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Hatcher JB, de Castro-Abeger A, LaRue RW, Hingorani M, Mawn L, Donahue SP, Sternberg P, Shieh C. MRSA Decolonization and the Eye: A Potential New Tool for Ophthalmologists. Semin Ophthalmol 2022; 37:541-553. [DOI: 10.1080/08820538.2022.2039220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jeremy B Hatcher
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Alex de Castro-Abeger
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Richard W LaRue
- Department of Medicine, Division of Infectious Disease, Vanderbilt Medical Center, Nashville, TN, United States
| | - Melanie Hingorani
- Department of Paediatrics, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Louise Mawn
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sean P Donahue
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Paul Sternberg
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christine Shieh
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
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2
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Zhou Y, Guo Y, Sun X, Ding R, Wang Y, Niu X, Wang J, Deng X. Application of Oleanolic Acid and Its Analogues in Combating Pathogenic Bacteria In Vitro/ Vivo by a Two-Pronged Strategy of β-Lactamases and Hemolysins. ACS OMEGA 2020; 5:11424-11438. [PMID: 32478231 PMCID: PMC7254530 DOI: 10.1021/acsomega.0c00460] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/30/2020] [Indexed: 05/06/2023]
Abstract
The rapid spread of β-lactamase-producing bacteria in clinical practice has increasingly deteriorated the performance of β-lactam antibiotics against such resistant strains. Thus, novel agents or strategies for the war against β-lactamase-producing bacteria, especially hypervirulent resistant bacteria (such as toxin-secreting Staphylococcus aureus) carrying complex β-lactamases, are urgently needed. In this study, we found that the natural compound oleanolic acid (OA) and its analogues (especially corosolic acid (CA)) significantly inhibited the activity of important β-lactamases (NDM-1, KPC-2, and VIM-1) in Enterobacteriaceae and β-lactamases (β-lactamase N1) in S. aureus. The results showed significant synergy with β-lactams against β-lactamase-positive bacteria (fractional inhibitory concentration (FIC) index <0.5). Additionally, OA treatment significantly inhibited the activity of hemolysin from various bacteria. In the mouse infection models, the combined therapy with OA and β-lactams exhibited a significant synergistic effect in the treatment of β-lactamase-producing bacteria, as evidenced by the survival rate of S. aureus- or Escherichia coli-infected mice, which increased from 25.0 to 75.0% or from 44.4 to 61.1% (CA increased to 77.8%), respectively, compared to treatment with individual β-lactams. Although OA treatment alone led to systemic protection against S. aureus-infected mice by directly targeting α-hemolysin (Hla), a relatively better therapeutic effect was observed for the combined therapy. To the best of our knowledge, this study is the first to find effective inhibitors against resistant bacterial infections with a two-pronged strategy by simultaneously targeting resistance enzymes and toxins, which may provide a promising therapeutic strategy for drug-resistant bacterial infections.
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Affiliation(s)
- Yonglin Zhou
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
- Department
of Respiratory Medicine, The First Hospital
of Jilin University, Changchun 130021, Jilin, China
| | - Yan Guo
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
- Department
of Respiratory Medicine, The First Hospital
of Jilin University, Changchun 130021, Jilin, China
| | - Xiaodi Sun
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
| | - Rui Ding
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
| | - Yanling Wang
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
- Qingdao
Vland Biological Limited Co., LTD, Qingdao 266102, Shandong, China
| | - Xiaodi Niu
- Department
of Food Quality and Safety, Jilin University, Changchun 130062, China
| | - Jianfeng Wang
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
- Department
of Respiratory Medicine, The First Hospital
of Jilin University, Changchun 130021, Jilin, China
- . Tel/Fax: +86 431-87836161
| | - Xuming Deng
- Key
Laboratory of Zoonosis Research, Ministry of Education, Institute
of Zoonosis, College of Veterinary Medicine, Jilin University, Changchun 130062, China
- Department
of Respiratory Medicine, The First Hospital
of Jilin University, Changchun 130021, Jilin, China
- . Tel/Fax: +86 431-87836161
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Liu T, Zhang Y, Wan Q. Methicillin-resistant Staphylococcus aureus bacteremia among liver transplant recipients: epidemiology and associated risk factors for morbidity and mortality. Infect Drug Resist 2018; 11:647-658. [PMID: 29765236 PMCID: PMC5939879 DOI: 10.2147/idr.s161180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bacteremia due to Staphylococcus aureus, especially methicillin-resistant S. aureus (MRSA), complicates the clinical course of liver transplantation and is associated with high morbidity and mortality. Intravascular catheters had been reported to be the most frequent source of MRSA bacteremia. Among bacteremic liver recipients, 26.3%-100% of S. aureus were MRSA. Previous studies identified pre-transplant and post-transplant acquired S. aureus carriage, greater severity of liver disease, hepatocellular carcinoma and infection with immuno-modulatory viruses as predictors of S. aureus bacteremia in liver recipients. MRSA bacteremia accompanied by pneumonia and abdominal infections was related to mortality. Vancomycin, as well as daptomycin, is a first-line antibiotic for MRSA bacteremia. The purpose of this review is to better understand the characteristics of MRSA bacteremia by summarizing the epidemiology and antimicrobial resistance of S. aureus, the primary source, and related risk factors for morbidity and mortality of MRSA bacteremia. We have also explored the diagnostic, therapeutic and preventive measures for MRSA bacteremia to improve the outcomes of liver recipients.
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Affiliation(s)
- Taohua Liu
- Department of Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, People’s Republic of China
| | - Yuezhong Zhang
- Department of Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, People’s Republic of China
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital, Central South University, Changsha, People’s Republic of China
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4
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Edmiston CE, Ledeboer NA, Buchan BW, Spencer M, Seabrook GR, Leaper D. Is Staphylococcal Screening and Suppression an Effective Interventional Strategy for Reduction of Surgical Site Infection? Surg Infect (Larchmt) 2016; 17:158-66. [DOI: 10.1089/sur.2015.257] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Charles E. Edmiston
- Departments of Surgery (Vascular), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan A. Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Blake W. Buchan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Gary R. Seabrook
- Departments of Surgery (Vascular), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Leaper
- Infection Prevention Consultants, Boston, Massachusetts
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, United Kingdom
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Kim YJ, Kim SI, Choi JY, Yoon SK, You YK, Kim DG. Clinical significance of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci colonization in liver transplant recipients. Korean J Intern Med 2015; 30:694-704. [PMID: 26354064 PMCID: PMC4578039 DOI: 10.3904/kjim.2015.30.5.694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 03/28/2014] [Accepted: 07/22/2014] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND/AIMS Liver transplant patients are at high risk for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) colonization. We evaluated patients before and after liver transplant using active surveillance culture (ASC) to assess the prevalence of MRSA and VRE and to determine the effect of bacterial colonization on patient outcome. METHODS We performed ASC on 162 liver transplant recipients at the time of transplantation and 7 days posttransplantation to monitor the prevalence of MRSA and VRE. RESULTS A total of 142 patients had both nasal and rectal ASCs. Of these patients, MRSA was isolated from 12 (7.4%) at the time of transplantation (group 1a), 9 (6.9%) acquired MRSA posttransplantation (group 2a), and 121 did not test positive for MRSA at either time (group 3a). Among the three groups, group 1a patients had the highest frequency of developing a MRSA infection (p < 0.01); however, group 2a patients had the highest mortality rate associated with MRSA infection (p = 0.05). Of the 142 patients, VRE colonization was detected in 37 patients (22.8%) at the time of transplantation (group 1b), 21 patients (20%) acquired VRE posttransplantation (group 2b), and 84 patients did not test positive for VRE at either time (group 3b). Among these three groups, group 2b patients had the highest frequency of VRE infections (p < 0.01) and mortality (p = 0.04). CONCLUSIONS Patients that acquired VRE or MRSA posttransplantation had higher mortality rates than did those who were colonized pre-transplantation or those who never acquired the pathogens. Our findings highlight the importance of preventing the acquisition of MRSA and VRE posttransplantation to reduce infections and mortality among liver transplant recipients.
