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Hurley J. Rebound Inverts the Staphylococcus aureus Bacteremia Prevention Effect of Antibiotic Based Decontamination Interventions in ICU Cohorts with Prolonged Length of Stay. Antibiotics (Basel) 2024; 13:316. [PMID: 38666992 PMCID: PMC11047347 DOI: 10.3390/antibiotics13040316] [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: 02/25/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/29/2024] Open
Abstract
Could rebound explain the paradoxical lack of prevention effect against Staphylococcus aureus blood stream infections (BSIs) with antibiotic-based decontamination intervention (BDI) methods among studies of ICU patients within the literature? Two meta-regression models were applied, each versus the group mean length of stay (LOS). Firstly, the prevention effects against S. aureus BSI [and S. aureus VAP] among 136 studies of antibiotic-BDI versus other interventions were analyzed. Secondly, the S. aureus BSI [and S. aureus VAP] incidence in 268 control and intervention cohorts from studies of antibiotic-BDI versus that among 165 observational cohorts as a benchmark was modelled. In model one, the meta-regression line versus group mean LOS crossed the null, with the antibiotic-BDI prevention effect against S. aureus BSI at mean LOS day 7 (OR 0.45; 0.30 to 0.68) inverted at mean LOS day 20 (OR 1.7; 1.1 to 2.6). In model two, the meta-regression line versus group mean LOS crossed the benchmark line, and the predicted S. aureus BSI incidence for antibiotic-BDI groups was 0.47; 0.09-0.84 percentage points below versus 3.0; 0.12-5.9 above the benchmark in studies with 7 versus 20 days mean LOS, respectively. Rebound within the intervention groups attenuated and inverted the prevention effect of antibiotic-BDI against S. aureus VAP and BSI, respectively. This explains the paradoxical findings.
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Affiliation(s)
- James Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, VIC 3052, Australia;
- Ballarat Health Services, Grampians Health, Ballarat, VIC 3350, Australia
- Ballarat Clinical School, Deakin University, Ballarat, VIC 3350, Australia
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McHugh MP, Pettigrew KA, Taori S, Evans TJ, Leanord A, Gillespie SH, Templeton KE, Holden MTG. Consideration of within-patient diversity highlights transmission pathways and antimicrobial resistance gene variability in vancomycin-resistant Enterococcus faecium. J Antimicrob Chemother 2024; 79:656-668. [PMID: 38323373 PMCID: PMC11090465 DOI: 10.1093/jac/dkae023] [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: 04/27/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND WGS is increasingly being applied to healthcare-associated vancomycin-resistant Enterococcus faecium (VREfm) outbreaks. Within-patient diversity could complicate transmission resolution if single colonies are sequenced from identified cases. OBJECTIVES Determine the impact of within-patient diversity on transmission resolution of VREfm. MATERIALS AND METHODS Fourteen colonies were collected from VREfm positive rectal screens, single colonies were collected from clinical samples and Illumina WGS was performed. Two isolates were selected for Oxford Nanopore sequencing and hybrid genome assembly to generate lineage-specific reference genomes. Mapping to closely related references was used to identify genetic variations and closely related genomes. A transmission network was inferred for the entire genome set using Phyloscanner. RESULTS AND DISCUSSION In total, 229 isolates from 11 patients were sequenced. Carriage of two or three sequence types was detected in 27% of patients. Presence of antimicrobial resistance genes and plasmids was variable within genomes from the same patient and sequence type. We identified two dominant sequence types (ST80 and ST1424), with two putative transmission clusters of two patients within ST80, and a single cluster of six patients within ST1424. We found transmission resolution was impaired using fewer than 14 colonies. CONCLUSIONS Patients can carry multiple sequence types of VREfm, and even within related lineages the presence of mobile genetic elements and antimicrobial resistance genes can vary. VREfm within-patient diversity could be considered in future to aid accurate resolution of transmission networks.
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Affiliation(s)
- Martin P McHugh
- School of Medicine, University of St Andrews, St Andrews, UK
- Medical Microbiology, Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Surabhi Taori
- Medical Microbiology, Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Thomas J Evans
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Alistair Leanord
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
- Scottish Microbiology Reference Laboratories, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Kate E Templeton
- Medical Microbiology, Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Brinkwirth S, Ayobami O, Eckmanns T, Markwart R. Hospital-acquired infections caused by enterococci: a systematic review and meta-analysis, WHO European Region, 1 January 2010 to 4 February 2020. Euro Surveill 2021; 26:2001628. [PMID: 34763754 PMCID: PMC8646982 DOI: 10.2807/1560-7917.es.2021.26.45.2001628] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 05/17/2021] [Indexed: 12/11/2022] Open
Abstract
BackgroundHospital-acquired infections (HAI) caused by Enterococcus spp., especially vancomycin-resistant Enterococcusspp. (VRE), are of rising concern.AimWe summarised data on incidence, mortality and proportion of HAI caused by enterococci in the World Health Organization European Region.MethodsWe searched Medline and Embase for articles published between 1 January 2010 and 4 February 2020. Random-effects meta-analyses were performed to obtain pooled estimates.ResultsWe included 75 studies. Enterococcus spp. and VRE accounted for 10.9% (95% confidence interval (CI): 8.7-13.4; range: 6.1-17.5) and 1.1% (95% CI: 0.21-2.7; range: 0.39-2.0) of all pathogens isolated from patients with HAI. Hospital wide, the pooled incidence of HAI caused by Enterococcus spp. ranged between 0.7 and 24.8 cases per 1,000 patients (pooled estimate: 6.9; 95% CI: 0.76-19.0). In intensive care units (ICU), pooled incidence of HAI caused by Enterococcus spp. and VRE was 9.6 (95% CI: 6.3-13.5; range: 0.39-36.0) and 2.6 (95% CI: 0.53-5.8; range: 0-9.7). Hospital wide, the pooled vancomycin resistance proportion among Enterococcus spp. HAI isolates was 7.3% (95% CI: 1.5-16.3; range: 2.6-11.5). In ICU, this proportion was 11.5% (95% CI: 4.7-20.1; range: 0-40.0). Among patients with hospital-acquired bloodstream infections with Enterococcus spp., pooled all-cause mortality was 21.9% (95% CI: 15.7-28.9; range: 14.3-32.3); whereas all-cause mortality attributable to VRE was 33.5% (95% CI: 13.0-57.3; range: 14.3-41.3).ConclusionsInfections caused by Enterococcus spp. are frequently identified among hospital patients and associated with high mortality.
