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Bush K. Past, present, and future perspectives on aztreonam and avibactam. Expert Rev Anti Infect Ther 2025; 23:277-290. [PMID: 40011051 DOI: 10.1080/14787210.2025.2473047] [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: 11/11/2024] [Revised: 02/13/2025] [Accepted: 02/20/2025] [Indexed: 02/28/2025]
Abstract
INTRODUCTION Aztreonam is a monobactam antibiotic approved in 1986 to treat infections caused by aerobic Gram-negative bacteria, but, together with cephalosporins, lost clinical utility due to the emergence of extended-spectrum β-lactamases (ESBLs) and novel (serine) carbapenemases. Avibactam was the first in a novel non-β-lactam β-lactamase inhibitor class to effectively inhibit these enzymes. It has been approved in combination with ceftazidime to treat Gram-negative infections caused by bacteria that produce AmpC, ESBLs and serine carbapenemases, and with aztreonam to treat patients infected with metallo-β-lactamase-producing enteric bacteria. Combinations of avibactam with ceftazidime and/or aztreonam have been used successfully to treat enteric pathogens producing multiple classes of β-lactamases. AREAS COVERED Development of aztreonam, avibactam, and avibactam combinations are placed into a historical perspective, based on both preclinical and clinical data. A search of MEDLINE (Ovid) was used to identify relevant literature. EXPERT OPINION Avibactam combined with ceftazidime and aztreonam in either dual or triple combinations provides the opportunity to treat previously untreatable Gram-negative infections that produce multiple β-lactamases. Aztreonam combinations should be particularly attractive, due to stability to metallo-β-lactamase hydrolysis and its safety advantage in treating penicillin-allergic patients. Other inhibitor combinations in development may challenge these combinations.
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Affiliation(s)
- Karen Bush
- Biology Department, Indiana University, Bloomington, IN, USA
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2
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Everard C, Schampaert A, Doyen L, Verbelen V, Marot JC, Wieërs G. Intravenous cefuroxime as a first-line treatment for women hospitalized for pyelonephritis. JAC Antimicrob Resist 2024; 6:dlae071. [PMID: 38716400 PMCID: PMC11073747 DOI: 10.1093/jacamr/dlae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/15/2024] [Indexed: 06/29/2024] Open
Abstract
Background Empirical treatment of pyelonephritis in the emergency ward includes broad-spectrum antibiotics. Such a strategy favours broad-spectrum antibiotic overuse. Local antibiotic stewardship teams can propose local recommendations to adapt empirical antibiotic treatment devoted to spare precious molecules that remain active on MDR bacteria, such as fluoroquinolones or other broad-spectrum antibiotics. Objectives We aimed to evaluate the incidence of urinary tract infection recurrence within 3 months after hospital discharge following empirical antibiotic therapy with cefuroxime in women with pyelonephritis in the emergency room. Patients and methods We conducted a retrospective, single-centre study. We identified 109 women treated for pyelonephritis, 95 with cefuroxime at any time, and 14 with only other antibiotics, and divided them into subgroups based on antibiotic switch to other molecules. We compared the incidence of urinary tract infection recurrence in the subgroups. Results In the group of patients treated with cefuroxime only, we identified five cases of recurrence (9.4%) in a total of 53 patients, but only 1 (1.9%) case of recurrence associated with the same uropathogen. No significant difference in clinical outcome, length of antibiotic treatment, or urinary tract infection recurrence was observed between the subgroups. Conclusions Our study supports that a strategy elaborated by an antibiotic stewardship team based on local ecology and aimed at proposing the narrowest-spectrum antibiotic upon treatment initiation in the emergency room is safe.
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Affiliation(s)
- Céline Everard
- Service of Internal Medicine, Clinique Saint-Pierre, Ottignies, Belgium
| | - Axelle Schampaert
- Service of Internal Medicine, Clinique Saint-Pierre, Ottignies, Belgium
| | - Louise Doyen
- Service of Internal Medicine, Clinique Saint-Pierre, Ottignies, Belgium
| | - Valérie Verbelen
- Service of Microbiology, Clinique Saint Pierre, Ottignies, Belgium
| | | | - Grégoire Wieërs
- Service of Internal Medicine, Clinique Saint-Pierre, Ottignies, Belgium
- Faculty of Medicine, Department of Medicine, URPC, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Muller AE, De Winter BCM, Koch BCP. Towards optimizing cefepime/tazobactam (WCK 4282) exposure to achieve efficacy against piperacillin/tazobactam-resistant ESBL infections: dose recommendations for various renal functions, including intermittent haemodialysis, in healthy individuals. J Antimicrob Chemother 2024; 79:1093-1100. [PMID: 38507250 DOI: 10.1093/jac/dkae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/29/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES WCK 4282 is a novel combination of cefepime 2 g and tazobactam 2 g being developed for the treatment of infections caused by piperacillin/tazobactam-resistant ESBL infections. The dosing regimen for cefepime/tazobactam needs to be optimized to generate adequate exposures to treat infections caused by ESBL-producing pathogens resistant to both cefepime and piperacillin/tazobactam. METHODS We developed pharmacokinetic population models of cefepime and tazobactam to evaluate the optimal dose adjustments in patients, including those with augmented renal clearance as well as various degrees of renal impairment, and also for those on intermittent haemodialysis. Optimal doses for various degrees of renal function were identified by determining the PTA for a range of MICs. To cover ESBL-producing pathogens with an cefepime/tazobactam MIC of 16 mg/L, a dosing regimen of 2 g q8h infused over 1.5 h resulted in a combined PTA of 99% for the mean murine 1 log10-kill target for the cefepime/tazobactam combination. RESULTS We found that to adjust for renal function, doses need to be reduced to 1 g q8h, 500 mg q8h and 500 mg q12h for patients with CLCR of 30-59, 15-29 and 8-14 mL/min (as well as patients with intermittent haemodialysis), respectively. In patients with high to augmented CLR (estimated CLCR 120-180 mL/min), a prolonged 4 h infusion of standard dose is required. CONCLUSIONS The suggested dosing regimens will result in exposures of cefepime and tazobactam that would be adequate for infections caused by ESBL-producing pathogens with a cefepime/tazobactam MICs up to 16 mg/L.