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Affiliation(s)
- Youn Jeong Kim
- Divisions of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sang Il Kim
- Divisions of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Sang Il Kim, M.D. Division of Infectious Disease, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6002 Fax: +82-2-2258-1254 E-mail:
| | - Jong Young Choi
- Divisions of Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Seung Kyu Yoon
- Divisions of Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young-Kyoung You
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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Nair N, Vinod V, Suresh MK, Vijayrajratnam S, Biswas L, Peethambaran R, Vasudevan AK, Biswas R. Amidase, a cell wall hydrolase, elicits protective immunity against Staphylococcus aureus and S. epidermidis. Int J Biol Macromol 2015; 77:314-21. [PMID: 25841371 DOI: 10.1016/j.ijbiomac.2015.03.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 02/08/2023]
Abstract
The morbidity and the mortality associated with Staphylococcus aureus and S. epidermidis infections have greatly increased due to the rapid emergence of highly virulent and antibiotic resistant strains. Development of a vaccine-based therapy is greatly desired. However, no staphylococcal vaccine is available till date. In this study, we have identified Major amidase (Atl-AM) as a prime candidate for future vaccine design against these pathogens. Atl-AM is a multi-functional non-covalently cell wall associated protein which is involved in staphylococcal cell separation after cell division, host extracellular matrix adhesion and biofilm formation. Atl-AM is present on the surface of diverse S. aureus and S. epidermidis strains. When used in combination with Freund's adjuvant, Atl-AM generated a mixed Th1 and Th2 mediated immune response which is skewed more toward Th1; and showed increased production of opsonophagocytic IgG2a and IgG2b antibodies. Significant protective immune response was observed when vaccinated mice were challenged with S. aureus or S. epidermidis. Vaccination prevented the systemic dissemination of both organisms. Our results demonstrate the remarkable efficacy of Atl-AM as a vaccine candidate against both of these pathogens.
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Affiliation(s)
- Nisha Nair
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Vivek Vinod
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Maneesha K Suresh
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Sukhithasri Vijayrajratnam
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Lalitha Biswas
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Reshmi Peethambaran
- Department of Veterinary Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Anil Kumar Vasudevan
- Department of Microbiology, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India
| | - Raja Biswas
- Amrita Center for Nanoscience and Molecular Medicine, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham University, AIMS - Ponekkara, Cochin, Kerala 682041, India.
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7
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Ziakas PD, Pliakos EE, Zervou FN, Knoll BM, Rice LB, Mylonakis E. MRSA and VRE colonization in solid organ transplantation: a meta-analysis of published studies. Am J Transplant 2014; 14:1887-94. [PMID: 25040438 DOI: 10.1111/ajt.12784] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/27/2014] [Accepted: 04/13/2014] [Indexed: 01/25/2023]
Abstract
The burden of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) colonization among the increasing number of solid organ transplant patients has not been systematically explored. We searched PubMed and EMBASE for pertinent articles, performed a meta-analysis of prevalence across eligible studies and estimated the risk of ensuing MRSA or VRE infections relative to colonization status. We stratified effects in the pretransplant and posttransplant period. Twenty-three studies were considered eligible. Seventeen out of 23 (74%) referred to liver transplants. Before transplantation, the pooled prevalence estimate for MRSA and VRE was 8.5% (95% confidence interval [CI] 3.2–15.8) and 11.9% (95% CI 6.8–18.2), respectively. MRSA estimate was influenced by small studies and was lower (4.0%; 95% CI 0.4–10.2) across large studies (>200 patients). After transplantation, the prevalence estimates were 9.4% (95% CI 3.0–18.5) for MRSA and 16.2% (95% CI 10.7–22.6) for VRE. Pretransplant as well as posttransplant MRSA colonization significantly increased the risk for MRSA infections (pooled risk ratio [RR] 5.51; 95% CI 2.36–12.90 and RR 10.56; 95% CI 5.58–19.95, respectively). Pretransplant and posttransplant VRE colonization were also associated with significant risk of VRE infection (RR 6.65; 95% CI 2.54–17.41 and RR 7.93; 95% CI 2.36–26.67, respectively). Solid organ transplantation is a high-risk setting for MRSA and VRE colonization, and carrier state is associated with infection. Upgraded focus in prevention and eradication strategies is warranted.
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8
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 685] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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9
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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10
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Viñuela EF, Mirza DF. Preparation of the patient for liver transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2011. [DOI: 10.1016/s2212-0017(11)60001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Infections associated with neutropenia and transplantation. ANTIBIOTIC AND CHEMOTHERAPY 2010. [PMCID: PMC7148738 DOI: 10.1016/b978-0-7020-4064-1.00040-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Vernadakis S, Saner F, Rath PM, Kaiser G, Mathe Z, Treckmann J, Paul A. Successful salvage therapy with daptomycin after linezolid and vancomycin failure in a liver transplant recipient with methicillin-resistantStaphylococcus aureusendocarditis. Transpl Infect Dis 2009; 11:346-8. [DOI: 10.1111/j.1399-3062.2009.00403.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Coates T, Bax R, Coates A. Nasal decolonization of Staphylococcus aureus with mupirocin: strengths, weaknesses and future prospects. J Antimicrob Chemother 2009; 64:9-15. [PMID: 19451132 PMCID: PMC2692503 DOI: 10.1093/jac/dkp159] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Staphylococcus aureus in the nose is a risk factor for endogenous staphylococcal infection. UK guidelines recommend the use of mupirocin for nasal decolonization in certain groups of patients colonized with methicillin-resistant S. aureus (MRSA). Mupirocin is effective at removing S. aureus from the nose over a few weeks, but relapses are common within several months. There are only a few prospective randomized clinical trials that have been completed with sufficient patients, but those that have been reported suggest that clearance of S. aureus from the nose is beneficial in some patient groups for the reduction in the incidence of nosocomial infections. There is no convincing evidence that mupirocin treatment reduces the incidence of surgical site infection. New antibiotics are needed to decolonize the nose because bacterial resistance to mupirocin is rising, and so it will become less effective. Furthermore, a more bactericidal antibiotic than mupirocin is needed, on the grounds that it might reduce the relapse rate, and so clear the patient of MRSA for a longer period of time than mupirocin.