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Affiliation(s)
- Simon Brinkwirth
- Unit 37: Nosocomial Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Berlin, Germany
| | - Olaniyi Ayobami
- Unit 37: Nosocomial Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Berlin, Germany
| | - Tim Eckmanns
- Unit 37: Nosocomial Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Berlin, Germany
| | - Robby Markwart
- Unit 37: Nosocomial Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Berlin, Germany
- Jena University Hospital, Institute of General Practice and Family Medicine, Jena, Germany
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Al-Khawaja S, Saeed NK, Al-khawaja S, Azzam N, Al-Biltagi M. Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain: Four years’ experience. World J Crit Care Med 2021; 10:220-231. [PMID: 34616658 PMCID: PMC8462019 DOI: 10.5492/wjccm.v10.i5.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/17/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The central venous line is an essential component in monitoring and managing critically ill patients. However, it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.
AIM To define the trends of the rates of central line-associated bloodstream infections (CLABSI) over four years, its predicted risk factors, aetiology, and the antimicrobial susceptibility of the isolated pathogens.
METHODS The study was a prospective case-control study, performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit (ICU) and auditing the implementation of its prevention bundle.
RESULTS Thirty-four CLABSI identified over the study period, giving an average CLABSI rate of 3.2/1000 central line days. The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018. The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms (59%). The most common offending organisms were Acinetobacter, Enterococcus, and Staphylococcus epidermidis, each of them accounted for 5 cases (15%). Multidrug-resistant organisms contributed to 56% of CLABSI. Its rate was higher when using femoral access and longer hospitalisation duration, especially in the ICU. Insertion of the central line in the non-ICU setting was another identified risk factor.
CONCLUSION Implementing the prevention bundles reduced CLABSI significantly in our ICU. Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.
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Affiliation(s)
- Safaa Al-Khawaja
- The Infection Disease Unit, Department of Internal Medicine, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama P.O. Box 12, Bahrain
- Department of Internal Medicine, Arabian Gulf University, Kingdom of Bahrain, Manama P.O. Box 26671, Bahrain
| | - Nermin Kamal Saeed
- The Medical Microbiology Section, Pathology Department, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama P.O. Box 12, Bahrain
- The Microbiology Section, Pathology Department, Irish Royal College of Surgeon, Manama P.O. Box 15503, Bahrain
| | - Sanaa Al-khawaja
- The Intensive Care Unit, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama P.O. Box 12, Bahrain
| | - Nashwa Azzam
- The High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Mohammed Al-Biltagi
- The Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama P.O. Box 26671, Bahrain
- Pediatric Department, Faculty of Medicine, Tanta University, Tanta P.O. Box 31512, Alghrabia, Egypt
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Bonazzetti C, Morena V, Giacomelli A, Oreni L, Casalini G, Galimberti LR, Bolis M, Rimoldi M, Ballone E, Colombo R, Ridolfo AL, Antinori S. Unexpectedly High Frequency of Enterococcal Bloodstream Infections in Coronavirus Disease 2019 Patients Admitted to an Italian ICU: An Observational Study. Crit Care Med 2021; 49:e31-e40. [PMID: 33122577 PMCID: PMC7737701 DOI: 10.1097/ccm.0000000000004748] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to assess the frequency of ICU-acquired bloodstream infections in coronavirus disease 2019 patients. DESIGN Retrospective observational study. SETTING The emergency expansion of an ICU from eight general beds to 30 coronavirus disease 2019 beds. PARTICIPANTS Patients with coronavirus disease 2019 admitted to the ICU of Luigi Sacco Hospital (Milan, Italy) for greater than or equal to 48 hours between February 21, 2020, and April 30, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The frequency of bloodstream infections per 1,000 days of ICU stay was calculated in 89 coronavirus disease 2019 patients, and the cumulative probability of bloodstream infection was estimated using death and ICU discharge as competing events. Sixty patients (67.4%) experienced at least one of the 93 recorded episodes of bloodstream infection, a frequency of 87 per 1,000 days of ICU stay (95% CI, 67-112).The patients who experienced a bloodstream infection had a higher Sequential Organ Failure Assessment score upon ICU admission (9.5; interquartile range, 8-12 vs 8, interquartile range, 5-10; p = 0.042), a longer median ICU stay (15 d; interquartile range, 11-23 vs 8, interquartile range, 5-12; p < 0.001), and more frequently required invasive mechanical ventilation (98.3% vs 82.8%; p = 0.013) than those who did not. The median time from ICU admission to the first bloodstream infection episode was 10 days. Gram-positive bacteria accounted for 74 episodes (79.6%), with Enterococcus species being the most prevalent (53 episodes, 55.8%). Thirty-two isolates (27.3%) showed multidrug resistance. CONCLUSIONS Coronavirus disease 2019 seemed to increase the frequency of bloodstream infections (particularly Enterococcus-related bloodstream infection) after ICU admission. This may have been due to enteric involvement in patients with severe coronavirus disease 2019 and/or limitations in controlling the patient-to-patient transmission of infectious agents in extremely challenging circumstances.
