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 10/11/2018] [Indexed: 01/27/2023] Open
Abstract
Background Infections caused by vancomycin-resistant enterococci (VRE) are on the rise worldwide. Few studies have tried to estimate the mortality burden as well as the financial burden of those infections and found that VRE are associated with increased mortality and higher hospital costs. However, it is unclear whether these worse outcomes are attributable to vancomycin resistance only or whether the enterococcal species (Enterococcus faecium or Enterococcus faecalis) play an important role. We therefore aimed to determine the burden of enterococci infections attributable to vancomycin resistance and pathogen species (E. faecium and E. faecalis) in cases of bloodstream infection (BSI). Methods We conducted a retrospective cohort study on patients with BSI caused by Enterococcus faecium or Enterococcus faecalis between 2008 and 2015 in three tertiary care hospitals. Data was collected on true hospital costs (in €), length of stay (LOS), basic demographic parameters, and underlying diseases including the results of the Charlson comorbidity index (CCI). We used univariate and multivariable regression analyses to compare risk factors for in-hospital mortality and length of stay (i) between vancomycin-susceptible E. faecium- (VSEm) and vancomycin-susceptible E. faecalis- (VSEf) cases and (ii) between vancomycin-susceptible E. faecium- (VSEm) and vancomycin-resistant E. faecium-cases (VREm). We calculated total hospital costs for VSEm, VSEf and VREm. Results Overall, we identified 1160 consecutive cases of BSI caused by enterococci: 596 (51.4%) cases of E. faecium BSI and 564 (48.6%) cases of E. faecalis BSI. 103 cases of E. faecium BSI (17.3%) and 1 case of E. faecalis BSI (0.2%) were infected by vancomycin-resistant isolates. Multivariable analyses revealed (i) that in addition to different underlying diseases E. faecium was an independent risk factor for in-hospital mortality and prolonged hospital stay and (ii) that vancomycin-resistance did not further increase the risk for the described outcomes among E. faecium-isolates. However, the overall hospital costs were significantly higher in VREm-BSI cases as compared to VSEm- and VSEf-BSI cases (80,465€ vs. 51,365€ vs. 31,122€ p < 0.001). Conclusion Our data indicates that in-hospital mortality and infection-attributed hospital stay in enterococci BSI might rather be influenced by Enterococcus species and underlying diseases than by vancomycin resistance. Therefore, future studies should consider adjusting for Enterococcus species in addition to vancomycin resistance in order to provide a conservative estimate for the burden of VRE infections. Electronic supplementary material The online version of this article (10.1186/s13756-018-0419-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tobias Siegfried Kramer
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Cornelius Remschmidt
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Sven Werner
- 3Department of Medical and Financial Controlling, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Behnke
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Frank Schwab
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Guido Werner
- 4Robert Koch Institute, FG13 Nosocomial Pathogens and Antibiotic Resistance, Wernigerode, Germany.,National Reference Centre for Staphylococci and Enterococci, Berlin, Germany
| | - Petra Gastmeier
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
| | - Rasmus Leistner
- 1Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.,National Reference Center for the Surveillance of Nosocomial Infections, Berlin, Germany
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4
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Lisboa LF, Miranda BG, Vieira MB, Dulley FL, Fonseca GG, Guimarães T, Levin AS, Shikanai-Yasuda MA, Costa SF. Empiric use of linezolid in febrile hematology and hematopoietic stem cell transplantation patients colonized with vancomycin-resistant Enterococcus spp. Int J Infect Dis 2015; 33:171-6. [PMID: 25660090 DOI: 10.1016/j.ijid.2015.02.