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Alnimr A. Carbapenem resistance in Enterobacterales: Predicting clinical outcomes in bloodstream infections. Indian J Med Microbiol 2024; 52:100728. [PMID: 39216688 DOI: 10.1016/j.ijmmb.2024.100728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/26/2024] [Accepted: 08/29/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Carbapenem-resistant Enterobacterales (CRE) are a global concern due to their high mortality rates and limited therapeutics. CRE-caused bloodstream infections (BSIs) are challenging to manage, especially in healthcare settings. This study aimed to investigate the predictors of mortality in BSI patients caused by CRE. METHODS A single center prospective study to examine the characteristics of BSI caused by CRE in a large academic hospital over 15 months. The main outcomes were microbiological characteristics and clinical outcomes of patients at 28 days based on a step-wise regression analysis. RESULTS A total of 76 episodes of BSI due to CRE were included. The study found that the most common type of carbapenemase was OXA-48 (69.7 %, n = 53), followed by the co-existence of OXA-48 and MBL (26.3 %, n = 20), with Klebsiella pneumoniae being the most common (90 %, n = 69). Patients with OXA-48-BSI were more likely to have a urinary source of infection, while patients with MBL-BSI were more likely to have a non-urinary source of infection. All cases (100 %) had medical devices. Around 30.3 % of patients received effective empirical treatment, while 61.8 % received adequate therapy at 48 h. The overall mortality rate was 42.1 % (n = 32), and the main predictors of mortality in this study were the presence of sepsis and inadequate initial therapy, while age >65 predicted mortality in the linear regression but not the stepwise regression model. CONCLUSION CRE-BSIs are a serious health threat. The study highlights the need for preventive strategies focused on high-risk patients and proper device management to reduce BSI.
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Affiliation(s)
- Amani Alnimr
- Department of Medical Microbiology, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box 2114, Dammam, 31451, Kingdom of Saudi Arabia.
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Qin J, Wang Z, Xu H, Li Y, Zhou J, Yaxier N, Wang C, Fu P. IncX3 plasmid-mediated spread of blaNDM gene in Enterobacteriaceae among children in China. J Glob Antimicrob Resist 2024; 37:199-207. [PMID: 38641225 DOI: 10.1016/j.jgar.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVES The blaNDM gene was prevalent among children and became the predominant cause of severe infection in infants and children. This study aimed to investigate the epidemiology and molecular characteristics of blaNDM in Enterobacteriaceae among children in China. METHODS Carbapenem-resistant Enterobacteriaceae (CRE) were collected in the Children's Hospital of Fudan University from January 2016 to December 2022. Five carbapenemase genes (blaKPC, blaNDM, blaVIM, blaIMP, blaOXA-48) were screened by PCR method. Multilocus sequence typing (MLST) was conducted for phylogenetic analyses. blaNDM-carrying plasmids were typed by PCR-based Incompatibility (Inc) typing method. Moreover, plasmid comparison was performed with 213 publicly available IncX3 plasmids. RESULTS A total of 330 CRE strains were enrolled, 96.4% of which carried carbapenemase genes. blaNDM gene accounted for 64.8% (214 strains) and included four variants, including blaNDM-1 (59.8%), blaNDM-5 (39.3%), blaNDM-7 (0.5%), and blaNDM-9 (0.5%). There were no predominant MLST lineages of blaNDM carrying strains. IncX3 was the major plasmid carrying blaNDM-1 (68.0%) and blaNDM-5 (72.6%) and was dominant in blaNDM-Klebsiella penumoniae (79.8%), blaNDM-Escherichia coli (58.2%), and blaNDM-Enterobacter cloacae (61.0%), respectively. Most (79.0%) clinical IncX3 plasmids in the world carried blaNDM, and the prevalence of blaNDM in IncX3 plasmids was more common in China (95.8%) than other countries (58.1%, P <0.01). CONCLUSION blaNDM is highly prevalent in CRE among children in China. The spread of blaNDM was mainly mediated by IncX3 plasmids. Surveillance and infection control on the spread of blaNDM among children are important.
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Affiliation(s)
- Jie Qin
- Lab of Microbiology, Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Zixuan Wang
- Department of Infectious Diseases, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Huihui Xu
- Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Yijia Li
- Lab of Microbiology, Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Jinlan Zhou
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Nijiati Yaxier
- Orthopedics Department, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China
| | - Chuanqing Wang
- Lab of Microbiology, Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China; Nosocomial Infection Control Department, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China.
| | - Pan Fu
- Lab of Microbiology, Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China; Nosocomial Infection Control Department, Children's Hospital of Fudan University, National Children's Medical Centre, Shanghai, China.