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Affiliation(s)
- Cecilia Bonazzetti
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Valentina Morena
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Andrea Giacomelli
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Letizia Oreni
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Giacomo Casalini
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Laura Rina Galimberti
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Matteo Bolis
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Matteo Rimoldi
- Technical and Rehabilitation Nursing Hospital Service, Epidemiological Office, SITRA, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Elisabetta Ballone
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Riccardo Colombo
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Anna Lisa Ridolfo
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Spinello Antinori
- Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milan, Italy
- Luigi Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Pouwels KB, Vansteelandt S, Batra R, Edgeworth J, Wordsworth S, Robotham JV. Estimating the Effect of Healthcare-Associated Infections on Excess Length of Hospital Stay Using Inverse Probability-Weighted Survival Curves. Clin Infect Dis 2020; 71:e415-e420. [PMID: 32047916 PMCID: PMC7713691 DOI: 10.1093/cid/ciaa136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Studies estimating excess length of stay (LOS) attributable to nosocomial infections have failed to address time-varying confounding, likely leading to overestimation of their impact. We present a methodology based on inverse probability-weighted survival curves to address this limitation. METHODS A case study focusing on intensive care unit-acquired bacteremia using data from 2 general intensive care units (ICUs) from 2 London teaching hospitals were used to illustrate the methodology. The area under the curve of a conventional Kaplan-Meier curve applied to the observed data was compared with that of an inverse probability-weighted Kaplan-Meier curve applied after treating bacteremia as censoring events. Weights were based on the daily probability of acquiring bacteremia. The difference between the observed average LOS and the average LOS that would be observed if all bacteremia cases could be prevented was multiplied by the number of admitted patients to obtain the total excess LOS. RESULTS The estimated total number of extra ICU days caused by 666 bacteremia cases was estimated at 2453 (95% confidence interval [CI], 1803-3103) days. The excess number of days was overestimated when ignoring time-varying confounding (2845 [95% CI, 2276-3415]) or when completely ignoring confounding (2838 [95% CI, 2101-3575]). CONCLUSIONS ICU-acquired bacteremia was associated with a substantial excess LOS. Wider adoption of inverse probability-weighted survival curves or alternative techniques that address time-varying confounding could lead to better informed decision making around nosocomial infections and other time-dependent exposures.
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Affiliation(s)
- Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rahul Batra
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King’s College London and Guy’s and St Thomas’ National Health Services Foundation Trust, London, United Kingdom
| | - Jonathan Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King’s College London and Guy’s and St Thomas’ National Health Services Foundation Trust, London, United Kingdom
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, United Kingdom
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Wang YC, Shih SM, Chen YT, Hsiung CA, Kuo SC. Clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan: a nationwide population-based retrospective cohort study. BMJ Open 2020; 10:e037484. [PMID: 33243790 PMCID: PMC7692834 DOI: 10.1136/bmjopen-2020-037484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To estimate the clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan. DESIGN Retrospective cohort study. SETTING Nationwide Taiwanese population in the National Health Insurance Research Database and the Taiwan Nosocomial Infections Surveillance (2007-2015) dataset. PARTICIPANTS The first episodes of intensive care unit-acquired bloodstream infections in patients ≥20 years of age in the datasets. Propensity score-matching (1:2) of demographic data, comorbidities and disease severity was performed to select a comparison cohort from a pool of intensive care unit patients without intensive care unit-acquired infections from the same datasets. PRIMARY AND SECONDARY OUTCOME MEASURES The mortality rate, length of hospitalisation and healthcare cost. RESULTS After matching, the in-hospital mortality of 14 234 patients with intensive care unit-acquired bloodstream infections was 44.23%, compared with 33.48% for 28 468 intensive care unit patients without infections. The 14-day mortality rate was also higher in the bloodstream infections cohort (4323, 30.37% vs 6766 deaths, 23.77%, respectively; p<0.001). Furthermore, the patients with intensive care unit-acquired bloodstream infections had a prolonged length of hospitalisation after their index date (18 days (IQR 7-39) vs 10 days (IQR 4-21), respectively; p<0.001) and a higher healthcare cost (US$16 038 (IQR 9667-25 946) vs US$10 372 (IQR 6289-16 932), respectively; p<0.001). The excessive hospital stay and healthcare cost per case were 12.69 days and US$7669, respectively. Similar results were observed in subgroup analyses of various WHO's priority pathogens and Candida spp. CONCLUSIONS Intensive care unit-acquired bloodstream infections in critically ill patients were associated with increased mortality, longer hospital stays and higher healthcare costs.
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Affiliation(s)
- Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Man Shih
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Yung-Tai Chen
- Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
- University of Taipei, Taipei, Taiwan
- Divisions of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao Agnes Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Shu-Chen Kuo
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
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Hurley JC. Studies of selective digestive decontamination as a natural experiment to evaluate topical antibiotic prophylaxis and cephalosporin use as population-level risk factors for enterococcal bacteraemia among ICU patients. J Antimicrob Chemother 2020; 74:3087-3094. [PMID: 31355880 DOI: 10.1093/jac/dkz300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) regimens appear protective against ICU-acquired overall bacteraemia. These regimens can be factorized as topical antibiotic prophylaxis (TAP) with (SDD) or without (SOD) protocolized parenteral antibiotic prophylaxis (PPAP) using cephalosporins. Both TAP and cephalosporins are risk factors for enterococcal colonization although their impact on enterococcal bacteraemia within studies of SDD/SOD remains unclear. OBJECTIVES To benchmark the enterococcal bacteraemia incidence within component (control and intervention) groups of SDD/SOD studies among ICU patients versus studies without intervention (observational groups). METHODS The literature was searched for SDD/SOD studies reporting enterococcal bacteraemia incidence data. In addition, component groups of studies of various non-antibiotic interventions served to provide additional points of reference. RESULTS The mean incidence per 100 patients (and 95% CI) for enterococcal bacteraemia among 19 SDD/SOD studies was equally increased among concurrent control (2.1; 1.0%-4.7%) and intervention (2.3; 2.0%-2.7%) groups versus the benchmark incidence (0.8; 0.6%-1.2%) derived from 16 observational study groups and also versus 9 component groups from non-antibiotic studies. These higher incidences remained apparent (P < 0.02) in a meta-regression model adjusting for groupwide factors such as PPAP use, mechanical ventilation proportion, group mean length of stay >7 days and publication year. CONCLUSIONS The incidences of enterococcal bacteraemia within both concurrent control and intervention groups of SDD/SOD studies are unusually high compared with the literature-derived benchmark. The impact of parenteral cephalosporin used as PPAP additional to TAP on enterococcal bacteraemia incidence was indeterminate in this analysis.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Internal Medicine Service, Ballarat Health Services, Ballarat, Victoria, Australia