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Affiliation(s)
- T Coates
- University College London, London, UK.
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14
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Khandavilli S, Wilson P, Cookson B, Cepeda J, Bellingan G, Brown J. Utility of spa typing for investigating the local epidemiology of MRSA on a UK intensive care ward. J Hosp Infect 2009; 71:29-35. [DOI: 10.1016/j.jhin.2008.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 09/12/2008] [Indexed: 12/18/2022]
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15
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Hashimoto M, Sugawara Y, Tamura S, Kaneko J, Matsui Y, Togashi J, Moriya K, Koike K, Makuuchi M. Acquisition of methicillin-resistant Staphylococcus aureus after living donor liver transplantation: a retrospective cohort study. BMC Infect Dis 2008; 8:155. [PMID: 19014465 PMCID: PMC2625350 DOI: 10.1186/1471-2334-8-155] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 11/11/2008] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The incidence and risk factors of methicillin-resistant Staphylococcus aureus (MRSA) acquisition after living donor liver transplantation (LDLT) are unclear. The aim of the present study was to assess the incidence and to analyze the risk factors for the acquisition of MRSA after LDLT in adults by multivariate analysis. METHODS We retrospectively reviewed the data from 158 adult patients that underwent LDLT at the Tokyo University Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the risk factors for postoperative acquisition of MRSA. RESULTS Postoperative MRSA acquisition was detected in 35 of 158 patients by median postoperative day 18. Age (>or= 60 y) and perioperative dialysis and/or apheresis predicted postoperative MRSA acquisition by multivariate analysis. In contrast, postoperative use of fluoroquinolone was negatively associated with acquisition of MRSA. CONCLUSION MRSA arose early after LDLT in adults with a high incidence (35 of 158 patients). Surveillance culture should be checked periodically after LDLT to identify and prevent the transmission of MRSA.
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Affiliation(s)
- Masao Hashimoto
- Artificial Organ and Transplantation Division, Department of Surgery, University of Tokyo, Tokyo, Japan.
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16
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Singh N, Sun HY. Iron overload and unique susceptibility of liver transplant recipients to disseminated disease due to opportunistic pathogens. Liver Transpl 2008; 14:1249-55. [PMID: 18756456 DOI: 10.1002/lt.21587] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The propensity of liver transplant recipients to develop more fulminant disease presentation and a higher risk of disseminated disease due to a number of opportunistic infections, including invasive aspergillosis, cryptococcosis, zygomycosis, may be related to iron overload. Abnormalities in iron homeostasis may also be a contributor to severe manifestations due to other pathogens such as cytomegalovirus and Staphylococcus aureus in liver transplant recipients. Iron is essential not only for microbial pathogenesis, but directly impairs pivotal pathogen specific host defenses. Studies to assess iron homeostasis and the mechanisms by which iron overload contributes to the pathogenesis of opportunistic infections in liver transplant recipients are warranted.
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Affiliation(s)
- Nina Singh
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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17
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Singh N, Wannstedt C, Keyes L, Mayher D, Tickerhoof L, Akoad M, Wagener MM, Frye R, Cacciarelli TV. Hepatic iron content and the risk of Staphylococcus aureus bacteremia in liver transplant recipients. Prog Transplant 2008; 17:332-6. [PMID: 18240700 DOI: 10.1177/152692480701700412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Iron is a critical nutrient source and contributes to staphylococcal pathogenesis. We assessed the role of hepatic explant iron overload as a risk factor for Staphylococcus aureus bacteremia in liver transplant recipients. Seven of 13 cases with S aureus bacteremia (53.8%) had hepatic explant iron concentrations that exceeded normal limits (grade > or = 2). Length of posttransplant intensive care unit stay (P= .013) and hepatocellular carcinoma as underlying liver disease (P = .04), but not hepatic explant iron concentration, correlated with a higher risk of S aureus bacteremia after transplantation. However, noncarriers (patients without S aureus nasal carriage) who developed S aureus bacteremia were more likely to have high hepatic iron content; 4 of 7 (57%) noncarriers with high-grade iron content developed S aureus bacteremia but no noncarriers with low-grade iron content did (P = .07). All noncarriers who became infected had high iron content (grade > or = 2) of the hepatic explant. A readily quantifiable assessment of hepatic iron at the time of transplantation can potentially identify patients without carriage who may be at risk for early S aureus bacteremia.
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Affiliation(s)
- Nina Singh
- Veterans Affairs Healthcare System, Pittsburgh, PA, USA
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18
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Impact of new methicillin-resistant Staphylococcus aureus carriage postoperatively after living donor liver transplantation. Transplant Proc 2008; 39:3271-5. [PMID: 18089369 DOI: 10.1016/j.transproceed.2007.09.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Accepted: 09/13/2007] [Indexed: 01/12/2023]
Abstract
BACKGROUND Preoperative carriage of methicillin-resistant Staphylococcus aureus (MRSA) is associated with an increased risk of MRSA infection after liver transplantation. It is not known, however, whether new MRSA carriage postoperatively also increases the risk of MRSA infection after liver transplantation. METHODS We retrospectively reviewed the data from 242 adult patients who underwent living donor liver transplantation (LDLT) including microbiological and medical records from admission to 3 months after LDLT. Uni and multivariate analyses were performed to identify independent risk factors for postoperative MRSA infection among preoperative noncarriers of MRSA. RESULTS Postoperative MRSA infection occurred in 18 of 219 preoperative noncarriers of MRSA by median postoperative day 26. Operation time of at least 16 hours and postoperative colonization with MRSA independently predicted postoperative MRSA infection. CONCLUSION Postoperative surveillance cultures should be performed periodically after liver transplantation to identify high-risk candidates for postoperative MRSA infection, even among preoperative noncarriers of MRSA.
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Singh N, Wannstedt C, Keyes L, Mayher D, Tickerhoof L, Akoad M, Wagener M, Frye R, Cacciarelli T. Hepatic iron content and the risk ofStaphylococcus aureusbacteremia in liver transplant recipients. Prog Transplant 2007. [DOI: 10.7182/prtr.17.4.b5403660465r1213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Hashimoto M, Sugawara Y, Tamura S, Kaneko J, Matsui Y, Moriya K, Koike K, Makuuchi M. Methicillin-resistant Staphylococcus aureus infection after living-donor liver transplantation in adults. Transpl Infect Dis 2007; 10:110-6. [PMID: 17605737 DOI: 10.1111/j.1399-3062.2007.00253.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) infection frequently complicates the postoperative course in deceased-donor liver transplantation. The incidence and risk factors of MRSA infection after Living-donor Liver transplantation (LDLT), however, are unclear. METHODS We retrospectively reviewed the data from 242 adult patients who underwent LDLT at the University of Tokyo Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the independent risk factors for postoperative MRSA infection. RESULTS Postoperative MRSA infection occurred in 25 of 242 patients by median postoperative day 23. Preoperative MRSA colonization, preoperative use of antimicrobials, operation time (> or =16 h), and postoperative apheresis independently predicted postoperative MRSA infection. CONCLUSION Surveillance culture should be checked periodically after admission to identify patients at high risk for MRSA infection and to administer appropriate antimicrobials for perioperative infection. Postoperative apheresis, suggesting postoperative liver dysfunction, predisposed patients to MRSA infection.