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 01/28/2015] [Accepted: 02/02/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES We conducted a retrospective study on the impact of the empiric use of linezolid on mortality in vancomycin-resistant Enterococcus spp (VRE)-colonized hematology and hematopoietic stem cell transplantation (HSCT) patients. METHODS VRE-colonized inpatients for whom complete data were available (n=100) were divided into two groups: those who received empiric linezolid in the course of fever refractory to broad-spectrum antibiotics, replacing the glycopeptide utilized for the previous 48 h, and those who did not (control group). All patients were followed until hospital discharge or death. The impact of linezolid and risk factors for all-cause mortality were evaluated; variables with p<0.10 were analyzed in a multivariate model. A Kaplan-Meier survival analysis was done to compare survival among febrile patients colonized by VRE who received empiric linezolid with patients who did not receive linezolid. RESULTS Patients empirically prescribed linezolid were generally younger (median age 33 vs. 44 years; p=0.008) and more likely to be recipients of an allogeneic HSCT (24 (68.6%) vs. 24 (36.9%); p=0.009) than patients who did not receive the drug. Fourteen (21.5%) VRE bloodstream infections were diagnosed, all in patients who did not receive empiric linezolid (p=0.002). In-hospital mortality was comparable in empiric linezolid and non-linezolid users (19 (54.3%) vs. 27 (41.5%), respectively; p=0.293). The Kaplan-Meier survival analysis showed no significant difference in survival comparing the group that received linezolid to the group that did not (p=0.72). Graft-versus-host disease (GVHD; odds ratio (OR) 5.90, 95% confidence interval (CI) 1.46-23.79; p=0.012) and persistence of neutropenia (OR 6.93, 95% CI 1.72-27.94; p=0.0065) were independent predictors of all-cause in-hospital death in HSCT patients, and persistence of neutropenia in non-HSCT patients (OR 8.12, 95% CI 1.22-53.8; p=0.030). CONCLUSIONS The empiric use of linezolid in VRE-colonized hematology patients had no impact on mortality, which appeared rather to be associated with the persistence of neutropenia in general and GVHD in the HSCT group.
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Affiliation(s)
- Luiz F Lisboa
- Transplant Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Bianca G Miranda
- Department of Infectious Diseases, Faculty of Medicine, University of Sao Paulo, Brazil
| | - Marjorie B Vieira
- Department of Infectious Diseases, Faculty of Medicine, University of Sao Paulo, Brazil
| | - Frederico L Dulley
- Discipline of Hematology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme G Fonseca
- Discipline of Hematology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Thais Guimarães
- Infection Control Committee, Hospital das Clínicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases, Faculty of Medicine, University of Sao Paulo, Brazil
| | | | - Silvia F Costa
- Department of Infectious Diseases, Faculty of Medicine, University of Sao Paulo, Brazil.
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5
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Kara A, Devrim İ, Bayram N, Katipoğlu N, Kıran E, Oruç Y, Demiray N, Apa H, Gülfidan G. Risk of vancomycin-resistant enterococci bloodstream infection among patients colonized with vancomycin-resistant enterococci. Braz J Infect Dis 2014; 19:58-61. [PMID: 25529366 PMCID: PMC9425232 DOI: 10.1016/j.bjid.2014.09.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/26/2014] [Accepted: 09/17/2014] [Indexed: 01/02/2023] Open
Abstract
Background Vancomycin-resistant enterococci colonization has been reported to increase the risk of developing infections, including bloodstream infections. Aim In this study, we aimed to share our experience with the vancomycin-resistant enterococci bloodstream infections following gastrointestinal vancomycin-resistant enterococci colonization in pediatric population during a period of 18 months. Method A retrospective cohort of children admitted to a 400-bed tertiary teaching hospital in Izmir, Turkey whose vancomycin-resistant enterococci colonization was newly detected during routine surveillances for gastrointestinal vancomycin-resistant enterococci colonization during the period of January 2009 and December 2012 were included in this study. All vancomycin-resistant enterococci isolates found within 18 months after initial detection were evaluated for evidence of infection. Findings Two hundred and sixteen patients with vancomycin-resistant enterococci were included in the study. Vancomycin-resistant enterococci colonization was detected in 136 patients (62.3%) while they were hospitalized at intensive care units; while the remaining majority (33.0%) were hospitalized at hematology-oncology department. Vancomycin-resistant enterococci bacteremia was present only in three (1.55%) patients. All these patients were immunosuppressed due to human immunodeficiency virus (one patient) and intensive chemotherapy (two patients). Conclusion In conclusion, our study found that 1.55% of vancomycin-resistant enterococci-colonized children had developed vancomycin-resistant enterococci bloodstream infection among the pediatric intensive care unit and hematology/oncology patients; according to our findings, we suggest that immunosupression is the key point for developing vancomycin-resistant enterococci bloodstream infections.