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Affiliation(s)
- Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), Rotterdam, The Netherlands
| | - Brenda C M De Winter
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
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Petit M, Bidar F, Fosse Q, Lefevre L, Paul M, Urbina T, Masi P, Bavozet F, Lemarié J, de Montmollin E, Andriamifidy-Berti C, Dessajan J, Zuber B, Zafrani L, Peju E, Meng P, Charrier L, Le Guennec L, Simon M, Luyt CE, Haudebourg L, Geri G. Antibiotic definitive treatment in ventilator associated pneumonia caused by AmpC-producing Enterobacterales in critically ill patients: a prospective multicenter observational study. Crit Care 2024; 28:40. [PMID: 38317262 PMCID: PMC10845500 DOI: 10.1186/s13054-024-04820-7] [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: 11/07/2023] [Accepted: 01/28/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Ventilator associated pneumonia (VAP) due to wild-type AmpC-producing Enterobacterales (wtAE) is frequent in intensive care unit (ICU) patients. Despite a low level of evidence, definitive antimicrobial therapy (AMT) with third generation cephalosporins (3GCs) or piperacillin is discouraged. METHODS Observational prospective study including consecutive wtAE VAP patients in 20 French ICUs. The primary objective was to assess the association of the choice of definitive AMT, i.e. piperacillin ± tazobactam (PTZ), 3GCs or other molecule (4GCs, carbapenems, quinolones, cotrimoxazole; control group), with treatment success at day-7. Recurrence of infection was collected as a secondary outcome, and analyzed accounting for the competing risk of death. RESULTS From February 2021 to June 2022, 274 patients were included. Enterobacter cloacae was the most prevalent specie (31%). Seventy-eight patients (28%) had PTZ as definitive AMT while 44 (16%) had 3GCs and 152 (56%) were classified in the control group. Day-7 success rate was similar between the 3 groups (74% vs. 73% vs. 68% respectively, p = 0.814). Recurrence probability at day-28 was 31% (95% CI 21-42), 40% (95% CI 26-55) and 21% (95% CI 15-28) for PTZ, 3GCs and control groups (p = 0.020). In multivariable analysis, choice of definitive AMT was not associated with clinical success, but definitive AMT with 3GCs was associated with recurrence at day-28 [csHR(95%CI) 10.9 (1.92-61.91)]. CONCLUSION Choice of definitive antimicrobial therapy was not associated with treatment success at day 7. However, recurrence of pneumonia at day-28 was higher in patients treated with third generation cephalosporins with no differences in mortality or mechanical ventilation duration.
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, APHP, UMR 1018, CESP Villejuif, 9, Avenue Charles de Gaulle, Boulogne-Billancourt, France.
| | - Frank Bidar
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Quentin Fosse
- AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles-Site André Mignot, Le Chesnay, France
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 94010, Créteil, France
| | | | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes, France
| | - Etienne de Montmollin
- INSERM UMR 1137, 75018, Department of Intensive Care Medicine, APHP, Bichat-Claude Bernard University Hospital, Université Paris Cité, 75018, Paris, France
| | - Chloé Andriamifidy-Berti
- Médecine Intensive - Réanimation, Centre Hospitalier de Poissy - Saint Germain en Laye, Poissy, France
| | - Julien Dessajan
- Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Zuber
- Intensive Care Unit, Hôpital Foch, 92150, Suresnes, France
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Edwige Peju
- Medical Intensive Care Unit, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris AP-HP Centre, Université Paris Cité, Paris, France
| | - Paris Meng
- Service de Médecine Intensive Réanimation, CHI Robert Ballanger, Aulnay-sous-Bois, France
| | - Liliane Charrier
- Service de Réanimation, Centre Hospitalier du Cotentin, Cherbourg, France
| | - Loic Le Guennec
- Médecine Intensive Réanimation Neurologique, Hôpital de la Pitié-Salpêtrière - APHP, Sorbonne Université, Paris, France
| | - Marie Simon
- Médecine Intensive Et Réanimation, CHU Edouard Herriot, Lyon, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Luc Haudebourg
- Service de Pneumologie et Réanimation Médicale du Département R3S, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, Paris, France
| | - Guillaume Geri
- Medical and Surgical Intensive Care Unit, Ambroise Paré Clinic, Neuilly-sur-Seine, France.