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Russo A, Fusco P, Morrone HL, Trecarichi EM, Torti C. New advances in management and treatment of multidrug-resistant Klebsiella pneumoniae. Expert Rev Anti Infect Ther 2023; 21:41-55. [PMID: 36416713 DOI: 10.1080/14787210.2023.2151435] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The management of multidrug-resistant (MDR) Klebsiella pneumoniae (KP) represents a major challenge in the field of infectious diseases. It is associated with a high rate of nosocomial infections with a mortality rate that reaches approximately 50%, even when using an effective antimicrobial therapy. Therefore, combined actions addressing infection control and antibiotic stewardship are required to delay the emergence of resistance. Since new antimicrobial agents targeting MDR-GNB bacteria have been produced during the last years and are now available for physicians to treat MDR, it is fundamental to choose appropriate antimicrobial therapy for K. pneumoniae infection. AREAS COVERED The PubMed database was searched to review the most significant recent literature on the topic, including data from articles coming from endemic areas and from the current European and American Guidelines. EXPERT OPINION We explore the most effective strategies for prevention of MDR-KP spread and the currently available treatment options, focusing on comparing old strategies and new compounds. We reviewed data concerning newly developed drugs that could play an important role in the future; we also propose a treatment algorithm that could be useful for physicians in daily clinical practice.
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Affiliation(s)
- Alessandro Russo
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Paolo Fusco
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Helen Linda Morrone
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Enrico Maria Trecarichi
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
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Paul M, Carrara E, Retamar P, Tängdén T, Bitterman R, Bonomo RA, de Waele J, Daikos GL, Akova M, Harbarth S, Pulcini C, Garnacho-Montero J, Seme K, Tumbarello M, Lindemann PC, Gandra S, Yu Y, Bassetti M, Mouton JW, Tacconelli E, Baño JR. European Society of clinical microbiology and infectious diseases (ESCMID) guidelines for the treatment of infections caused by Multidrug-resistant Gram-negative bacilli (endorsed by ESICM -European Society of intensive care Medicine). Clin Microbiol Infect 2021; 28:521-547. [PMID: 34923128 DOI: 10.1016/j.cmi.2021.11.025] [Citation(s) in RCA: 365] [Impact Index Per Article: 121.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
SCOPE These ESCMID guidelines address the targeted antibiotic treatment of 3rd generation cephalosporin-resistant Enterobacterales (3GCephRE) and carbapenem-resistant Gram-negative bacteria, focusing on the effectiveness of individual antibiotics and on combination vs. monotherapy. METHODS An expert panel was convened by ESCMID. A systematic review was performed including randomized controlled trials and observational studies, examining different antibiotic treatment regimens for the targeted treatment of infections caused by the 3GCephRE, carbapenem-resistant Enterobacterales (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumanni (CRAB). Treatments were classified as head-to-head comparisons between individual antibiotics and monotherapy vs. combination therapy regimens, including defined monotherapy and combination regimens only. The primary outcome was all-cause mortality, preferably at 30 days and secondary outcomes included clinical failure, microbiological failure, development of resistance, relapse/recurrence, adverse events and length of hospital stay. The last search of all databases was conducted in December 2019, followed by a focused search for relevant studies up until ECCMID 2021. Data were summarized narratively. The certainty of the evidence for each comparison between antibiotics and between monotherapy vs. combination therapy regimens was classified by the GRADE recommendations. The strength of the recommendations for or against treatments was classified as strong or conditional (weak). RECOMMENDATIONS The guideline panel reviewed the evidence per pathogen, preferably per site of infection, critically appraising the existing studies. Many of the comparisons were addressed in small observational studies at high risk of bias only. Notably, there was very little evidence on the effects of the new, recently approved, beta-lactam beta-lactamase inhibitors on infections caused by carbapenem-resistant Gram-negative bacteria. Most recommendations are based on very-low and low certainty evidence. A high value was placed on antibiotic stewardship considerations in all recommendations, searching for carbapenem-sparing options for 3GCephRE and limiting the recommendations of the new antibiotics for severe infections, as defined by the sepsis-3 criteria. Research needs are addressed.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Pilar Retamar
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Roni Bitterman
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Robert A Bonomo
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Medical Service, Research Service, and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA;; VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, OH, USA
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - George L Daikos
- First Department of Medicine, National and Kapodistrian University of Athens
| | - Murat Akova
- Hacettepe University School of Medicine, Department Of Infectious Diseases, Ankara, Turkey
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Celine Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | | | - Katja Seme
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Italy
| | | | - Sumanth Gandra
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of Microbial Technology and Bioinformatics of Zhejiang Province, Hangzhou, China; Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy; Clinica Malattie Infettive, San Martino Policlinico Hospital, Genoa, Italy
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany; German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany.