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Affiliation(s)
- Ahu Kara
- Department of Pediatric Infectious Disease, Dr. Behçet Uz Children's Hospital, İzmir, Turkey.
| | - İlker Devrim
- Department of Pediatric Infectious Disease, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Nuri Bayram
- Department of Pediatric Infectious Disease, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Nagehan Katipoğlu
- Department of Pediatrics, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Ezgi Kıran
- Department of Pediatrics, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Yeliz Oruç
- Hospital Infection Control Committee, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Nevbahar Demiray
- Hospital Infection Control Committee, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Hurşit Apa
- Department of Pediatrics, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Gamze Gülfidan
- Department of Clinical Microbiology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
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6
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Gandra S, Barter D, Laxminarayan R. Economic burden of antibiotic resistance: how much do we really know? Clin Microbiol Infect 2014; 20:973-80. [DOI: 10.1111/1469-0691.12798] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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7
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Gastrointestinal colonization with a cephalosporinase-producing bacteroides species preserves colonization resistance against vancomycin-resistant enterococcus and Clostridium difficile in cephalosporin-treated mice. Antimicrob Agents Chemother 2014; 58:4535-42. [PMID: 24867962 DOI: 10.1128/aac.02782-14] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antibiotics that are excreted into the intestinal tract may disrupt the indigenous intestinal microbiota and promote colonization by health care-associated pathogens. β-Lactam, or penicillin-type, antibiotics are among the most widely utilized antibiotics worldwide and may also adversely affect the microbiota. Many bacteria are capable, however, of producing β-lactamase enzymes that inactivate β-lactam antibiotics. We hypothesized that prior establishment of intestinal colonization with a β-lactamase-producing anaerobe might prevent these adverse effects of β-lactam antibiotics, by inactivating the portion of antibiotic that is excreted into the intestinal tract. Here, mice with a previously abolished microbiota received either oral normal saline or an oral cephalosporinase-producing strain of Bacteroides thetaiotaomicron for 3 days. Mice then received 3 days of subcutaneous ceftriaxone, followed by either oral administration of vancomycin-resistant Enterococcus (VRE) or sacrifice and assessment of in vitro growth of epidemic and nonepidemic strains of Clostridium difficile in murine cecal contents. Stool concentrations of VRE and ceftriaxone were measured, cecal levels of C. difficile 24 h after incubation were quantified, and denaturing gradient gel electrophoresis (DGGE) of microbial 16S rRNA genes was performed to evaluate the antibiotic effect on the microbiota. The results demonstrated that establishment of prior colonization with a β-lactamase-producing intestinal anaerobe inactivated intraintestinal ceftriaxone during treatment with this antibiotic, allowed recovery of the normal microbiota despite systemic ceftriaxone, and prevented overgrowth with VRE and epidemic and nonepidemic strains of C. difficile in mice. These findings describe a novel probiotic strategy to potentially prevent pathogen colonization in hospitalized patients.
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8
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Vancomycin-resistant enterococci colonization does not increase mortality in end-stage kidney failure: a case–control study. J Hosp Infect 2013; 85:289-96. [DOI: 10.1016/j.jhin.2013.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 09/03/2013] [Indexed: 11/23/2022]
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9
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Abstract
BACKGROUND Existing estimates of the costs of antimicrobial resistance exhibit broad variability, and the contributing factors are not well understood. This study examines factors that contribute to variation in these estimates. METHODS Studies of the costs of resistant infections (1995-2009) were identified, abstracted, and stated in comparable terms (eg, converted to 2007 U.S. dollars). Linear regressions were conducted to assess how costs incurred by patients with resistant infections versus those incurred by uninfected or susceptible-organism-infected controls varied according to (1) costs incurred by control subjects; (2) study population characteristics; (3) methodological factors (eg, matching); and (4) length of stay. RESULTS Estimates of difference in costs incurred by patients with resistant infections versus patients without resistant infections varied between $-27,609 (control costs exceeded case costs) and $126,856. Differences were greater when the costs incurred by control subjects were higher (ie, when the underlying cost of care was high). Study-adjusted cost differences were greater for bloodstream infections (vs. any other infection site), for studies that reported median (vs. mean) costs, for studies that reported total (vs. postinfection or infection-associated) costs, for studies that used uninfected (vs. susceptible-organism-infected) controls, and for studies that did not match or adjust for length of stay before infection. CONCLUSION The cost of antimicrobial resistance seems to vary with the underlying cost of care. Increased costs of resistance are partially explained by longer length of stay for patients with resistant infections. Further research is needed to assess whether interventions should be differentially targeted at the highest cost cases.