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Tsai WC, Syue LS, Ko WC, Lo CL, Lee NY. Antimicrobial treatment of monomicrobial phenotypic carbapenem-resistant Klebsiella pneumoniae bacteremia: Two are better than one. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:1219-1228. [PMID: 34635426 DOI: 10.1016/j.jmii.2021.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/25/2021] [Accepted: 09/04/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUNDS Infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) are emerging worldwide. The optimal treatment for CRKP infections is challenging for clinicians because therapeutic agents are greatly limited. MATERIAL AND METHODS A retrospective study of CRKP monomicrobial bacteremia was conducted at a medical center between 2010 and 2016. The use of at least one or more drugs with in vitro activity against the blood isolates was defined as appropriate combination therapy. The logistic regression model and propensity score analysis was used to assess clinical effects of therapeutic strategies. The 30-day crude mortality was the primary end point. RESULTS Two hundred and three patients were eligible and the 30-day mortality rate was 37.9% (77 patients). As compared with monotherapy, empirical (11.6 vs. 57.3%, p < .001) or definitive (26.5% vs. 48.6%, p = .001) combination antibiotic therapy showed a lower 30-day mortality rate independently. The propensity score analysis showed that those receiving combination therapy had less clinical (p ≤ .001) or microbiological failure (p = .003) and a lower 30-day mortality rate (p < .001). Among various regimens of definitive therapy, the 30-day mortality rate was the lowest among patients with appropriate combination therapy 23.6%, (p < .001; by log rank test). The primary outcome was similar in those with definitive carbapenem-containing and carbapenem-sparing combination regimens (p = .81). The presence or absence of carbapenemase production did not affect the mortality rate (p = .26). CONCLUSION Combination therapy, regardless of carbapenem-containing or carbapenem-sparing regimens, was associated with a favorable outcome.
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Affiliation(s)
- Wen-Chia Tsai
- Division of Infectious Diseases, Department of Internal Medicine and Tainan, Taiwan
| | - Ling-Shan Syue
- Division of Infectious Diseases, Department of Internal Medicine and Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Diseases, Department of Internal Medicine and Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lung Lo
- Division of Infectious Diseases, Department of Internal Medicine and Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Nan-Yao Lee
- Division of Infectious Diseases, Department of Internal Medicine and Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Mounier R, Le Guen R, Woerther PL, Nacher M, Bonnefon C, Mongardon N, Langeron O, Levesque E, Couffin S, Houcke S, Wolff M, Roujansky A, Schimpf C, Mekontso Dessap A, Cook F, Razazi K, Kallel H. Clinical outcome of wild-type AmpC-producing Enterobacterales infection in critically ill patients treated with β-lactams: a prospective multicenter study. Ann Intensive Care 2022; 12:107. [PMID: 36394673 PMCID: PMC9672193 DOI: 10.1186/s13613-022-01079-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background β-lactams are the main antibiotics used against wild-type AmpC-producing Enterobacterales (wtAE). However, they may fail or select AmpC-overproducing mutants. Our aim was to assess factors associated with clinical failure of β-lactams in the treatment of wtAE infection. Methods From September 2017 to December 2020, we prospectively included all consecutive patients treated by definitive β-lactams therapy for wtAE infection in four university ICUs. Clinical failure was defined as inadequate response to antimicrobial therapy leading to death or to the switch for a broader-spectrum antibiotic. Results 177 patients were included and 29.4% progressed to clinical failure. E. cloacae was the most prevalent species (42.4%) and ventilator-associated pneumonia (VAP) was the most frequent wtAE infection (69.5%). Cefepime and cefotaxime were used as definitive antibiotic treatment in 42.9% and 27.7% of patients, respectively. Occurrence of AmpC-overproduction was documented in 5.6% of patients and was associated with clinical failure (p = 0.004). In multivariate analysis, VAP (p < 0.001, OR 11.58 [95% CI 3.11–43.02] and K. aerogenes (p = 0.030, OR 3.76 [95% CI 1.13–12.46]) were independently associated with clinical failure. Conversely, cefotaxime as definitive treatment was found inversely associated with the risk of clinical failure (p = 0.022, OR 0.25 [95% CI 0.08–0.82]). After inverse probability weighting, cefotaxime showed a 20% risk reduction of clinical failure (95% CI 5–35%, p = 0.007) whatever the location of infection, the SOFA score on the day of wtAE infection, or the bacterial species. Conclusions Clinical failure in the treatment of wtAE infections is associated with the infection site and the causal microorganism. Additionally, cefotaxime use is probably protective against clinical failure in wtAE infection. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01079-5.