| | - Jesus Rodriguez Baño
- Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena/ Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
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Trimethoprim-sulfamethoxazole as de-escalation in ventilator-associated pneumonia: a cohort study subanalysis. Eur J Clin Microbiol Infect Dis 2021; 40:1511-1516. [PMID: 33625621 PMCID: PMC7902240 DOI: 10.1007/s10096-021-04184-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/03/2021] [Indexed: 12/19/2022]
Abstract
Purpose This is a subanalysis of a previous study which compared the effectiveness of trimetoprim-sulfametoxazole (TMP-SMX) with all other regimens for treatment of ventilator-associated pneumonia (VAP). Aim of the current study was to focus on the effectiveness of a strategy based on TMP-SMX as de-escalation from β-lactam including regimens. Methods Retrospective cohort study including patients who were hospitalized for VAP from 2011 to 2019. Patients were distributed in two groups: NO SWITCH TO TMP-SMX group, including patients who received β-lactams for all treatment duration, and SWITCH TO TMP-SMX group, which included patients who switched to TMP-SMX from a β-lactam including regimen after microbiology diagnosis. Three clinical outcomes were analyzed: mortality at 30 days from the start of the antibiotic treatment (T30), mortality at the end of treatment (EoT), and acquisition of multidrug-resistant bacteria during hospitalization in intensive care unit. Results Overall, 70 patients were included in the current study, 32/70 (45.7%) in NO SWITCH TO TMP-SMX group and 38/70 (54.3%) in SWITCH TO TMP-SMX group, 37/70 (52.8%) had been already included in the previous study. No significant differences in clinical outcomes and patient’s characteristics were found when the two groups were compared. Conclusions De-escalation to TMP-SMX for VAP treatment was not associated with higher mortality at EoT and T30 than standard treatment with β-lactam. Monotherapy with TMP-SMX as de-escalation from broad-spectrum empirical regimens is a β-lactam sparing strategy worthy to be further investigated in either multicenter cohort studies or randomized clinical trials.
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Chambers HF, Evans SR, Patel R, Cross HR, Harris AD, Doi Y, Boucher HW, van Duin D, Tsalik EL, Holland TL, Pettigrew MM, Tamma PD, Hodges KR, Souli M, Fowler VG. Antibacterial Resistance Leadership Group 2.0 - Back to Business. Clin Infect Dis 2021; 73:730-739. [PMID: 33588438 DOI: 10.1093/cid/ciab141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Indexed: 11/12/2022] Open
Abstract
In December 2019, the Antibacterial Resistance Leadership Group (ARLG) was awarded funding for another seven-year cycle to support a clinical research network on antibacterial resistance. ARLG 2.0 has three overarching research priorities: (1) infections caused by antibiotic resistant (AR) Gram-negative bacteria; (2) infections caused by AR Gram-positive bacteria, and (3) diagnostic tests to optimize use of antibiotics. To support the next generation of AR researchers, the ARLG offers three mentoring opportunities: the ARLG Fellowship, Early Stage Investigator Seed Grants, and the Trialists in Training Program. The purpose of this article is to update the scientific community on the progress made in the original funding period and to encourage submission of clinical research that addresses one or more of the research priority areas of ARLG 2.0.