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Worth LJ, Thursky KA, Seymour JF, Slavin MA. Vancomycin-resistant Enterococcus faecium infection in patients with hematologic malignancy: patients with acute myeloid leukemia are at high-risk. Eur J Haematol 2007; 79:226-33. [PMID: 17655696 DOI: 10.1111/j.1600-0609.2007.00911.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) are significant nosocomial pathogens in patients with hematologic malignancy. Identification of risk factors for infection is necessary for targeted prevention and surveillance. OBJECTIVES AND METHODS An outbreak of VRE infection occurred at a tertiary cancer hospital between 1 August 2003 and 30 June 2005. Infection control measures recommended by the Society for Healthcare Epidemiology of America were used throughout the outbreak period. A matched case-control study was performed to identify risk factors for VRE infection. RESULTS Fourteen VRE infections (13 episodes of bacteremia, one urinary tract infection) occurred a median of 10.5 d following hospital admission. All were due to Enterococcus faecium vanB. Univariate analysis identified the following variables to be significantly associated with VRE infection: presence of neutropenia, neutropenia >or=7 d, underlying diagnosis of acute myeloid leukemia (AML), and receipt of vancomycin, metronidazole or carbapenem antibiotic therapy in the 30 d prior to infection. On multivariate analysis, an underlying diagnosis of AML [odds ratio (OR), 15.00; P = 0.017] and vancomycin therapy during the previous 30 d (OR, 17.96; P = 0.036) were retained as independent risk factors for infection. CONCLUSIONS Risk stratification for development of VRE infection is possible for patients with hematologic malignancy. Patients with AML represent a high-risk population, and targeted prevention strategies must include improved antibiotic stewardship, particularly judicious use of vancomycin therapy.
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Affiliation(s)
- Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia.
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11
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Lowrance TC, Loneragan GH, Kunze DJ, Platt TM, Ives SE, Scott HM, Norby B, Echeverry A, Brashears MM. Changes in antimicrobial susceptibility in a population of Escherichia coli isolated from feedlot cattle administered ceftiofur crystalline-free acid. Am J Vet Res 2007; 68:501-7. [PMID: 17472449 DOI: 10.2460/ajvr.68.5.501] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine effects of administration of ceftiofur crystalline-free acid (CCFA) on antimicrobial susceptibility of Escherichia coli in feedlot cattle. ANIMALS 61 feedlot steers. PROCEDURES A cohort study was conducted. Steers were housed in pens (5 pens with 10 steers and 1 pen with 11 steers). Five steers in each pen were administered CCFA, and 5 served as control steers (1 pen had 6 control steers). The CCFA administration included a single-dose regimen (6.6 mg/kg, SC, on day 0), two-thirds-dose regimen (4.4 mg/kg, SC, on day 0), and 3-dose regimen (6.6 mg/kg, SC, on days 0, 6, and 13). Fecal samples were collected on days 0, 2, 6, 9, 13, 16, 20, and 28. Fecal samples were collected immediately before CCFA administration. Minimum inhibitory concentrations of 15 antimicrobials were determined for 3 E coli isolates/fecal sample. Escherichia coli were enumerated by use of direct-plating techniques. RESULTS Resistance to 1 or more antimicrobials was detected in 986 of 1,441 (68.4%) isolates recovered. Administration of CCFA was associated with a transient increase in the population of ceftiofur-resistant isolates. Susceptibility returned to day 0 values (ie, samples collected immediately before CCFA administration) approximately 2 weeks after completion of CCFA administration. Agreement between ceftiofur resistance and co-resistance to ampicillin, chloramphenicol, streptomycin, sulfisoxazole, and tetracycline was almost perfect (kappa 0.97). We did not detect variation in susceptibility of E coli recovered from commingled control steers. CONCLUSIONS AND CLINICAL RELEVANCE Administration of CCFA provided selection pressure that favored transient expansion of multiple-resistant variants.