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Alam M, Bano N, Ahmad T, Sharangi AB, Upadhyay TK, Alraey Y, Alabdallah NM, Rauf MA, Saeed M. Synergistic Role of Plant Extracts and Essential Oils against Multidrug Resistance and Gram-Negative Bacterial Strains Producing Extended-Spectrum β-Lactamases. Antibiotics (Basel) 2022; 11:855. [PMID: 35884109 PMCID: PMC9312036 DOI: 10.3390/antibiotics11070855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/20/2022] [Accepted: 06/22/2022] [Indexed: 02/06/2023] Open
Abstract
Plants, being the significant and natural source of medication for humankind against several ailments with characteristic substances hidden on them, have been recognized for many centuries. Accessibility of various methodologies for the revelation of therapeutically characteristic items has opened new avenues to redefine plants as the best reservoirs of new structural types. The role of plant metabolites to hinder the development and movement of pathogenic microbes is cherished. Production of extended-spectrum β-lactamases is an amazing tolerance mechanism that hinders the antibacterial treatment of infections caused by Gram-negative bacteria and is a serious problem for the current antimicrobial compounds. The exploration of the invention from sources of plant metabolites gives sustenance against the concern of the development of resistant pathogens. Essential oils are volatile, natural, complex compounds described by a solid odor and are framed by aromatic plants as secondary metabolites. The bioactive properties of essential oils are commonly controlled by the characteristic compounds present in them. They have been commonly utilized for bactericidal, virucidal, fungicidal, antiparasitic, insecticidal, medicinal, and antioxidant applications. Alkaloids are plant secondary metabolites that have appeared to have strong pharmacological properties. The impact of alkaloids from Callistemon citrinus and Vernonia adoensis leaves on bacterial development and efflux pump activity was assessed on Pseudomonas aeruginosa. Plant-derived chemicals may have direct antibacterial activity and/or indirect antibacterial activity as antibiotic resistance modifying agents, increasing the efficiency of antibiotics when used in combination. The thorough screening of plant-derived bioactive chemicals as resistance-modifying agents, including those that can act synergistically with antibiotics, is a viable method to overcome bacterial resistance. The synergistic assessment studies with the plant extract/essential oil and the antibiotic compounds is essential with a target for achieving a redesigned model with sustainable effects which are appreciably noticeable in specific sites of the plants compared to the entirety of their individual parts.
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Affiliation(s)
- Manzar Alam
- Department of Biosciences, Integral University, Lucknow 226026, India
| | - Nilofer Bano
- Department of Bioengineering, Integral University, Lucknow 226026, India;
| | - Taufeeq Ahmad
- Faculty of Biosciences, Shri Ramswaroop Memorial University, Lucknow 225003, India;
| | - Amit Baran Sharangi
- Department of Plantation Spices Medicinal and Aromatic Crops, Bidhan Chandra Krishi Viswavidyalaya, Mohanpur 741252, India;
| | - Tarun Kumar Upadhyay
- Department of Biotechnology, Parul Institute of Applied Sciences and Centre of Research for Development, Parul University, Vadodara 391760, India
| | - Yasser Alraey
- Department of Clinical Laboratory Sciences, Central Research Laboratory, College of Applied Medical Sciences, King Khalid University, Abha 62559, Saudi Arabia;
| | - Nadiyah M. Alabdallah
- Department of Biology, College of Science, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 31441, Saudi Arabia;
| | - Mohd Ahmar Rauf
- Department of Pharmaceutical Sciences, Wayne State University, Detroit, MI 48201, USA;
| | - Mohd Saeed
- Department of Biology, College of Sciences, University of Hail, Hail 4464, Saudi Arabia;
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Isler B, Harris P, Stewart AG, Paterson DL. An update on cefepime and its future role in combination with novel β-lactamase inhibitors for MDR Enterobacterales and Pseudomonas aeruginosa. J Antimicrob Chemother 2021; 76:550-560. [PMID: 33332545 DOI: 10.1093/jac/dkaa511] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Cefepime, a wide-spectrum β-lactam antibiotic, has been in use for the treatment of serious bacterial infections for almost 25 years. Since its clinical development, there has been a dramatic shift in its dosing, with 2 g every 8 hours being preferred for serious infections to optimize pharmacokinetic/pharmacodynamic considerations. The advent of ESBLs has become a threat to its ongoing use, although future coadministration with β-lactamase inhibitors (BLIs) under development is an area of intense study. There are currently four new cefepime/BLI combinations in clinical development. Cefepime/zidebactam is generally active against MBL-producing Enterobacterales and Pseudomonas aeruginosa, in vitro and in animal studies, and cefepime/taniborbactam has activity against KPC and OXA-48 producers. Cefepime/enmetazobactam and cefepime/tazobactam are potential carbapenem-sparing agents with activity against ESBLs. Cefepime/enmetazobactam has completed Phase III and cefepime/taniborbactam is in Phase III clinical studies, where they are being tested against carbapenems or piperacillin/tazobactam for the treatment of complicated urinary tract infections. While these combinations are promising, their role in the treatment of MDR Gram-negative infections can only be determined with further clinical studies.