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Kern WV, Roth JA, Bertz H, Götting T, Dettenkofer M, Widmer AF, Theilacker C. Contribution of specific pathogens to bloodstream infection mortality in neutropenic patients with hematologic malignancies: Results from a multicentric surveillance cohort study. Transpl Infect Dis 2019; 21:e13186. [PMID: 31574202 DOI: 10.1111/tid.13186] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/19/2019] [Accepted: 09/14/2019] [Indexed: 01/03/2023]
Abstract
Bloodstream infection (BSI) remains a serious complication in patients with hematologic malignancies and neutropenia. The risk factors for mortality after BSI and the contributions of BSI pathogens to mortality remain incompletely understood. We evaluated first BSI among adult neutropenic patients undergoing high-dose chemotherapy for hematologic malignancies in the setting of (a) an early disease stage of autologous (auto-HSCT) or allogeneic (allo-HSCT) hematopoietic stem cell transplantation or (b) for acute leukemia. Risk factors for intensive care admission and all-cause mortality were analyzed by multivariable logistic regression 7 and 30 days after onset of the first BSI in the first neutropenic episode. Between 2002 and 2015, 9080 patients met the study inclusion criteria, and 1424 (16%) developed BSIs, most of them during the first week of neutropenia. Mortality during neutropenia within 7 days and 30 days after BSI onset was 2.5% and 5.1%, respectively, and differed considerably between BSI pathogens. Both 7-day and 30-day mortalities were highest for Pseudomonas aeruginosa BSI (16.7% and 26.7%, respectively) and lowest for BSI due to coagulase-negative Staphylococcus spp. (CoNS) and Streptococcus spp. BSI pathogens were independently associated with 7-day mortality included P aeruginosa, Klebsiella spp., Enterobacter spp., Serratia spp., and enterococci. Only gram-negative BSI and candidemia were associated with admission to intensive care within 7 days after BSI onset. BSI caused by P aeruginosa continues to carry a particularly poor prognosis in neutropenic patients. The unexpected association between enterococcal BSI and increased mortality needs further study.
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Affiliation(s)
- Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - Jan A Roth
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Hartmut Bertz
- Division of Hematology, Oncology, and Stem Cell Transplantation/Department, Faculty of Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - Tim Götting
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - Markus Dettenkofer
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - Andreas F Widmer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Theilacker
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Austin PC, Latouche A, Fine JP. A review of the use of time-varying covariates in the Fine-Gray subdistribution hazard competing risk regression model. Stat Med 2019; 39:103-113. [PMID: 31660633 PMCID: PMC6916372 DOI: 10.1002/sim.8399] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 12/17/2022]
Abstract
In survival analysis, time‐varying covariates are covariates whose value can change during follow‐up. Outcomes in medical research are frequently subject to competing risks (events precluding the occurrence of the primary outcome). We review the types of time‐varying covariates and highlight the effect of their inclusion in the subdistribution hazard model. External time‐dependent covariates are external to the subject, can effect the failure process, but are not otherwise involved in the failure mechanism. Internal time‐varying covariates are measured on the subject, can effect the failure process directly, and may also be impacted by the failure mechanism. In the absence of competing risks, a consequence of including internal time‐dependent covariates in the Cox model is that one cannot estimate the survival function or the effect of covariates on the survival function. In the presence of competing risks, the inclusion of internal time‐varying covariates in a subdistribution hazard model results in the loss of the ability to estimate the cumulative incidence function (CIF) or the effect of covariates on the CIF. Furthermore, the definition of the risk set for the subdistribution hazard function can make defining internal time‐varying covariates difficult or impossible. We conducted a review of the use of time‐varying covariates in subdistribution hazard models in articles published in the medical literature in 2015 and in the first 5 months of 2019. Seven percent of articles published included a time‐varying covariate. Several inappropriately described a time‐varying covariate as having an association with the risk of the outcome.
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Affiliation(s)
- Peter C Austin
- ICES, Toronto, Ontario, Canada.,Institute of Health Management, Policy and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Aurélien Latouche
- Conservatoire National des Arts et Métiers, Paris, France.,Institut Curie, St-Cloud, France
| | - Jason P Fine
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina.,Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina
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11
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Echeverria-Esnal D, Sorli L, Prim N, Conde-Estévez D, Mateu-De Antonio J, Martin-Ontiyuelo C, Horcajada JP, Grau S. Linezolid vs glycopeptides in the treatment of glycopeptide-susceptible Enterococcus faecium bacteraemia: A propensity score matched comparative study. Int J Antimicrob Agents 2019; 54:572-578. [PMID: 31476435 DOI: 10.1016/j.ijantimicag.2019.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 08/19/2019] [Accepted: 08/24/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND The incidence of ampicillin-resistant Enterococcus faecium bacteraemia is increasing. Vancomycin remains the first-line treatment in areas with a high prevalence of glycopeptide-susceptible isolates, but data comparing its clinical outcomes with other treatments are lacking. The objective of this study was to compare the effectiveness and safety of linezolid and glycopeptides for the treatment of glycopeptide-susceptible E. faecium bloodstream infection (GSEF-BSI). METHODS This retrospective observational cohort study was conducted from January 2006 to May 2018 at the Hospital del Mar, Barcelona, Spain, and compared the clinical outcomes and safety of linezolid and glycopeptides in adult patients with GSEF-BSI. The main outcomes included clinical cure at the end of therapy, 30-day mortality, microbiological eradication and attributable length of stay (LOS). Propensity score matching was performed to reduce potential confounders among groups. RESULTS In total, 105 patients with GSEF-BSI were included (linezolid, n=38; glycopeptides, n=67). After propensity score matched analysis, 56 (53.3%) patients, 28 in each cohort, entered the final analysis. No differences were observed in any of the main clinical outcomes among patients treated with linezolid or glycopeptides: clinical cure [16/28 (57.1%) vs 13/28 (46.4%), P=0.593], 30-day mortality [8/28 (28.6%) vs 12/28 (42.9%), P=0.403], microbiological eradication [22/28 (78.6%) vs 20/28 (71.4%), P=0.758] and median attributable LOS (18.0 vs 17.0 days, P=0.924). Adverse events were similar in both groups. CONCLUSIONS Linezolid and glycopeptides showed similar clinical effectiveness and safety in the treatment of GSEF-BSI. Linezolid could be an alternative to glycopeptides in the treatment of GSEF-BSI.