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Affiliation(s)
- M Hashimoto
- Artificial Organ and Transplantation Division, Department of Surgery, University of Tokyo, Tokyo, Japan
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21
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Saner FH, Heuer M, Rath PM, Gensicke J, Radtke A, Drühe N, Rüngeler EM, Nadalin S, Malagó M, Broelsch CE. Successful salvage therapy with tigecycline after linezolid failure in a liver transplant recipient with MRSA pneumonia. Liver Transpl 2006; 12:1689-92. [PMID: 17058251 DOI: 10.1002/lt.20885] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary infections are a significant cause of morbidity and mortality after liver transplantation. Infections with methicillin-resistant Staphylococcus aureus (MRSA) have increased in the last 10 years. Mortality may exceed 80% in liver transplant recipients who develop MRSA pneumonia. A 57-year-old male following living-donor liver transplantation developed a right-sided MRSA pneumonia 6 weeks after transplantation, which required artificial ventilation for 14 weeks. Initially, pneumonia was treated with linezolid. However, after 12 days under current therapy, the infection spread out to both lungs. At that time. we initiated the treatment with tigecycline. Under this therapy, the patient could be cured from MRSA pneumonia and was extubated. We detected no tigecycline related hepatotoxic effect. In conclusion, this case suggests that tigecycline may be useful in the salvage therapy of pneumonia due to MRSA after linezolid failure.
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Affiliation(s)
- Fuat H Saner
- Department of General Surgery and Transplantation, University Essen, Germany.
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22
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Singh N. Infections in solid organ transplant recipients. Curr Opin Infect Dis 2006; 12:365-70. [PMID: 17035801 DOI: 10.1097/00001432-199908000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A disturbing trend in evolution for sometime has culminated in the fact that resistant Gram-positive bacteria including enterococci and staphylococci have emerged as the leading pathogens at many transplant centers. Recently published reports have highlighted the formidable challenge such antimicrobial-resistant microorganisms now pose in transplant recipients. Studies published within the past year have documented the clinical relevance of human herpesvirus-6 after transplantation, as well as the transmission of human herpesvirus-8 by transplanted allograft and the subsequent development of Kaposi's sarcoma in these patients. A novel hepatitis virus has been discovered; studies to elucidate its significance in the transplant setting are underway.
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Affiliation(s)
- N Singh
- Veterans Affairs Medical Center and University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, USA. nis5+@pitt.edu
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23
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Obed A, Schnitzbauer AA, Bein T, Lehn N, Linde HJ, Schlitt HJ. Fatal pneumonia caused by Panton-Valentine Leucocidine-positive methicillin-resistant Staphylococcus aureus (PVL-MRSA) transmitted from a healthy donor in living-donor liver transplantation. Transplantation 2006; 81:121-4. [PMID: 16421487 DOI: 10.1097/01.tp.0000187886.18720.8a] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Severe infections are the most dangerous complications in liver transplantation and their prevention is one of the major goals. A 60-year-old Saudi-Arabian female with decompensated hepatitis C liver cirrhosis received a right-lobe liver graft from her healthy daughter. After 9 days, the patient developed a rapidly progressive necrotizing pneumonia that was fatal in spite of extracorporal lung assist. The pneumonia was due to a Panton-Valentine Leucocidine-positive (PVL) methicillin-resistant Staphylococcus aureus (MRSA), or "community-acquired" MRSA, that had not been detectable in the patient preoperatively. The same strain of PVL-MRSA could be demonstrated in the nares of the asymptomatic donor, but not of other relatives, patients, or medical staff. These findings strongly suggest transmission of PVL-MRSA from the donor to the recipient. This case demonstrates a previously unknown, and potentially fatal, risk in living-donor liver transplantation: transmission of a severe infection from a healthy donor to the recipient.
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Affiliation(s)
- Aiman Obed
- Klinik und Poliklinik für Chirurgie, Universität Regensburg, Regensburg, Germany
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24
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Wertheim HFL, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, Nouwen JL. The role of nasal carriage in Staphylococcus aureus infections. THE LANCET. INFECTIOUS DISEASES 2005; 5:751-62. [PMID: 16310147 DOI: 10.1016/s1473-3099(05)70295-4] [Citation(s) in RCA: 1643] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Staphylococcus aureus is a frequent cause of infections in both the community and hospital. Worldwide, the increasing resistance of this pathogen to various antibiotics complicates treatment of S aureus infections. Effective measures to prevent S aureus infections are therefore urgently needed. It has been shown that nasal carriers of S aureus have an increased risk of acquiring an infection with this pathogen. The nose is the main ecological niche where S aureus resides in human beings, but the determinants of the carrier state are incompletely understood. Eradication of S aureus from nasal carriers prevents infection in specific patient categories-eg, haemodialysis and general surgery patients. However, recent randomised clinical trials in orthopaedic and non-surgical patients failed to show the efficacy of eliminating S aureus from the nose to prevent subsequent infection. Thus we must elucidate the mechanisms behind S aureus nasal carriage and infection to be able to develop new preventive strategies. We present an overview of the current knowledge of the determinants (both human and bacterial) and risks of S aureus nasal carriage. Studies on the population dynamics of S aureus are also summarised.
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Affiliation(s)
- Heiman F L Wertheim
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
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25
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Blair JE, Kusne S. Bacterial, mycobacterial, and protozoal infections after liver transplantation--part I. Liver Transpl 2005; 11:1452-9. [PMID: 16315310 DOI: 10.1002/lt.20624] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Janis E Blair
- Division of Infectious Diseases, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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26
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Woeste G, Zapletal C, Wullstein C, Golling M, Bechstein WO. Influence of methicillin-resistant Staphylococcus aureus carrier status in liver transplant recipients. Transplant Proc 2005; 37:1710-2. [PMID: 15919440 DOI: 10.1016/j.transproceed.2005.03.136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The prevalence of methicillin-resistant Staphylococus aureus (MRSA) has increased worldwide and MRSA has emerged as an important cause of sepsis in cirrhotic patients and liver transplant recipients. In this retrospective study, the prevalence of MRSA colonization and its influence on infections following orthotopic liver transplantation (OLT) was investigated. From August, 2002 until November, 2004, 66 primary cadaver OLT were performed for adult recipients. Antibody induction used Daclizumab (n = 49) or ATG (n = 14). Maintenance immunosuppression consisted of tacrolimus and steroids, with 30 patients receiving mycophenolate mofetil and 4, rapamune. For perioperative anti-infectious prophylaxis cefotaxime, metronidazole, and tobramycin were administered for 48 hours. The preoperatively performed routine swabs revealed MRSA colonization in 12 of 66 (18.2%) patients. The stage of cirrhosis was equivalent for MRSA(-) patients according to Child score. The mean MELD score was significantly higher for MRSA(+) patients (24.3 versus 18.7, P = .036). More MRSA(+) patients were hospitalized at the time of transplantation (14/54 versus 8/12, P = .018). The incidence of posttransplant infections was not significantly different among the two groups. Within the first year 7 of 66 (10.6%) patients died: 3 of 12 (25%) MRSA(+) and 4 of 54 (7.4%) MRSA(-). The 1-year survival was lower in the MRSA(+) group (74.1% versus 94.1%). In conclusion, this study did not show that an MRSA-positive carrier status implies an increased risk for septic complications following OLT. Mortality was increased for MRSA(+), but failed to show a significant difference. A significantly higher MELD score and pretransplant hospitalization for MRSA(+) patients may contribute to the higher mortality and reflect sicker patients.