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Affiliation(s)
- Burcu Isler
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Patrick Harris
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Adam G Stewart
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - David L Paterson
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Mathers AJ, Lewis JS. CON: Testing for ESBL production is unnecessary for ceftriaxone-resistant Enterobacterales. JAC Antimicrob Resist 2021; 3:dlab020. [PMID: 34223109 PMCID: PMC8210140 DOI: 10.1093/jacamr/dlab020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Phenotypic testing for Enterobacterales that harbour ESBLs is not additive to accurate in vitro β-lactam MICs for clinical decision-making. ESBL testing is an outdated practice established in an era of higher cephalosporin breakpoints to prevent resistant Enterobacterales carrying Ambler class A β-lactamases with affinity for later-generation β-lactams from being reported as susceptible to later-generation cephalosporins, leading to clinical failures. ESBL testing is problematic because of inaccuracies when multiple classes of β-lactamases are produced by the same organism, thus limiting the testing application to specific species and resistance types. Clinical laboratories should instead focus finite resources on accurate susceptibility testing using contemporary interpretative criteria to help guide therapeutic decisions. With continued emergence of antimicrobial resistance and in the setting of accurate susceptibility testing and current breakpoints the use of ESBL phenotypic testing is not helpful in clinical decision-making.
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Affiliation(s)
- Amy J Mathers
- Department of Medicine, Division of Infectious Diseases, University of Virginia Health System, Charlottesville, VA 22908, USA.,Department of Pathology, Clinical Microbiology Laboratory, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, OR 97239, USA.,Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, 97239, USA
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10
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Paterson DL, Isler B, Harris PNA. PRO: Carbapenems should be used for ALL infections caused by ceftriaxone-resistant Enterobacterales. JAC Antimicrob Resist 2021; 3:dlab013. [PMID: 34223090 PMCID: PMC8210194 DOI: 10.1093/jacamr/dlab013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ceftriaxone resistance in the Enterobacterales is typically the result of production of ESBLs or AmpC β-lactamases. The genes encoding these enzymes are often co-located with other antibiotic resistance genes leading to resistance to aminoglycosides, quinolones and trimethoprim/sulfamethoxazole. Carbapenems are stable to ESBLs and AmpC giving them reliable in vitro activity against producers of these β-lactamases. In contrast, piperacillin/tazobactam and amoxicillin/clavulanate are compromised by co-production of OXA-1, which is not inhibited by tazobactam or clavulanate. These in vitro findings provide an explanation for the MERINO trial outcomes, where 3.7% (7/191) randomized to meropenem died compared with 12.3% (23/187) randomized to piperacillin/tazobactam as definitive treatment of bloodstream infection due to ceftriaxone-resistant organisms. No randomized trials have yet put cefepime and carbapenems head to head, but some observational studies have shown worse outcomes with cefepime. We argue that carbapenems are the antibiotics of choice for ceftriaxone-resistant Enterobacterales.
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Affiliation(s)
- David L Paterson
- University of Queensland Centre for Clinical Research (UQCCR), RBWH Campus, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Brisbane, Australia
| | - Burcu Isler
- University of Queensland Centre for Clinical Research (UQCCR), RBWH Campus, Brisbane, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Patrick N A Harris
- University of Queensland Centre for Clinical Research (UQCCR), RBWH Campus, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Brisbane, Australia.,Central Microbiology Laboratory, Pathology Queensland, Brisbane, Australia
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11
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Performance of ceftriaxone susceptibility testing on the Accelerate Pheno® system of ESBL-producing isolates. Diagn Microbiol Infect Dis 2020; 98:115171. [PMID: 32927411 DOI: 10.1016/j.diagmicrobio.2020.115171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/23/2020] [Accepted: 08/05/2020] [Indexed: 11/22/2022]
Abstract
The correlation of ceftriaxone nonsusceptibility and ESBL production was evaluated in 40 characterized isolates. Performance of ceftriaxone susceptibility testing on the Accelerate Pheno was evaluated and compared with reference broth microdilution in triplicate. The CLSI ESBL confirmatory test was also evaluated. Ceftriaxone categorical agreement of the Accelerate Pheno was 97.5% with 1 minor error. The ESBL confirmatory disk test resulted in 4 false-negatives and 1 false positive. The Accelerate Pheno provides an expedited and accurate method of ceftriaxone susceptibility testing allowing for optimization of antimicrobial regimens sooner. These data indicate that ESBL production has a high likelihood of ceftriaxone non-susceptibility.