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Affiliation(s)
- T Courtney Lowrance
- Feedlot Research Group, Department of Agricultural Sciences, College of Agriculture, Science and Engineering, West Texas A&M University, Canyon, TX 79016, USA
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12
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McNeil SA, Malani PN, Chenoweth CE, Fontana RJ, Magee JC, Punch JD, Mackin ML, Kauffman CA. Vancomycin-resistant enterococcal colonization and infection in liver transplant candidates and recipients: a prospective surveillance study. Clin Infect Dis 2005; 42:195-203. [PMID: 16355329 DOI: 10.1086/498903] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Accepted: 08/30/2005] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vancomycin-resistant enterococcal (VRE) infections cause significant morbidity and mortality among patients undergoing liver transplantation. We performed a prospective study among patients awaiting transplantation to assess rates, risk factors, and outcomes associated with VRE colonization before and after transplantation. METHODS All adults on the transplantation waiting list from 2000-2003 were eligible. Demographic, historical, and laboratory data, as well as stool samples to be analyzed for VRE, were collected at enrollment and every 4-6 months thereafter until transplantation. After transplantation, samples were obtained every 3 days during hospitalization and were analyzed for VRE; outcomes were assessed at 90 days. RESULTS Overall, 375 patients were enrolled in our study, and 142 received transplants. VRE colonization occurred in 50 (13%) of 375 patients before transplantation and was independently associated with treatment with antianaerobic antimicrobials, third-generation cephalosporins, proton pump inhibitors, or neomycin; having a recent endoscopic retrograde cholangiopancreatogram or paracentesis procedure; and admission to the liver unit. Of these 50 patients, 22 (44%) received a transplant, and 7 (32%) of 22 developed a VRE infection after transplantation. An additional 22 patients (18%) who were not colonized before transplantation acquired VRE after transplantation; VRE infection developed in 5 (23%) of these patients. Patients colonized with VRE either before or after transplantation had longer stays in the intensive care unit and the hospital. Mortality at 90 days was significantly greater among those who acquired VRE after transplantation (5 [23%] of 22), compared with those who had VRE colonization before transplantation (2 [9%] of 22). CONCLUSIONS Liver transplantation candidates with VRE colonization before transplantation experience greater morbidity but not greater mortality, compared with noncolonized candidates. Transplant recipients who acquire VRE after transplantation have a higher mortality rate than noncolonized recipients. Strategies should be implemented to reduce nosocomial VRE acquisition after transplantation among this vulnerable group.
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Affiliation(s)
- Shelly A McNeil
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
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13
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Yoo JH, Lee DG, Choi SM, Choi JH, Shin WS, Kim M, Yong D, Lee K, Min WS, Kim CC. Vancomycin-resistant enterococcal bacteremia in a hematology unit: molecular epidemiology and analysis of clinical course. J Korean Med Sci 2005; 20:169-76. [PMID: 15831982 PMCID: PMC2808587 DOI: 10.3346/jkms.2005.20.2.169] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An increase in vancomycin-resistant enterococcal (VRE) bacteremia in hemato-oncological patients (n=19) in our institution from 2000 through 2001 led us to analyze the molecular epidemiologic patterns and clinical features unique to our cases. The pulsed field gel electrophoresis of the isolates revealed that the bacteremia was not originated from a single clone but rather showed endemic pattern of diverse clones with small clusters. A different DNA pattern of blood and stool isolates from one patient suggested exogenous rather than endogenous route of infection. Enterococcus faecium carrying vanA gene was the causative pathogen in all cases. Patients with VRE bacteremia showed similar clinical courses compared with those with vancomycin-susceptible enterococcal (VSE) bacteremia. Vancomycin resistance did not seem to be a poor prognostic factor because of similar mortality (5/8, 62.5%) noted in VSE bacteremia. Initial disease severity and neutropenic status may be major determinants of prognosis in patients with VRE bacteraemia.