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Affiliation(s)
- G Woeste
- Department of Surgery, Johann Wolfgang Goethe-University Frankfurt, Frankfurt am Main, Germany.
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27
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Rouse MS, Rotger M, Piper KE, Steckelberg JM, Scholz M, Andrews J, Patel R. In vitro and in vivo evaluations of the activities of lauric acid monoester formulations against Staphylococcus aureus. Antimicrob Agents Chemother 2005; 49:3187-91. [PMID: 16048923 PMCID: PMC1196268 DOI: 10.1128/aac.49.8.3187-3191.2005] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Due to increasing mupirocin resistance, alternatives for Staphylococcus aureus nasal decolonization are needed. Lauric acid monoesters combined with lactic, mandelic, malic, or benzoic acid are being evaluated as possible alternatives. We determined the in vitro activity of 13 lauric acid monoester (LAM) formulations and mupirocin against 30 methicillin-susceptible S. aureus (MSSA) isolates and 30 methicillin-resistant S. aureus (MRSA) isolates. We then used a murine model of MRSA nasopharyngeal colonization to compare the in vivo activity of mupirocin with three LAM formulations. MSSA and MRSA MIC(90) values were 0.25 microg/ml for mupirocin and </=4 microl/ml for all LAM formulations tested. Hsd:ICR mice were challenged with 10(8) CFU/naris MRSA. Five days later, S. aureus colonization was documented by culture. Treatment with bland, mupirocin, or one of three LAM ointments was then administered unblinded thrice daily for 2 days. Three days after treatment, both anterior nares were cultured for S. aureus. Administration of 128774-49E or 128774-53A was associated with greater eradication of MRSA carriage (24/34 [71%] or 33/40 [83%]) of animals, respectively) than bland ointment (12/38 [32%]) (P < 0.005). 128774-53A administration resulted in greater MRSA carriage eradication than mupirocin (19/38 [50%]) (P < 0.005) in this model. LAM formulations warrant evaluation for S. aureus nasal decolonization in humans.
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Affiliation(s)
- Mark S Rouse
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, USA
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28
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Rotger M, Trampuz A, Piper KE, Steckelberg JM, Patel R. Phenotypic and genotypic mupirocin resistance among Staphylococci causing prosthetic joint infection. J Clin Microbiol 2005; 43:4266-8. [PMID: 16081996 PMCID: PMC1234000 DOI: 10.1128/jcm.43.8.4266-4268.2005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Mupirocin MICs and mupA presence were determined in 108 staphylococci causing prosthetic joint infection. Zero of 35 isolates (0%) of methicillin-susceptible Staphylococcus aureus, 4/15 (27%) methicillin-resistant S. aureus isolates, 3/16 (19%) methicillin-susceptible coagulase-negative staphylococci, and 11/42 (26%) methicillin-resistant coagulase-negative staphylococci were mupirocin resistant. mupA was detected in all five high-level mupirocin-resistant staphylococci and one mupirocin-susceptible staphylococcus.
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Affiliation(s)
- Margalida Rotger
- Division of Infectious Diseases, Department of Internal Medicine, Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Andrej Trampuz
- Division of Infectious Diseases, Department of Internal Medicine, Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Kerryl E. Piper
- Division of Infectious Diseases, Department of Internal Medicine, Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - James M. Steckelberg
- Division of Infectious Diseases, Department of Internal Medicine, Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Robin Patel
- Division of Infectious Diseases, Department of Internal Medicine, Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota
- Corresponding author. Mailing address: Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905. Phone: (507) 255-6482. Fax: (507) 284-9066. E-mail:
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29
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Bert F, Bellier C, Lassel L, Lefranc V, Durand F, Belghiti J, Mentré F, Fantin B. Risk factors for Staphylococcus aureus infection in liver transplant recipients. Liver Transpl 2005; 11:1093-9. [PMID: 16123951 DOI: 10.1002/lt.20491] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Staphylococcus aureus is the leading cause of bacterial infection in liver transplant recipients. Preoperative nasal carriage of methicillin-resistant S. aureus (MRSA) is associated with a high risk of infection. We conducted a retrospective cohort study in order to identify independent risk factors for early-onset S. aureus infection after liver transplantation. Patients were screened preoperatively for methicillin-susceptible S. aureus (MSSA) and MRSA nasal carriage. Risk factor analysis was performed by univariate analysis followed by stepwise logistic regression. Of the 323 patients included, 63 (19.5%) patients developed S. aureus infection (36 MRSA, 27 MSSA) within 1 month of surgery. Variables significantly associated with infection in the univariate analysis were MRSA and MSSA nasal carriage, alcoholic cirrhosis, absence of hepatocellular carcinoma, decreased prothrombin ratio, and presence of ascites. In the multivariate analysis, MRSA carriage (odds ratio [OR]: 20.9, P < 0.0001), MSSA carriage (OR: 3.4, P = 0.0004), alcoholic cirrhosis (OR: 2.4, P = 0.01) and decreased prothrombin ratio (OR: 1.2, P = 0.01) were independent predictors of infection. Molecular typing showed that the infecting isolate was identical to the isolate from the nose in most patients. In conclusion, preoperative nasal carriage of MRSA and MSSA is an independent risk factor for S. aureus infection in liver transplant recipients. The infection is most often of endogenous origin. Alcoholic cirrhosis and the severity of liver failure are also associated with a high risk of infection.
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Affiliation(s)
- Frédéric Bert
- Services de Microbiologie, Hôpital Beaujon, Clichy, France.
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30
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Schuenck RP, Dadalti P, Silva MG, Fonseca LS, Santos KRN. Oxacillin- and mupirocin-resistant Staphylococcus aureus: in vitro activity of silver sulphadiazine and cerium nitrate in hospital strains. J Chemother 2005; 16:453-8. [PMID: 15565911 DOI: 10.1179/joc.2004.16.5.453] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Nasal carriage is an important reservoir of oxacillin-resistant Staphylococcus aureus (ORSA). Mupirocin is a topical drug used to remove S. aureus from nares. However, isolates resistant to mupirocin have been reported all over the world. Silver sulphadiazine (SSD) is a topical agent, which when associated with cerium nitrate (CN), has been shown to be useful in the treatment of burn infections and could be an alternative drug for patient decolonization. Susceptibility to oxacillin in 203 S. aureus isolates was evaluated by the agar diffusion test, while the agar diffusion and agar dilution methods were used for mupirocin. A PCR-multiplex method was performed to detect the mecA and ileS-2 genes. Minimum inhibitory concentration (MICs) to SSD and CN, used alone or in association, were determined by the agar dilution method. One hundred and sixty-three (80.3%) strains were oxacillin-resistant, and 37 (18.2%) were mupirocin resistant. The MIC of SSD alone or in association with CN was 64 microg/mL, while for CN alone was 2048 microg/mL for all isolates. SSD presented anti-staphylococcal activity at concentrations (64 microg/mL) much lower than those commonly used in commercial preparations (10 mg/g) and had good activity against mupirocin-resistant strains, showing that this drug could be used for nasal decolonization in ORSA carries.