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12
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Cantón R, Oliver A, Alós JI, de Benito N, Bou G, Campos J, Calvo J, Canut A, Castillo J, Cercenado E, Domínguez MÁ, Fernández-Cuenca F, Guinea J, Larrosa N, Liñares J, López-Cerero L, López-Navas A, Marco F, Mirelis B, Moreno-Romo MÁ, Morosini MI, Navarro F, Oteo J, Pascual Á, Pérez-Trallero E, Pérez-Vázquez M, Soriano A, Torres C, Vila J, Martínez-Martínez L. Recommendations of the Spanish Antibiogram Committee (COESANT) for selecting antimicrobial agents and concentrations for in vitro susceptibility studies using automated systems. Enferm Infecc Microbiol Clin 2020; 38:182-187. [PMID: 30878313 DOI: 10.1016/j.eimc.2019.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/06/2019] [Indexed: 02/05/2023]
Abstract
Automated antimicrobial susceptibility testing devices are widely implemented in clinical microbiology laboratories in Spain, mainly using EUCAST (European Committee on Antimicrobial Susceptibility Testing) breakpoints. In 2007, a group of experts published recommendations for including antimicrobial agents and selecting concentrations in these systems. Under the patronage of the Spanish Antibiogram Committee (Comité Español del Antibiograma, COESANT) and the Study Group on Mechanisms of Action and Resistance to Antimicrobial Agents (GEMARA) from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), and aligned with the Spanish National Plan against Antimicrobial Resistance (PRAN), a group of experts have updated this document. The main modifications from the previous version comprise the inclusion of new antimicrobial agents, adaptation of the ranges of concentrations to cover the EUCAST breakpoints and epidemiological cut-off values (ECOFFs), and the inference of new resistance mechanisms. This proposal should be considered by different manufacturers and users when designing new panels or cards. In addition, recommendations for selective reporting are also included. With this approach, the implementation of EUCAST breakpoints will be easier, increasing the quality of antimicrobial susceptibility testing data and their microbiological interpretation. It will also benefit epidemiological surveillance studies as well as the clinical use of antimicrobials aligned with antimicrobial stewardship programs.
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Affiliation(s)
- Rafael Cantón
- Servicio de Microbiología, Hospital Universtario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain.
| | - Antonio Oliver
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Juan Ignacio Alós
- Servicio de Microbiología, Hospital Universitario de Getafe, Madrid, Spain
| | - Natividad de Benito
- Unidad de Enfermedades Infecciosas, Hospital de la Santa Creu i Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma, Barcelona, Spain
| | - Germán Bou
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología-INIBIC, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - José Campos
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Jorge Calvo
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Andrés Canut
- Servicio de Microbiología, Hospital Universitario de Álava, Vitoria, Spain
| | - Javier Castillo
- Servicio de Microbiología, Hospital Clínico Universitario, Zaragoza, Spain
| | - Emilia Cercenado
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Maria Ángeles Domínguez
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Felipe Fernández-Cuenca
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Virgen Macarena, Sevilla, Spain
| | - Jesús Guinea
- Servicio de Microbiología y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nieves Larrosa
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Josefina Liñares
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universtario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Lorena López-Cerero
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Virgen Macarena, Sevilla, Spain
| | - Antonio López-Navas
- Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Spain
| | - Francesc Marco
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Microbiología, Centro de Diagnóstico Biomédico (CDB), Hospital Clínic, Universidad de Barcelona, and ISGlobal, Barcelona, Spain
| | - Beatriz Mirelis
- Servicio de Microbiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - María Isabel Morosini
- Servicio de Microbiología, Hospital Universtario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Ferran Navarro
- Servicio de Microbiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jesús Oteo
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Álvaro Pascual
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Virgen Macarena, Sevilla, Spain
| | - Emilio Pérez-Trallero
- Servicio de Microbiología, Hospital Universitario Donostia-IIS Biodonostia, San Sebastián, Spain
| | - María Pérez-Vázquez
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Laboratorio de Referencia e Investigación en Resistencia a Antibióticos e Infecciones Relacionadas con la Asistencia Sanitaria, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Alex Soriano
- Servicio de Enfermedades Infecciosas, Hospital Clínic, Barcelona, Spain
| | - Carmen Torres
- Facultad de Ciencias y Tecnología, Área de Bioquímica y Biología Molecular, Universidad de La Rioja, Logroño, Spain
| | - Jordi Vila