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Affiliation(s)
- Henry F Chambers
- Division of HIV, Infectious Diseases, and Global Medicine Zuckerberg San Francisco General Hospital University of California San Francisco, California, USA
| | - Scott R Evans
- Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington DC, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester Minnesota, USA
| | - Heather R Cross
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health University of Maryland School of Medicine; Baltimore, Maryland, USA
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ephraim L Tsalik
- Emergency Medicine Service, Durham VA Health Care System, Durham, North Carolina, USA.,Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas L Holland
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Melinda M Pettigrew
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Maria Souli
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vance G Fowler
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Gajdács M, Ábrók M, Lázár A, Jánvári L, Tóth Á, Terhes G, Burián K. Detection of VIM, NDM and OXA-48 producing carbapenem resistant Enterobacterales among clinical isolates in Southern Hungary. Acta Microbiol Immunol Hung 2020; 67:209-215. [PMID: 33258795 DOI: 10.1556/030.2020.01181] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023]
Abstract
Infections caused by carbapenem-resistant Enterobacterales (CRE) present an important therapeutic problem, as there are limited number of effective therapeutic alternatives available. In this study, phenotypic and genotypic methods were used to characterize carbapenemase-production and other resistance-determinants (AmpC and ESBL-production, efflux pump-overexpression) in 50 isolates (Klebsiella spp. n = 35, Escherichia coli n = 12 and Enterobacter cloacae complex n = 3) collected at the Albert Szent-Györgyi Clinical Center (University of Szeged) between 2014 and 2017. Minimum inhibitory concentrations of meropenem, sulfamethoxazole/trimethoprim, tigecycline, amikacin, moxifloxacin, colistin and fosfomycin were also determined. 24% of isolates were AmpC-producers, while 30% carried blaCTX-M ESBL-genes. Carbapenemase-genes were detected in 18 (36%) of the tested isolates: in 2 isolates blaNDM, in 6 isolates blaOXA-48-like and in 12 isolates, blaVIM was detected by PCR. The species-distribution for isolates positive for carbapenemase-genes was the following: Klebsiella pneumoniae n = 11, Klebsiella oxytoca n = 1, E. coli n = 5, E. cloacae complex n = 1. Efflux pump-overexpression based on the PAβN-screening agar was shown in n = 3 of the tested strains. In nine isolates (18%), carbapenemase and ESBL-genes were detected simultaneously. Highest levels of resistance were noted for fosfomycin (74%) and moxifloxacin (70%), while all isolates were susceptible to colistin. Among applied phenotypic tests in this study the modified carbapenem inactivation method (mCIM) proved to be the most accurate one compared to that of PCR results.
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Affiliation(s)
- Márió Gajdács
- 1Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, Eötvös utca 6., 6720 Szeged, Hungary
| | - Marianna Ábrók
- 2Institute of Clinical Microbiology, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis utca 6., 6725 Szeged, Hungary
| | - Andrea Lázár
- 2Institute of Clinical Microbiology, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis utca 6., 6725 Szeged, Hungary
| | - Laura Jánvári
- 3Department of Bacteriology, Mycology and Parasitology, National Public Health Centre, Albert Flórián út 2-6., 1097 Budapest, Hungary
| | - Ákos Tóth
- 3Department of Bacteriology, Mycology and Parasitology, National Public Health Centre, Albert Flórián út 2-6., 1097 Budapest, Hungary
| | - Gabriella Terhes
- 3Department of Bacteriology, Mycology and Parasitology, National Public Health Centre, Albert Flórián út 2-6., 1097 Budapest, Hungary
| | - Katalin Burián
- 2Institute of Clinical Microbiology, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis utca 6., 6725 Szeged, Hungary
- 4Department of Medical Microbiology and Immunobiology, Faculty of Medicine, University of Szeged, Dóm tér 10., 6720 Szeged, Hungary
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Abbott IJ, Roberts JA, Meletiadis J, Peleg AY. Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections. Expert Rev Anti Infect Ther 2020; 19:271-295. [PMID: 32820686 DOI: 10.1080/14787210.2020.1813567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment. AREAS COVERED Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response. EXPERT OPINION The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Haidari, Greece
| | - Anton Y Peleg
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia
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Hughes S, Gilchrist M, Heard K, Hamilton R, Sneddon J. Treating infections caused by carbapenemase-producing Enterobacterales (CPE): a pragmatic approach to antimicrobial stewardship on behalf of the UKCPA Pharmacy Infection Network (PIN). JAC Antimicrob Resist 2020; 2:dlaa075. [PMID: 34223030 PMCID: PMC8210165 DOI: 10.1093/jacamr/dlaa075] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The emergence of carbapenemase-producing Enterobacterales (CPE) as a major cause of invasive infection both within the UK and internationally poses a very real concern for all providers of healthcare. The burden of morbidity and mortality associated with CPE infections is well described. The need for early, targeted, effective and safe antimicrobial therapy remains key for the management of these infected patients yet reliable antimicrobial treatment options remain scarce. In the absence of a universal treatment for these CPE invasive infections, individual treatment options tailored to susceptibilities and severity of infection are required. This working group from within the UK Clinical Pharmacy Association (UKCPA) Pharmacy Infection Network has developed evidence-based treatment recommendations to support infection specialists in managing these complex infections. A systematic review of peer-reviewed research was performed and analysed. We report consensus recommendations for the management of CPE-associated infections. The national expert panel makes therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, dosing, dosage adjustment and monitoring of parameters for novel and established antimicrobial therapies with CPE activity. This manuscript provides the infection specialist with pragmatic and evidence-based options for the management of CPE infections.