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Affiliation(s)
- R P Schuenck
- Institute of Microbiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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31
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Santoro-Lopes G, de Gouvêa EF, Monteiro RCM, Branco RC, Rocco JR, Halpern M, Ferreira ALP, de Araújo EGP, Basto ST, Silveira VG, Ribeiro-Filho J. Colonization with methicillin-resistant Staphylococcus aureus after liver transplantation. Liver Transpl 2005; 11:203-9. [PMID: 15666377 DOI: 10.1002/lt.20338] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of infection after orthotopic liver transplantation (OLT). Colonization with MRSA is associated with a higher risk of infection. Previous studies have shown a high prevalence of MRSA colonization among OLT candidates. However, the risk of colonization with MRSA after OLT is still unclear. The objective of this study was to estimate the incidence and the factors associated with colonization with MRSA after OLT. This was a prospective cohort study including patients submitted to OLT between the years 2000 and 2002. Surveillance cultures of nasal swab specimens were performed within the 1st 72 hours of hospital admission and, subsequently, on weeks 2, 6, 13, and 26. Patients whose baseline cultures revealed nasal carriage of MRSA were excluded. A total of 60 patients were included in the study. The median follow-up was 72 days. A total of 9 patients (15%) became colonized. In multiple logistic regression analyses, the use of a urinary catheter for > or =5 days (P = .006), postoperative bleeding at the surgical site (P = .009), and preoperative use of fluoroquinolones (P = .08) were associated with a higher risk of colonization. Patients without any of these risk factors did not become colonized. In conclusion, nasal carriage of MRSA is frequently acquired after OLT. Periodic postoperative screening for MRSA carriage should be an integral component in programs designed to reduce nosocomial MRSA transmission in these patients. Further studies are needed to set up and validate a predictive model that could allow targeting postoperative screening to high-risk OLT recipients.
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Affiliation(s)
- Guilherme Santoro-Lopes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
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32
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Desai D, Desai N, Nightingale P, Elliott T, Neuberger J. Carriage of methicillin-resistant Staphylococcus aureus is associated with an increased risk of infection after liver transplantation. Liver Transpl 2003; 9:754-9. [PMID: 12827565 DOI: 10.1053/jlts.2003.50142] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of sepsis in patients with cirrhosis and after liver transplantation. The association between nasal carriage of MRSA and sepsis in these patients is unclear. The goal of this study was to investigate the relationship between MRSA carriage before liver transplantation and subsequent sepsis after transplantation. This was a retrospective study of 374 consecutive adults who underwent orthotopic liver transplantation between 1998 and 2001 and for whom full data were available. Of these, 157 had been screened for MRSA as part of a study assessing the prevalence of MRSA infection. All MRSA carriers were treated with nasal mupirocin and chlorhexidine baths. The records of MRSA carriers and noncarriers were analyzed for Child and Model for End-Stage Liver Disease (MELD) score, posttransplantation MRSA, and other infections and mortality. Of the 157 patients who had an MRSA screen, 35 patients were MRSA nasal carriers. These carriers had significantly greater MELD score (mean, 16.2 compared with 13.1; P =.02) and Child scores (mean, 10 versus 9; P =.001) than noncarriers. The incidence of posttransplantation MRSA infection was significantly higher in MRSA carriers (31% versus 9%; P =.002). The incidence of other posttransplantation infection was not significantly different in the two groups. There was no significant difference in survival between the two groups (1-year patient survival, 74% and 82%, respectively). Patients carrying MRSA are predisposed to an increased risk of sepsis after liver transplantation with a trend to increased mortality. Screening for MRSA should be considered in high-risk patients being assessed for liver transplantation.
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Affiliation(s)
- Devendra Desai
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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33
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Kokai-Kun JF, Walsh SM, Chanturiya T, Mond JJ. Lysostaphin cream eradicates Staphylococcus aureus nasal colonization in a cotton rat model. Antimicrob Agents Chemother 2003; 47:1589-97. [PMID: 12709327 PMCID: PMC153340 DOI: 10.1128/aac.47.5.1589-1597.2003] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The anterior nares are a primary ecologic niche for Staphylococcus aureus, and nasal colonization by this opportunistic pathogen increases the risk of development of S. aureus infection. Clearance of S. aureus nasal colonization greatly reduces this risk. Mupirocin ointment is the current standard of care for clearance of S. aureus nasal colonization, but resistance to this antibiotic is emerging. Lysostaphin is a glycylglycine endopeptidase which specifically cleaves the cross-linking pentaglycine bridges in the cell walls of staphylococci. Lysostaphin is extremely staphylocidal (MIC at which 90% of isolates are inhibited, 0.001 to 0.064 micro g/ml) and rapidly lyses both actively growing and quiescent S. aureus. This study demonstrates that a single application of 0.5% lysostaphin (actual dose, approximately 150 micro g of lysostaphin), formulated in a petrolatum-based cream, dramatically reduces S. aureus nasal colonization in 100% of animals tested and eradicates S. aureus nasal colonization in 93% of animals in a cotton rat model. A single dose of lysostaphin cream is more effective than a single dose of mupirocin ointment in eradicating S. aureus nasal colonization in this animal model. The lantibiotic peptide nisin, which has potent in vitro antistaphylococcal activity, was ineffective in reducing staphylococcal nasal carriage in this model. Nasal colonization was not reduced after three treatments with 5% nisin ( approximately 1,500 micro g/dose) in any of the treated animals. Lysostaphin formulated in cream may prove to be a superior alternative to mupirocin ointment for clearance of S. aureus nasal colonization.
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34
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Paterson DL, Rihs JD, Squier C, Gayowski T, Sagnimeni A, Singh N. Lack of efficacy of mupirocin in the prevention of infections with Staphylococcus aureus in liver transplant recipients and candidates. Transplantation 2003; 75:194-8. [PMID: 12548122 DOI: 10.1097/01.tp.0000040602.01701.85] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infections with Staphylococcus aureus are a significant problem in patients in liver transplant units. An association between prior nasal carriage with and subsequent infections has been documented previously in liver transplant recipients and patients with cirrhosis. However, the role of decolonization with mupirocin applied intranasally for the prevention of S. aureus infections in these patients has not been determined. METHODS S. aureus nasal carriage was prospectively sought in 70 consecutive liver transplant candidates. Mupirocin two times per day for 5 days was administered to the carriers. Follow-up nasal cultures to document decolonization were performed 5 days after the final application of mupirocin. The primary endpoint was the development of S. aureus infections. RESULTS Thirty-one of 70 patients (44%) were found to be nasal carriers and 27 of 31 nasal carriers (87%) were successfully decolonized. However, 12 of 27 patients (37%) successfully decolonized became recolonized with S. aureus, and an additional nine patients who were initially noncarriers became newly colonized with S. aureus during the study period. Despite the use of mupirocin, 16 of 70 patients (23%) developed an infection with S. aureus. No isolate was found to be mupirocin resistant. CONCLUSION Elimination of S. aureus nasal carriage by mupirocin did not prevent S. aureus infections in patients in our liver transplant unit.