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Departamento de Microbiología, Centro de Diagnóstico Biomédico (CDB), Hospital Clínic, Universidad de Barcelona, and ISGlobal, Barcelona, Spain
| | - Luis Martínez-Martínez
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Unidad de Gestión Clínica de Microbiología, Hospital Reina Sofía, Departamento de Microbiología, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
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13
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Lee NY, Tsai CS, Syue LS, Chen PL, Li CW, Li MC, Ko WC. Treatment Outcome of Bacteremia Due to Non-Carbapenemase-producing Carbapenem-Resistant Klebsiella pneumoniae Bacteremia: Role of Carbapenem Combination Therapy. Clin Ther 2020; 42:e33-e44. [PMID: 32061374 DOI: 10.1016/j.clinthera.2020.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Infections caused by carbapenemase-producing Klebsiella pneumoniae are emerging causes of morbidity and mortality worldwide. Optimal treatment for non-carbapenemase-producing carbapenem-resistant K pneumoniae (nCP-CRKP) bacteremia remains undefined. The goal of this study was to assess the clinical outcome, predictors of mortality, and therapeutic strategy of carbapenems for nCP-CRKP bacteremia. METHODS A retrospective study of monomicrobial bacteremia caused by nCP-CRKP, at a medical center between 2010 and 2015 was conducted. CRKP which was defined as a minimum inhibitory concentration (MIC) of ≥ 2 for ertapenem or ≥ 4 mg/L for meropenem, or imipenem. Multiplex polymerase chain was applied to detect carbapenemase genes. The patients definitively treated with combination therapy were compared with monotherapy using a propensity score-matched analysis to assess therapeutic effectiveness. The primary end point was the 30-day crude mortality and clinical prognostic factors were assessed. FINDINGS Overall 171 patients met criteria were eligible for the study and their overall 30-day mortality rate was 38.6%. The multivariate logistic regression analysis showed that combination therapy was associated with a lower 30-day mortality rate (adjusted odds ratio [aOR], 0.11; 95% CI, 0.03-0.43; P = 0.001) and less clinical (aOR, 0.21; 95% CI, 0.08-0.58; P = 0.003) and microbiologic (aOR, 0.36; 95% CI, 0.19-0.71; P = 0.003) failure. However, the 30-day mortality rate in the cases infected by a pathogen with a meropenem MIC ≤8 mg/L receiving carbapenem-containing or carbapenem-sparing combination regimens was similar (15 of 58 [25.9%] vs 5 of 20 [23.3%]; P = 1.0). IMPLICATIONS Combination therapy, regardless of carbapenem-containing or carbapenem-sparing, with one or more active agents improved survival more than monotherapy and was more effective in patients with critical illness. (Clin Ther. 2020; 42:XXX-XXX) © 2020 Elsevier HS Journals, Inc.
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Affiliation(s)
- Nan-Yao Lee
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University Tainan, Tainan, Taiwan
| | - Chin-Shiang Tsai
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ling-Shan Syue
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Po-Lin Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University Tainan, Tainan, Taiwan
| | - Chia-Wen Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University Tainan, Tainan, Taiwan.
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14
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Grzybowski A, Koerner JC, George MJ. Postoperative endophthalmitis after cataract surgery: a worldwide review of etiology, incidence and the most studied prophylaxis measures. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1674140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, Univeristy of Warmia and Mazury, Olsztyn, Poland
| | - Jagger C. Koerner
- Department of Ophthalmology, Wake Forest University, Winston Salem, North Carolina, USA
| | - Mary J. George
- Department of Microbiology, Albany Medical College, Albany, New York, USA
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15
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Evaluation of Empiric β-Lactam Susceptibility Prediction among Enterobacteriaceae by Molecular β-Lactamase Gene Testing. J Clin Microbiol 2019; 57:JCM.00674-19. [PMID: 31340995 DOI: 10.1128/jcm.00674-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/17/2019] [Indexed: 12/31/2022] Open
Abstract
The use of rapid diagnostic tests (RDTs) for blood cultures has become standard of care in the United States to inform early antimicrobial optimization. The relative ability of genotypic and phenotypic approaches to identify beta-lactam susceptibility in Escherichia coli, Klebsiella spp., and Proteus mirabilis was evaluated, using incidence rates of resistance mechanisms to third-generation cephalosporins, aztreonam, and piperacillin-tazobactam seen across U.S. census regions. Overall, the presence of CTX-M, KPC, and/or NDM genes was 81% (range, 57 to 87%) sensitive for the prediction of ceftriaxone, ceftazidime, and aztreonam resistance and 73% (range, 25 to 90%) sensitive for the detection of piperacillin-tazobactam resistance. The sensitivity of KPC or NDM to predict imipenem or meropenem resistance was 94.3% overall, and for meropenem ranged from 70 to 100% across U.S. census regions. Institutions that use genotypic RDTs to inform therapeutic de-escalation decisions should be aware of the incidence-base performance across U.S. geographies and in different patient populations, where resistance rates may vary.