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Affiliation(s)
- Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Katie Heard
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Ryan Hamilton
- School of Pharmacy, De Montfort University, Leicester LE2 7DP, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, 50 West Nile Street, Glasgow G1 2NP, UK
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Bassetti M, Peghin M. How to manage KPC infections. Ther Adv Infect Dis 2020; 7:2049936120912049. [PMID: 32489663 PMCID: PMC7238785 DOI: 10.1177/2049936120912049] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 01/31/2020] [Indexed: 11/16/2022] Open
Abstract
Carbapenemase-producing Enterobacteriaceae represent an increasing global threat worldwide and Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas. Risk stratification and rapid diagnostics laboratory workflows are of paramount importance and indication for therapy of KPC-KP infection must be individualized according to the baseline characteristics of the patient and severity of infection. The optimal treatment of infection because of KPC-KP organisms is uncertain and antibiotic options are limited. The knowledge of the patient's pathophysiology, infection site, and application of the pharmacokinetic/pharmacodynamic principles on the basis of minimum inhibitory concentration (MIC) has progressively gained major relevance. Combination therapies including high-dose meropenem, colistin, fosfomycin, tigecycline, and aminoglycosides are widely used, with suboptimal results. In the past few years, new antimicrobials targeting KPC-KP have been developed and are now at various stages of clinical research. However, their optimal use should be guaranteed in the long term for delaying, as much as possible, the emergence of resistance. Strict infection control measures remain necessary. The aim of this review is to discuss the challenges in the management and treatment of patients with infections because KPC-KP and provide an expert opinion.
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Affiliation(s)
- Matteo Bassetti
- Clinica Malattie Infettive, Azienda Ospedaliero-Universitaria "Santa Maria della Misericordia", Piazzale S. Maria della Misericordia, n. 15, Udine, 33100, Italy
| | - Maddalena Peghin
- Department of Medicine, Infectious Diseases Clinic, University of Udine and Azienda Sanitaria Universitaria, Integrata di Udine, Udine, Italy
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Surleac M, Czobor Barbu I, Paraschiv S, Popa LI, Gheorghe I, Marutescu L, Popa M, Sarbu I, Talapan D, Nita M, Iancu AV, Arbune M, Manole A, Nicolescu S, Sandulescu O, Streinu-Cercel A, Otelea D, Chifiriuc MC. Whole genome sequencing snapshot of multi-drug resistant Klebsiella pneumoniae strains from hospitals and receiving wastewater treatment plants in Southern Romania. PLoS One 2020; 15:e0228079. [PMID: 31999747 PMCID: PMC6992004 DOI: 10.1371/journal.pone.0228079] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023] Open
Abstract
We report on the genomic characterization of 47 multi-drug resistant, carbapenem resistant and ESBL-producing K. pneumoniae isolates from the influent (I) and effluent (E) of three wastewater treatment plants (WWTPs) and from Romanian hospital units which are discharging the wastewater in the sampled WWTPs. The K. pneumoniae whole genome sequences were analyzed for antibiotic resistance genes (ARGs), virulence genes and sequence types (STs) in order to compare their distribution in C, I and E samples. Both clinical and environmental samples harbored prevalent and widely distributed ESBL genes, i.e. blaSHV, blaOXA, blaTEM and blaCTX M. The most prevalent carbapenemase genes were blaNDM-1, blaOXA-48 and blaKPC-2. They were found in all types of isolates, while blaOXA-162, a rare blaOXA-48 variant, was found exclusively in water samples. A higher diversity of carbapenemases genes was seen in wastewater isolates. The aminoglycoside modifying enzymes (AME) genes found in all types of samples were aac(6’), ant(2'')Ia, aph(3'), aaD, aac(3) and aph(6). Quinolone resistance gene qnrS1 and the multi-drug resistance oqxA/B pump gene were found in all samples, while qnrD and qnrB were associated to aquatic isolates. The antiseptics resistance gene qacEdelta1 was found in all samples, while qacE was detected exclusively in the clinical ones. Trimethroprim-sulfamethoxazole (dfrA, sul1 and sul2), tetracyclines (tetA and tetD) and fosfomycin (fosA6, known to be located on a transpozon) resistance