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Affiliation(s)
- D Echeverria-Esnal
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L Sorli
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - N Prim
- Service of Microbiology, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - D Conde-Estévez
- Service of Pharmacy, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - J P Horcajada
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S Grau
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona, Barcelona, Spain.
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12
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Orihuela-Martín J, Rodríguez-Núñez O, Morata L, Cardozo C, Puerta-Alcalde P, Hernández-Meneses M, Ambrosioni J, Linares L, Bodro M, de Los Angeles Guerrero-León M, Del Río A, Garcia-Vidal C, Almela M, Pitart C, Marco F, Soriano A, Martínez JA. Performance of differential time to positivity as a routine diagnostic test for catheter-related bloodstream infections: a single-centre experience. Clin Microbiol Infect 2019; 26:383.e1-383.e7. [PMID: 31288101 DOI: 10.1016/j.cmi.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/05/2019] [Accepted: 07/01/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the performance of differential time to positivity (DTP) for the diagnosis of catheter-related bloodstream infections (CRBSI). METHODS From all episodes of bloodstream infections (BSI) diagnosed during a 15-year period (2003-17) those in which a paired set of blood cultures drawn from a catheter and a peripheral vein were positive for the same microorganism and had a clinically and/or microbiologically defined source were selected. To assess diagnostic discrimination ability and accuracy of DTP for CRBSI, area under the receiver operating characteristic curves (AUC) and performance characteristics of a DTP ≥2 h were computed. RESULTS A total of 512 BSI were included, of which 302 (59%) were CRBSI. Discrimination ability of DTP was low for Staphylococcus aureus (AUC 0.656 ± 0.06), coagulase-negative staphylococci (AUC 0.618 ± 0.081), enterococci (AUC 0.554 ± 0.117) and non-AmpC-producing Enterobacteriaceae (AUC 0.653 ± 0.053); moderate for Pseudomonas aeruginosa (AUC 0.841 ± 0.073), and high for AmpC-producing Enterobacteriaceae (AUC 0.944 ± 0.039). For the entire sample, DTP had a low-to-moderate discrimination ability (AUC 0.698 ± 0.024). A DTP ≥2 h has a low sensitivity for coagulase-negative staphylococci (60%) and very low for S. aureus (34%), enterococci (40%) and non-AmpC-producing Enterobacteriaceae (42%). A DTP cut-off of 1 h improved sensitivity (90%) for AmpC-producing Enterobacteriaceae. CONCLUSIONS Differential time to positivity performs well for diagnosing CRBSI only when AmpC-producing Enterobacteriaceae and P. aeruginosa are involved. Performance is low for common Gram-positive organisms and non-AmpC-producing enteric bacilli; a negative test should not be used to rule out CRBSI due to these microorganisms. A DTP ≥1 h may improve accuracy for AmpC-producing Enterobacteriaceae, particularly Enterobacter spp.
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Affiliation(s)
- J Orihuela-Martín
- Service of Internal Medicine, Insular University Hospital of Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - O Rodríguez-Núñez
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - L Morata
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - C Cardozo
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - P Puerta-Alcalde
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M Hernández-Meneses
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - J Ambrosioni
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - L Linares
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M Bodro
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M de Los Angeles Guerrero-León
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - A Del Río
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - C Garcia-Vidal
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M Almela
- Service of Microbiology, ISGlobal, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - C Pitart
- Service of Microbiology, ISGlobal, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - F Marco
- Service of Microbiology, ISGlobal, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - A Soriano
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - J A Martínez
- Service of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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13
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Falcone M, Tiseo G, Dentali F, Foglia E, Campanini M, Menichetti F, Mazzone A. Early alert from the microbiology laboratory improves the outcome of elderly patients with Enterococcus spp. bloodstream infection: Results from a multicentre prospective study. J Glob Antimicrob Resist 2019; 18:139-144. [PMID: 30825701 DOI: 10.1016/j.jgar.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/04/2019] [Accepted: 02/19/2019] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES This study describes the clinical features and outcomes of patients with bloodstream infection (BSI) due to Enterococcus spp. and identified factors predictive of mortality. METHODS This analysis is part of a prospective multicentre observational study of consecutive hospitalised patients with BSI conducted from March 2012 to December 2012 in 31 internal medicine wards in Italy. Patients with enterococcal BSI were selected from the entire cohort. Patient characteristics, therapeutic interventions and outcome were reviewed. Cox regression analysis was performed to identify factors associated with in-hospital mortality. Hazard ratios (HRs) and 95% interval confidences (CIs) were calculated. RESULTS Among 533 patients with BSI, 41 (7.7%) had BSI by Enterococcus spp. (28 Enterococcus faecalis, 4 Enterococcus faecium and 3 each of Enterococcus avium, Enterococcus casseliflavus and Enterococcus gallinarum). Six BSIs (14.6%) were polymicrobial. Median (IQR) patient age was 73 (66-85.5) years. In-hospital mortality was 24.4%. Polymicrobial infection (HR = 9.100, 95% CI 1.295-63.949; P = 0.026), age (HR = 1.261, 95% CI 1.029-1.546; P = 0.025) and SOFA score (HR = 1.244, 95% CI 1.051-1.474; P = 0.011) were risk factors for in-hospital mortality. Conversely, receiving an alert from the microbiology laboratory before obtaining final antimicrobial susceptibility results was associated with survival (HR = 0.073, 95% CI 0.007-0.805; P = 0.033). CONCLUSION BSI due to Enterococcus spp. in elderly patients is associated with high mortality. Polymicrobial infection, age and SOFA score are factors associated with poor outcome. Conversely, early alert from the microbiology laboratory improves patient survival.