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Affiliation(s)
- David L Paterson
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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35
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Squier C, Rihs JD, Risa KJ, Sagnimeni A, Wagener MM, Stout J, Muder RR, Singh N. Staphylococcus aureus rectal carriage and its association with infections in patients in a surgical intensive care unit and a liver transplant unit. Infect Control Hosp Epidemiol 2003; 23:495-501. [PMID: 12269445 DOI: 10.1086/502095] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The role of rectal carriage of Staphylococcus aureus as a risk factor for nosocomial S. aureus infections in critically ill patients has not been fully discerned. METHODS Nasal and rectal swabs for S. aureus were obtained on admission and weekly thereafter until discharge or death from 204 consecutive patients admitted to the surgical intensive care unit and liver transplant unit RESULTS Overall, 49.5% (101 of 204) of the patients never harbored S. aureus, 21.6% (44 of 204) were nasal carriers only, 3.4% (7 of 204) were rectal carriers only, and 25.5% (52 of 204) were both nasal and rectal carriers. Infections due to S. aureus developed in 15.7% (32 of 204) of the patients; these included 3% (3 of 101) of the non-carriers, 18.2% (8 of 44) of the nasal carriers only, 0% (0 of 7) of the rectal carriers only, and 40.4% (21 of 52) of the patients who were both nasal and rectal carriers (P - .001). Patients with both rectal and nasal carriage were significantly more likely to develop S. aureus infection than were those with nasal carriage only (odds ratio, 3.9; 95% confidence interval, 1.18 to 7.85; P= .025). By pulsed-field gel electrophoresis, the infecting rectal and nasal isolates were clonally identical in 82% (14 of 17) of the patients with S. aureus infections. CONCLUSIONS Rectal carriage represents an underappreciated reservoir for S. aureus in patients in the intensive care unit and liver transplant recipients. Rectal plus nasal carriage may portend a greater risk for S. aureus infections in these patients than currently realized.
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Affiliation(s)
- Cheryl Squier
- Veterans Affairs Medical Center, Infectious Disease Section, Pittsburgh, PA 15240, USA
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36
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Avery RK. Recipient screening prior to solid-organ transplantation. Clin Infect Dis 2002; 35:1513-9. [PMID: 12471571 DOI: 10.1086/344777] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2002] [Accepted: 08/13/2002] [Indexed: 12/15/2022] Open
Abstract
Screening a potential transplant recipient for infectious diseases is an important component of the transplantation process. Such screening may lead to the discovery and treatment of occult active infection, may help determine posttransplant prophylactic strategies, or may disqualify the recipient from receiving a transplant. The pretransplant period also affords an opportunity for updating vaccination status and providing education regarding the reduction of posttransplant infectious risks. The present brief review will outline the investigation of preexisting active infection, as well as latent bacterial, mycobacterial, fungal, parasitic, and viral infections. Recommendations for pretransplant immunization and education are provided.
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Affiliation(s)
- Robin K Avery
- Department of Infectious Diseases and Transplant Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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37
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Losada I, Cuervas-Mons V, Millán I, Dámaso D. [Early infection in liver transplant recipients: incidence, severity, risk factors and antibiotic sensitivity of bacterial isolates]. Enferm Infecc Microbiol Clin 2002; 20:422-30. [PMID: 12425875 DOI: 10.1016/s0213-005x(02)72837-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To conduct a descriptive study with an analysis of risk factors for early infection in liver transplant patients, and to determine the resistance of the bacteria involved. PATIENTS AND METHODS The study included 149 liver transplant recipients. All cases of infection occurring 0-90 days after transplantation were considered early infection. Pre-, intra- and postoperative variables were analyzed, and isolated microorganisms were studied. Selective bowel decontamination with quinolones, and perioperative and antifungal prophylaxis were carried out in all patients. RESULTS The incidence of infection was 73.1%: bacterial (49.7%), viral (35.5%), fungal (10.1%) and mixed (4.5%). In the first postoperative month the most frequent infections were bacterial and in the second and third months, viral (p = 0.001). Multivariate analysis of risk factors identified the following: days of parenteral nutrition, duration of surgery > 5 hours, rejection and CMV seronegative status. Among 1278 cultures, the following microorganisms were isolated: 77.9% gram-positive cocci (GP) and 19% aerobic gram-negative bacilli (GNB). Sensitivity of Staphylococcus to vancomycin was 99.6-100% and to teicoplanin 97.9-100%. VAN resistance was observed in 1.2% of E. faecalis and 4.5% of E. faecium. Among S. aureus strains, 68.7% were MRSA. The resistance rate of GNB to quinolones was 38.8%. CONCLUSIONS Incidence of infection was higher the first 30 days after transplantation, with bacterial infection predominating. Duration of surgery > 5 hours was the most important risk factor for acquiring bacterial infection. GP were the most frequently isolated bacteria. Empirical treatment of early bacterial infection should include vancomycin or teicoplanin. Selective bowel decontamination resulted in a low incidence of GNB infections, among which there was 38.8% resistance to quinolones.
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Affiliation(s)
- Isabel Losada
- Servicio de Microbiología. Complexo Hospitalario Juan Canalejo de A Coruña. España.
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38
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Dupeyron C, Campillo SB, Mangeney N, Richardet JP, Leluan G. Carriage of Staphylococcus aureus and of gram-negative bacilli resistant to third-generation cephalosporins in cirrhotic patients: a prospective assessment of hospital-acquired infections. Infect Control Hosp Epidemiol 2001; 22:427-32. [PMID: 11583211 DOI: 10.1086/501929] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To study the relation between Staphylococcus aureus nasal and stool colonization, stool carriage of gram-negative bacilli resistant to third-generation cephalosporins (CephR), and subsequent infections during hospitalization. DESIGN Prospective study. PATIENTS 551 cirrhotic patients with 589 consecutive hospital stays. All patients were screened within 48 hours of admission; 589 nasal swabs, 417 stool specimens, and 589 urine samples were analyzed. RESULTS Carriage rates were 18.8% for methicillin-sensitive S aureus (MSSA), 16.3% for methicillin-resistant S aureus (MRSA), and 13.7% for CephR. We observed 87 episodes of spontaneous bacterial peritonitis, 63 cases of bacteremia, and 167 urinary tract infections occurred. Only 1 case of bacteremia and 4 urinary tract infections due to CephR occurred in patients carrying the same organism in their stools. The risk of MRSA ascitic fluid infections, bacteremia, and urinary tract infections was 3.1% versus 1% (not significant), 8.3% versus 0.8% (P<.001), and 11.4% versus 0.6% (P<.001) in carriers and noncarriers, respectively. Pulsed-field gel electrophoresis (PFGE) of isolates from 16 patients infected by MSSA (3 cases) and MRSA (13 cases) demonstrated that the colonizing strains matched the invasive strains in the 3 MSSA cases and in 8 of 13 MRSA cases. CONCLUSION Carriage of CephR strains is not associated with subsequent infection by these organisms in hospitalized cirrhotic patients. In contrast, MRSA carriage was an important risk factor for MRSA bacteremia and urinary tract infection.