genes were found in all samples, while for choramphenicol and macrolides some ARGs were detected in all samples (catA1 and catB3 / mphA), while other (catA2, cmIA5 and aac(6’)Ib / mphE and msrE) only in wastewater samples. The rifampin resistance genes arr2 and 3 (both carried by class I integrons) were detected only in water samples. The highly prevalent ARGs preferentially associating with aquatic versus clinical samples could ascribe potential markers for the aquatic (blaSHV-145, qacEdelta1, sul1, aadA1, aadA2) and clinical (blaOXA-1, blaSHV-106,blaTEM-150, aac(3)Iia, dfrA14, oqxA10; oqxB17,catB3, tetD) reservoirs of AR. Moreover, some ARGs (oqxA10; blaSHV-145; blaSHV-100, aac(6')Il, aph(3')VI, armA, arr2, cmlA5, blaCMY-4, mphE, msrE, oqxB13, blaOXA-10) showing decreased prevalence in influent versus effluent wastewater samples could be used as markers for the efficiency of the WWTPs in eliminating AR bacteria and ARGs. The highest number of virulence genes (75) was recorded for the I samples, while for E and C samples it was reduced to half. The most prevalent belong to three functional groups: adherence (fim genes), iron acquisition (ent, fep, fyu, irp and ybt genes) and the secretion system (omp genes). However, none of the genes associated with hypervirulent K. pneumoniae have been found. A total of 14 STs were identified. The most prevalent clones were ST101, ST219 in clinical samples and ST258, ST395 in aquatic isolates. These STs were also the most frequently associated with integrons. ST45 and ST485 were exclusively associated with I samples, ST11, ST35, ST364 with E and ST1564 with C samples. The less frequent ST17 and ST307 aquatic isolates harbored blaOXA-162, which was co-expressed in our strains with blaCTX-M-15 and blaOXA-1.
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Affiliation(s)
- Marius Surleac
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
- Institute of Biochemistry, Romanian Academy, Bucharest, Romania
| | - Ilda Czobor Barbu
- The Research Institute of the University of Bucharest, Bucharest, Romania
| | - Simona Paraschiv
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
| | - Laura Ioana Popa
- The Research Institute of the University of Bucharest, Bucharest, Romania
- Department of Botany and Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
- The National Institute of Research and Development for Biological Sciences, Bucharest, Romania
| | - Irina Gheorghe
- The Research Institute of the University of Bucharest, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Luminita Marutescu
- The Research Institute of the University of Bucharest, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Marcela Popa
- The Research Institute of the University of Bucharest, Bucharest, Romania
| | - Ionela Sarbu
- The Research Institute of the University of Bucharest, Bucharest, Romania
- Department of Genetics, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Daniela Talapan
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
| | - Mihai Nita
- National Institute for R & D in Industrial Ecology (ECOIND), Bucharest, Romania
| | - Alina Viorica Iancu
- Infectious Diseases Hospital Galati, Galati, Romania
- Faculty of Medicine and Pharmacy “Dunarea de Jos”, University of Galati, Galati, Romania
| | - Manuela Arbune
- Infectious Diseases Hospital Galati, Galati, Romania
- Faculty of Medicine and Pharmacy “Dunarea de Jos”, University of Galati, Galati, Romania
| | - Alina Manole
- Department of Botany and Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | | | - Oana Sandulescu
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Adrian Streinu-Cercel
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Dan Otelea
- National Institute for Infectious Diseases ‘Matei Bals’, Bucharest, Romania
- * E-mail:
| | - Mariana Carmen Chifiriuc
- The Research Institute of the University of Bucharest, Bucharest, Romania
- Department of Botany and Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
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Bandali A, Bias TE. Trimethoprim-sulfamethoxazole for the treatment of carbapenem-resistantEnterobacteriaceae(CRE) infections. Infect Dis (Lond) 2019; 51:456-458. [DOI: 10.1080/23744235.2019.1580384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Aiman Bandali
- Pharmacy Department, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Tiffany E. Bias
- Pharmacy Department, Hahnemann University Hospital, Philadelphia, PA, USA
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