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Affiliation(s)
- M Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - G Tiseo
- Department of Internal Medicine and Medical Specialties, 'Sapienza' University of Rome, Rome, Italy
| | - F Dentali
- Department of Clinical Medicine, University of Insubria, Varese, Italy
| | - E Foglia
- Centre for Research on Health Economics, Social and Health Care Management (CREMS), University Carlo Cattaneo-LIUC, Castellanza, Italy
| | - M Campanini
- Internal Medicine Ward, Ospedale Maggiore della Carità, Novara, Italy
| | - F Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Mazzone
- Internal Medicine Ward, Ospedale Civile, Legnano, Italy
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14
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Hygienemaßnahmen zur Prävention der Infektion durch Enterokokken mit speziellen Antibiotikaresistenzen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1310-1361. [DOI: 10.1007/s00103-018-2811-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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15
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Poguntke I, Schumacher M, Beyersmann J, Wolkewitz M. Simulation shows undesirable results for competing risks analysis with time-dependent covariates for clinical outcomes. BMC Med Res Methodol 2018; 18:79. [PMID: 30012114 PMCID: PMC6048847 DOI: 10.1186/s12874-018-0535-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 06/27/2018] [Indexed: 11/26/2022] Open
Abstract
Background We evaluate three methods for competing risks analysis with time-dependent covariates in comparison with the corresponding methods with time-independent covariates. Methods We used cause-specific hazard analysis and two summary approaches for in-hospital death: logistic regression and regression of the subdistribution hazard. We analysed real hospital data (n=1864) and considered pneumonia on admission / hospital-acquired pneumonia as time-independent / time-dependent covariates for the competing events ’discharge alive’ and ’in-hospital death’. Several simulation studies with time-constant hazards were conducted. Results All approaches capture the effect of time-independent covariates, whereas the approaches perform differently with time-dependent covariates. The subdistribution approach for time-dependent covariates detected effects in a simulated no-effects setting and provided counter-intuitive effects in other settings. Conclusions The extension of the Fine and Gray model to time-dependent covariates is in general not a helpful synthesis of the cause-specific hazards. Cause-specific hazard analysis and, for uncensored data, the odds ratio are capable of handling competing risks data with time-dependent covariates but the use of the subdistribution approach should be neglected until the problems can be resolved. For general right-censored data, cause-specific hazard analysis is the method of choice. Electronic supplementary material The online version of this article (10.1186/s12874-018-0535-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Inga Poguntke
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, Freiburg, 79104, Germany.
| | - Martin Schumacher
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, Freiburg, 79104, Germany
| | - Jan Beyersmann
- Institute of Statistics, Ulm University, Helmholtzstr. 20, Ulm, 89081, Germany
| | - Martin Wolkewitz
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, Freiburg, 79104, Germany
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16
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Morfin-Otero R, Perez-Gomez HR, Gonzalez-Diaz E, Esparza-Ahumada S, Rodriguez-Noriega E. Enterococci as Increasing Bacteria in Hospitals: Why Are Infection Control Measures Challenging for This Bacteria? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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ICU mortality following ICU-acquired primary bloodstream infections according to the type of pathogen: A prospective cohort study in 937 Germany ICUs (2006-2015). PLoS One 2018. [PMID: 29518133 PMCID: PMC5843291 DOI: 10.1371/journal.pone.0194210] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objective Mortality due to intensive care unit (ICU) acquired primary blood stream infections (PBSI) is related primarily to patient co-morbidities, types of pathogens and quality of care. The objective of this study is to determine the impact of various types of pathogen on ICU mortality. Methods Data from the German National Nosocomial Infection Surveillance System of patients with PBSI from 2006 to 2015 was used for this analysis. A BSI is primary when the pathogen recognized is not related to an infection on another site. Only mono-microbial infections stratified into the 13 pathogens most frequently causing PBSI were considered. Univariate and multivariate risk factor analyses were performed using the following risk factors: Sex, age, length of stay, device use, time until onset of PBSI, type and size of hospital, type of ICU and type of pathogen. ICU mortality following S.aureus PBSI was used as the reference value. Results A total of 4,556,360 patients with 16,978,882 patient days from 937 ICUs were considered in the analysis. Of 14,626 PBSI in total, 12,745 mono-microbial PBSI were included. The ICU mortality was 18.6%. Compared with S.aureus and adjusted by age, sex and type of ICU, S.maltophilia was associated with significantly higher ICU mortality (OR 1.71; 95%CI 1.19–2.47) as followed by Enterococci (OR 1.20; 95%CI 1.06–1.36), E.coli (OR 1.24; 95%CI 1.02–1.49), C.albicans (OR 1.37; 95%CI 1.16–1.61), non albicans Candida spp. (OR 1.49; 95%CI 1.18–1.88) and P.aeruginosa (OR 1.49; 95%CI 1.21–1.84). Coagulase negative Staphylococci were associated with significant lower ICU mortality (OR 0.86; 95%CI 0.75–0.99). Conclusion Because of the limitation of the study in adjusting for severity of illness and appropriateness of therapy, the differences between the pathogens may not only be explained by differences in virulence, but may reflect the prognosis after receiving the microbiological results and may therefore be useful for intensive care physicians.