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Affiliation(s)
- Jin-Hong Yoo
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dong-Gun Lee
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Su Mi Choi
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Wan-Shik Shin
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Myungshin Kim
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Dongeun Yong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Woo-Sung Min
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Chun-Choo Kim
- Department of Internal Medicine, The Catholic Haematopoietic Stem Cell Transplantion Center, The Catholic University of Korea, College of Medicine, Seoul, Korea
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14
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Shorr AF, Susla GM, Kollef MH. Linezolid for treatment of ventilator-associated pneumonia: A cost-effective alternative to vancomycin*. Crit Care Med 2004; 32:137-43. [PMID: 14707572 DOI: 10.1097/01.ccm.0000104110.74657.25] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the incremental cost-effectiveness of linezolid compared with vancomycin for treatment of ventilator-associated pneumonia due to Staphylococcus aureus. DESIGN Decision model analysis of the cost and efficacy of linezolid vs. vancomycin for treatment of ventilator-associated pneumonia. The primary outcome was the incremental cost-effectiveness of linezolid in terms of cost per added quality-adjusted life-year gained. Other outcomes were the marginal costs per hospital survivor and per year of life saved generated by using linezolid. Model estimates were derived from prospective trials of linezolid for ventilator-associated pneumonia and from other studies describing the costs and outcomes for ventilator-associated pneumonia. SETTING AND PATIENTS Hypothetical cohort of 1,000 patients diagnosed with ventilator-associated pneumonia. INTERVENTIONS In the model, patients received either linezolid or vancomycin. MEASUREMENTS AND MAIN RESULTS The incremental cost-effectiveness of linezolid was calculated as the additional quality-adjusted life-years resulting from therapy with linezolid divided by the sum of the incremental costs arising because of use of linezolid (e.g., higher direct costs for linezolid, costs per in-hospital care of survivors, and posthospitalization costs). Despite its higher cost, linezolid was cost-effective for treatment of ventilator-associated pneumonia. The cost per quality-adjusted life-year equals approximately 30,000 dollars. The model was moderately sensitive to the estimated efficacy of linezolid over vancomycin. Nonetheless, even with all inputs simultaneously skewed against, linezolid remains a cost-effective option (cost per quality-adjusted life-year approximately 100,000 dollars). Based on Monte Carlo simulation, the results of our analysis are robust across a range of model inputs and assumptions (95% confidence interval for cost per quality-adjusted life-year ranges from 23,637 dollars to 42,785 dollars). CONCLUSIONS Linezolid is a cost-effective alternative to vancomycin for the treatment of ventilator-associated pneumonia.
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Affiliation(s)
- Andrew F Shorr
- Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA
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15
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Diekema DJ, BootsMiller BJ, Vaughn TE, Woolson RF, Yankey JW, Ernst EJ, Flach SD, Ward MM, Franciscus CLJ, Pfaller MA, Doebbeling BN. Antimicrobial Resistance Trends and Outbreak Frequency in United States Hospitals. Clin Infect Dis 2004; 38:78-85. [PMID: 14679451 DOI: 10.1086/380457] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2003] [Accepted: 08/25/2003] [Indexed: 11/03/2022] Open
Abstract
We assessed resistance rates and trends for important antimicrobial-resistant pathogens (oxacillin-resistant Staphylococcus aureus [ORSA], vancomycin-resistant Enterococcus species [VRE], ceftazidime-resistant Klebsiella species [K-ESBL], and ciprofloxacin-resistant Escherichia coli [QREC]), the frequency of outbreaks of infection with these resistant pathogens, and the measures taken to control resistance in a stratified national sample of 670 hospitals. Four hundred ninety-four (74%) of 670 surveys were returned. Resistance rates were highest for ORSA (36%), followed by VRE (10%), QREC (6%), and K-ESBL (5%). Two-thirds of hospitals reported increasing ORSA rates, whereas only 4% reported decreasing rates, and 24% reported ORSA outbreaks within the previous year. Most hospitals (87%) reported having implemented measures to rapidly detect resistance, but only approximately 50% reported having provided appropriate resources for antimicrobial resistance prevention (53%) or having implemented antimicrobial use guidelines (60%). The most common resistant pathogen in US hospitals is ORSA, which accounts for many recognized outbreaks and is increasing in frequency in most facilities. Current practices to prevent and control antimicrobial resistance are inadequate.
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Affiliation(s)
- Daniel J Diekema
- Iowa City Veterans Affairs Medical Center, Dept. of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.
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