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Affiliation(s)
- C Dupeyron
- Laboratoire de Bactériologie, Hopital Albert Chenevier, Créteil, France
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39
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Abstract
In addition to the net state of immunosuppression, the risk of infection after transplantation is largely determined by the transplant recipient's epidemiologic exposures. Potential sources of infection in the transplant recipient include the environment and the recipient's endogenous flora. This article presents aspects of prevention of infection after solid-organ transplantation such as avoidance of epidemiologic exposures, antibacterial prophylaxis, prophylaxis for tuberculin-positive transplant recipients, and prophylaxis against infections with Pneumocystis carinii and Toxoplasma gondii.
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Affiliation(s)
- R Soave
- Division of Infectious Diseases, Weill Medical College of Cornell University, New York, NY 10021, USA.
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40
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Singh N. Recent Advances in the Management of Infections in Liver Transplant Recipients. Curr Infect Dis Rep 2001; 3:123-130. [PMID: 11286652 DOI: 10.1007/s11908-996-0034-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Antimicrobial-resistant bacteria (vancomycin-resistant enterococci and Staphylococcus aureus) have emerged as leading pathogens in liver transplant recipients. Liver transplant recipients have also been shown to be uniquely more susceptible to harboring extended-spectrum beta-lactamase-producing Enterobacteriaceae. The frequency of mycelial fungal infections has increased; however, effective prophylaxis and management of these infections remains suboptimal. Emerging reports have highlighted the morbidity due to novel herpesviruses in these patients. Finally, the emergence of ganciclovir resistance in cytomegalovirus has implications relevant for all solid organ transplant recipients.
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Affiliation(s)
- Nina Singh
- VA Medical Center, Infectious Disease Section, University Drive C, Pittsburgh, PA 15240, USA
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41
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Rubinovitch B, Pittet D. Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned? J Hosp Infect 2001; 47:9-18. [PMID: 11161895 DOI: 10.1053/jhin.2000.0873] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Control of methicillin-resistant Staphylococcus aureus (MRSA) still generates controversy among infection control practitioners. Opponents claim that once MRSA becomes endemic in an institution, control efforts are no longer justified. This review examines the usefulness, feasibility and cost-effectiveness of control programmes in acute-care hospitals where eradication of MRSA has either failed or has never been attempted; hence, the pathogen has become endemic. High endemicity is associated with increased hospital-acquired infection rates, increased use of glycopeptides and subsequent risk of emergence of antibiotic-resistant Gram-positive bacteria, and additional healthcare costs. Thus, MRSA control has many advantages. Indeed, in many institutions the actual benefit of containment efforts was manifested through the resultant decrease in the incidence of hospital-acquired MRSA infections. Successful programmes are based on an early identification of the MRSA reservoir and prompt implementation of contact precautions. The most efficacious strategy to detect occult MRSA carriage is via the screening of high-risk patients on admission to the hospital which has proven to be cost-effective in varied acute-care endemic settings.
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Affiliation(s)
- B Rubinovitch
- Infection Control Programme, University of Geneva Hospitals, Geneva, Switzerland
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42
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Singh N, Gayowski T, Rihs JD, Wagener MM, Marino IR. Evolving trends in multiple-antibiotic-resistant bacteria in liver transplant recipients: a longitudinal study of antimicrobial susceptibility patterns. Liver Transpl 2001; 7:22-6. [PMID: 11150417 DOI: 10.1053/jlts.2001.20769] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence, sources, impact on outcome, and temporal trends in multiple-antibiotic-resistant bacteria in liver transplant recipients over the last decade (from 1990 through 1999) were assessed. Of 165 consecutive patients who underwent transplantation, 31% (51 of 165 patients) had at least 1 infection caused by multiple-antibiotic-resistant bacteria. Overall, 69% (66 of 96 infections) of all bacterial infections were multiple-antibiotic resistant. Ninety-one percent (45 of 49 isolates) of the Staphylococcus aureus isolates, 50% (6 of 12 isolates) of the enterococci, and 54% of the gram-negative bacteria (47%; 7 of 15 Pseudomonas aeruginosa, and 60%; 12 of 20 Enterobacteriaceae) were multiple-antibiotic resistant. A significant trend toward an increase in infections caused by multiple-antibiotic-resistant bacteria (P =.003), largely caused by an increase in gram-positive infections, was documented through the decade. There was a significant increase in infections caused by methicillin-resistant S aureus (P =.0001) and vancomycin-resistant enterococci (P =.04) over time. The proportion of gram-negative isolates that were multiple-antibiotic resistant (P =.447) did not increase significantly over time. However, a strikingly high frequency of resistance to piperacillin or ceftazidime suggests that extended-spectrum beta-lactamase production in our Enterobacteriaceae may have been more prevalent than realized. Mortality at 1 year was significantly greater in patients with multiple-antibiotic resistant bacteria compared with all other patients (P =.001). These longitudinal trends have implications not only for guiding therapeutic practices, but ultimately for devising strategies to curtail multiple-antibiotic resistance in liver transplant recipients.
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Affiliation(s)
- N Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, PA 15240, USA. nis+@pitt.edu
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43
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Bert F, Galdbart JO, Zarrouk V, Le Mée J, Durand F, Mentré F, Belghiti J, Lambert-Zechovsky N, Fantin B. Association between nasal carriage of Staphylococcus aureus and infection in liver transplant recipients. Clin Infect Dis 2000; 31:1295-9. [PMID: 11073769 DOI: 10.1086/317469] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We reviewed the records of 87 patients who underwent liver transplantation and who were screened by use of nasal swabs on the day before surgery. Twenty-four patients harbored methicillin-susceptible Staphylococcus aureus (MSSA), and 8 harbored methicillin-resistant S. aureus (MRSA). MSSA infection occurred in 3 (12.5%) of 24 MSSA carriers and in 2 (3.2%) of 63 noncarriers (nonsignificant). In contrast, MRSA infection occurred more frequently in MRSA carriers (7 [87.5%] of 8) than in MRSA noncarriers (8 [10.1%] of 79; P<.001). Nasal carriage of MRSA is associated with a very high risk of MRSA infection in liver transplant recipients.
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Affiliation(s)
- F Bert
- Hôpital Beaujon, Service de Microbiologie, Clichy, France
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44
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Abstract
The spectrum of major infections after transplantation has undergone a striking evolution. The epidemiologic trends in infectious diseases through the last decade have been most notable for a dramatic decrease in the incidence of several opportunistic infections, largely because of advances in prophylaxis against these pathogens. Paralleling these trends has been an exponential rise in the proportion of infections caused by antimicrobial-resistant bacteria. These multiresistant organisms have now emerged as leading pathogens at many transplant centers, and their management is a daunting challenge.
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Affiliation(s)
- N Singh
- Infectious Disease Section, Veterans Affairs Medical Center, Pittsburgh, Pennsylvania, USA
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