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18
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Ong DSY, Bonten MJM, Spitoni C, Verduyn Lunel FM, Frencken JF, Horn J, Schultz MJ, van der Poll T, Klein Klouwenberg PMC, Cremer OL. Epidemiology of Multiple Herpes Viremia in Previously Immunocompetent Patients With Septic Shock. Clin Infect Dis 2018; 64:1204-1210. [PMID: 28158551 DOI: 10.1093/cid/cix120] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 02/01/2017] [Indexed: 01/12/2023] Open
Abstract
Background Systemic reactivations of herpesviruses may occur in intensive care unit (ICU) patients, even in those without prior immune deficiency. However, the clinical relevance of these events is uncertain. Methods In this study we selected patients admitted with septic shock and treated for more than 4 days from a prospectively enrolled cohort of consecutive adults in the mixed ICUs of 2 tertiary care hospitals in the Netherlands. We excluded patients who had received antiviral treatment in the week before ICU admission and those with known immunodeficiency. We studied viremia episodes with cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), and varicella zoster virus (VZV) by weekly polymerase chain reaction in plasma. Results Among 329 patients, we observed 399 viremia episodes in 223 (68%) patients. Viremia with CMV, EBV, HHV-6, HSV-1, HSV-2, and VZV was detected in 60 (18%), 157 (48%), 80 (24%), 87 (26%), 13 (4%), and 2 (0.6%) patients, respectively; 112 (34%) patients had multiple concurrent viremia events. Crude mortality in the ICU was 36% in this latter group compared to 19% in remaining patients (P < .01). After adjustment for potential confounders, time-dependent bias, and competing risks, only concurrent CMV and EBV reactivations remained independently associated with increased mortality (adjusted subdistribution hazard ratio, 3.17; 95% confidence interval, 1.41-7.13). Conclusions Herpesvirus reactivations were documented in 68% of septic shock patients without prior immunodeficiency and frequently occurred simultaneously. Concurrent reactivations could be independently associated with mortality. Clinical Trials Registration NCT01905033.
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Affiliation(s)
- David S Y Ong
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cristian Spitoni
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Mathematics, Utrecht University, The Netherlands
| | - Frans M Verduyn Lunel
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jos F Frencken
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Tom van der Poll
- Division of Infectious Diseases & Center of Experimental and Molecular Medicine Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Center for Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Peter M C Klein Klouwenberg
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge: addressing time-varying confounding using appropriate methodology. J Hosp Infect 2017; 99:42-47. [PMID: 29175434 DOI: 10.1016/j.jhin.2017.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/17/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies often ignore time-varying confounding or may use inappropriate methodology to adjust for time-varying confounding. AIM To estimate the effect of intensive care unit (ICU)-acquired bacteraemia on ICU mortality and discharge using appropriate methodology. METHODS Marginal structural models with inverse probability weighting were used to estimate the ICU mortality and discharge associated with ICU-acquired bacteraemia among patients who stayed more than two days at the general ICU of a London teaching hospital and remained bacteraemia-free during those first two days. For comparison, the same associations were evaluated with (i) a conventional Cox model, adjusting only for baseline confounders and (ii) a Cox model adjusting for baseline and time-varying confounders. FINDINGS Using the marginal structural model with inverse probability weighting, bacteraemia was associated with an increase in ICU mortality (cause-specific hazard ratio (CSHR): 1.29; 95% confidence interval (CI): 1.02-1.63) and a decrease in discharge (CSHR: 0.52; 95% CI: 0.45-0.60). By 60 days, among patients still in the ICU after two days and without prior bacteraemia, 8.0% of ICU deaths could be prevented by preventing all ICU-acquired bacteraemia cases. The conventional Cox model adjusting for time-varying confounders gave substantially different results [for ICU mortality, CSHR: 1.08 (95% CI: 0.88-1.32); for discharge, CSHR: 0.68 (95% CI: 0.60-0.77)]. CONCLUSION In this study, even after adjusting for the timing of acquiring bacteraemia and time-varying confounding using inverse probability weighting for marginal structural models, ICU-acquired bacteraemia was associated with a decreased daily ICU discharge risk and an increased risk of ICU mortality.
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Ulrich N, Gastmeier P. Where is the difference between an epidemic and a high endemic level with respect to nosocomial infection control measures? An analysis based on the example of vancomycin-resistant Enterococcus faecium in hematology and oncology departments. GMS HYGIENE AND INFECTION CONTROL 2017; 12:Doc14. [PMID: 28890862 PMCID: PMC5574254 DOI: 10.3205/dgkh000299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Some infection control recommendations distinguish epidemic and endemic levels for infection control. However, it is often difficult to separate long lasting outbreaks from high endemic levels and it remains open, if this distinction is really useful. Aim: To compare infection control measures in endemic and epidemic outbreaks. Methods: The example of vancomycin-resistant Enterococcus faecium outbreaks in haematology or oncology departments was used to analyse differences in infection control measures between outbreaks and high endemic levels. The outbreak database and PubMed, including long lasting outbreaks, were used for this analysis. Two time limits were used for separation: 6 and 12 months. In addition, monoclonal and polyclonal outbreaks were distinguished. Findings: A total of 36 outbreaks were included. 13 outbreaks lasted 6 months or less, 9 outbreaks more than 6 months but at maximum 12 months and 9 more than 12 months. For the remaining outbreaks, no information about their duration was available. Altogether, 11 outbreaks were monoclonal and 20 polyclonal. Considering infection control measures, there were almost no differences between the different groups compared. Patient screening was given up in 37.5% of long lasting outbreaks (>12 months) and hand hygiene not reported in the majority of polyclonal outbreaks (77.8%). Conclusion: Despite many institutions trying to add further infection control measures in case of an outbreak, evidence based infection control measures should be implemented in endemic and epidemic situations. The crucial aspect is probably the degree of implementation and its control in both situations.
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Affiliation(s)
- Nikos Ulrich
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Petra Gastmeier
- Institute for Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
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21
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Strich JR, Palmore TN. Preventing Transmission of Multidrug-Resistant Pathogens in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:535-550. [PMID: 28687211 DOI: 10.1016/j.idc.2017.05.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Infection control in the intensive care unit (ICU) has seen many advances, including rapid molecular screening tests for resistant organisms and chlorhexidine use in daily baths. Although these developments advance the cause of infection prevention, compliance with some of the basic measures remains elusive. Hand hygiene, antimicrobial stewardship, and reduction in device use remain the low-technology interventions that could have a major impact on nosocomial transmission of antimicrobial-resistant organisms. Although continued research is needed on new and old ways of preventing nosocomial infections, ICU staff must persevere in improving adherence with the measures that are known to be effective.
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Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive, MSC 1662, Bethesda, MD 20892-1662, USA
| | - Tara N Palmore
- Hospital Epidemiology Service, National Institutes of Health Clinical Center, 10 Center Drive, MSC 1899, Bethesda, MD 20892-1899, USA.
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22
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Multistate Modeling to Analyze Nosocomial Infection Data: An Introduction and Demonstration. Infect Control Hosp Epidemiol 2017. [PMID: 28633679 DOI: 10.1017/ice.2017.107] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Multistate and competing risks models have become an established and adequate tool with which to quantify determinants and consequences of nosocomial infections. In this tutorial article, we explain and demonstrate the basics of these models to a broader audience of professionals in health care, infection control, and hospital epidemiology. METHODS Using a publicly available data set from a cohort study of intensive care unit patients, we show how hospital infection data can be displayed and explored graphically and how simple formulas are derived under some simplified assumptions for illustrating the basic ideas behind multistate models. Only a few simply accessible values (event counts and patient days) and a pocket calculator are needed to reveal basic insights into cumulative risk and clinical outcomes of nosocomial infection in terms of mortality and length of stay. RESULTS We show how to use these values to perform basic multistate analyses in own data or to correct biased estimates in published data, as these values are often reported. We also show relationships between multistate-based hazard ratios and odds ratios, which are derived from the popular logistic regression model. CONCLUSIONS No sophisticated statistical software is required to apply a basic multistate model and to avoid typical pitfalls such as time-dependent or competing-risks bias. Infect Control Hosp Epidemiol 2017;38:953-959.
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23
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Holloway TL, Nicholson SE, Rani M, Cap AP, Schwacha MG. Toll-like receptor responses are suppressed in trauma ICU patients. J Surg Res 2016; 206:139-145. [PMID: 27916353 DOI: 10.1016/j.jss.2016.06.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/05/2016] [Accepted: 06/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Inflammation and activation of the innate immune system are often associated with traumatic injury and may involve alterations in toll-like receptor (TLR)-mediated responses. METHODS A prospective observational study was designed and conducted. Twenty-one severely injured (ISS = 16-41) trauma intensive care unit (ICU) patients and six healthy volunteers that served as controls were enrolled. Anticoagulated whole blood was collected at 2-12 d after ICU admission and incubated in the presence of media alone (baseline), zymosan (TLR2 agonist) or lipopolysaccharide (LPS; TLR4 agonist) for 3 h. Supernatant levels of inflammatory cytokines (IL-1β, IL-6, IL-10, and TNFα) were determined. RESULTS TLR2-mediated and TLR4-mediated activation of whole blood cell cultures from both healthy volunteers and subjects-induced elevated cytokine levels over that observed in unstimulated cultures. Baseline values of IL-6 were significantly elevated in subject cultures as compared to healthy volunteers. Healthy volunteer cultures had 2-3-fold greater levels of IL-6 and TNFα than subject cultures when stimulated with zymosan (TLR2 agonist) or LPS (TLR4 agonist). IL-1β and IL-10 levels did not differ significantly between healthy volunteers and subjects. CONCLUSIONS The ability of circulating leukocytes from trauma ICU patients to be activated by TLR agonists is markedly suppressed and may play a role in the development of subsequent infectious complications.
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Affiliation(s)
- Travis L Holloway
- Department of Surgery, The University of Texas Health Science Center at San Antonio, Texas
| | - Susannah E Nicholson
- Department of Surgery, The University of Texas Health Science Center at San Antonio, Texas
| | - Meenakshi Rani
- Department of Surgery, The University of Texas Health Science Center at San Antonio, Texas
| | - Andrew P Cap
- Department of Surgery, The University of Texas Health Science Center at San Antonio, Texas; Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Martin G Schwacha
- Department of Surgery, The University of Texas Health Science Center at San Antonio, Texas; Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas.
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24
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Hoogendijk AJ, Wiewel MA, van Vught LA, Scicluna BP, Belkasim-Bohoudi H, Horn J, Zwinderman AH, Klein Klouwenberg PMC, Cremer OL, Bonten MJ, Schultz MJ, van der Poll T. Plasma fractalkine is a sustained marker of disease severity and outcome in sepsis patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:412. [PMID: 26603530 PMCID: PMC4658804 DOI: 10.1186/s13054-015-1125-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 11/03/2015] [Indexed: 12/21/2022]
Abstract
Introduction Fractalkine is a chemokine implicated as a mediator in a variety of inflammatory conditions. Knowledge of fractalkine release in patients presenting with infection to the Intensive Care Unit (ICU) is highly limited. The primary objective of this study was to establish whether plasma fractalkine levels are elevated in sepsis and associate with outcome. The secondary objective was to determine whether fractalkine can assist in the diagnosis of infection upon ICU admission. Methods Fractalkine was measured in 1103 consecutive sepsis patients (including 271 patients with community-acquired pneumonia (CAP)) upon ICU admission and at days 2 and 4 thereafter; in 73 ICU patients treated for suspected CAP in whom this diagnosis was refuted in retrospect; and in 5 healthy humans intravenously injected with endotoxin. Results Compared to healthy volunteers, sepsis patients had strongly elevated fractalkine levels. Fractalkine levels increased with the number of organs failing, were higher in patients presenting with shock, but did not vary by site of infection. Non-survivors had sustained elevated fractalkine levels when compared to survivors. Fractalkine was equally elevated in CAP patients and patients treated for CAP but in whom the diagnosis was retrospectively refuted. Fractalkine release induced by intravenous endotoxin followed highly similar kinetics as the endothelial cell marker E-selectin. Conclusions Plasma fractalkine is an endothelial cell derived biomarker that, while not specific for infection, correlates with disease severity in sepsis patients admitted to the ICU. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1125-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arie J Hoogendijk
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Maryse A Wiewel
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Hakima Belkasim-Bohoudi
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Aeilko H Zwinderman
- Clinical Epidemiology Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Peter M C Klein Klouwenberg
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Marc J Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, G2-130, 1105 AZ, Amsterdam, The Netherlands. .,Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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