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16
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Tascini C. Antibiotic stewardship: ripartiamo dalla pratica clinica. Urologia 2019; 85:S20-S23. [PMID: 30081776 DOI: 10.1177/0391560318770093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antibiotic stewardship: a milestone in everyday clinical practice Infectious diseases caused by multi-resistant pathogens are increasing worldwide and are challenging for clinicians, also in urological setting. The alarming situation is worsened by the limited perspective of new antibiotic developments. Several authors demonstrated that in Italy we have alarming data about resistance rates: in Campania about 58% of Escherichia coli are resistant to fluroquinolones, as 46% to sulfamethoxazole-trimethoprim. On the other hand, the resistance rate against fosfomycin is still low less than 5%. More alarming data are reported about Klebsiella pneumoniae: resistance rate to flurquinolones 65% and 58% to sulfamethoxazole-trimethoprim. A continuing uncritical, non-guideline-conform and overuse of antibiotics leads to selection of multidrug-resistant pathogens, which can colonize patients and make the treatment a real challenge. A revision of our approach to urinary tract infections at the light of antibiotic stewardiship principles are urgently required, in particular starting from the everyday clinical practice.
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Affiliation(s)
- Carlo Tascini
- Direttore U.O.C, Malattie Infettive a indirizzo neurologico, Azienda Ospedaliera dei Colli, Ospedale Cotugno, Napoli, Italy
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17
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Smiline A, Vijayashree JP, Paramasivam A. Molecular characterization of plasmid-encoded blaTEM, blaSHV and blaCTX-M among extended spectrum β-lactamases [ESBLs] producing Acinetobacter baumannii. Br J Biomed Sci 2018; 75:200-202. [PMID: 29962277 DOI: 10.1080/09674845.2018.1492207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Asg Smiline
- a Department of Microbiology , Saveetha Dental College and Hospitals, [SIMATS] , Chennai , India
| | - J P Vijayashree
- b BRULAC-DRC , Saveetha Dental College and Hospitals, [SIMATS] , Chennai , India
| | - A Paramasivam
- c Centre for cellular and Molecular Biology , Hyderabad , India
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18
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Rationale Antibiotikaverordnung in der Humanmedizin. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:580-588. [DOI: 10.1007/s00103-018-2727-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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19
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Sheu CC, Lin SY, Chang YT, Lee CY, Chen YH, Hsueh PR. Management of infections caused by extended-spectrum β-lactamase-producing Enterobacteriaceae: current evidence and future prospects. Expert Rev Anti Infect Ther 2018; 16:205-218. [PMID: 29402125 DOI: 10.1080/14787210.2018.1436966] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The spread of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae has become a major public health threat worldwide. Area covered: A thorough systematic literature review describing the current evidence and future prospects of therapeutic options for infections caused by ESBL-producing Enterobacteriaceae. Expert commentary: The methods of detecting ESBLs have been evolving. The Clinical and Laboratory Standards Institute and the European Committee on Antimicrobial Susceptibility Testing lowered the MIC breakpoints of cephalosporins against ESBL-producing Enterobacteriaceae in 2010. Phenotypic testing for ESBLs is no longer recommended. Instead, the selection of appropriate antimicrobial agents largely depends on the report of minimum inhibitory concentrations (MICs). To date, therapeutic options for these multidrug-resistant organisms remain limited. The clinical efficacy of piperacillin/tazobactam and cefepime on in vitro-susceptible ESBL-producing Enterobacteriaceae remains a concern. Many studies found an in vitro-in vivo discordance based on current breakpoints. Carbapenems are the most reliable antibiotics for severe infections caused by ESBL-producing Enterobacteriaceae. However, their overuse has led to a serious problem of increasing drug resistance. Recently, ceftolozane/tazobactam and ceftazidime/avibactam have been approved for the treatment of complicated urinary tract infections and complicated intra-abdominal infections. The introduction of these new β-lactam/β-lactamase inhibitor combinations offers new carbapenem-sparing options for the treatment of ESBL infections.
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Affiliation(s)
- Chau-Chyun Sheu
- a Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,b School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, College of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan
| | - Shang-Yi Lin
- b School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, College of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan.,c Division of Infectious Disease, Department of Internal Medicine , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan
| | - Ya-Ting Chang
- b School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, College of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan.,c Division of Infectious Disease, Department of Internal Medicine , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan
| | - Chun-Yuan Lee
- b School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, College of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan.,c Division of Infectious Disease, Department of Internal Medicine , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan
| | - Yen-Hsu Chen
- b School of Medicine, Sepsis Research Institute, Graduate Institute of Medicine, College of Medicine , Kaohsiung Medical University , Kaohsiung , Taiwan.,c Division of Infectious Disease, Department of Internal Medicine , Kaohsiung Medical University Hospital , Kaohsiung , Taiwan.,d Department of Biological Science and Technology , College of Biological Science and Technology, National Chiao Tung University , Hsin Chu , Taiwan
| | - Po-Ren Hsueh
- e Department of Laboratory Medicine , National Taiwan University Hospital, College of Medicine, National Taiwan University , Taipei , Taiwan.,f Department of Internal Medicine , National Taiwan University Hospital, College of Medicine, National Taiwan University , Taipei , Taiwan
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Walker KJ, Lee YR, Klar AR. Clinical Outcomes of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Infections with Susceptibilities among Levofloxacin, Cefepime, and Carbapenems. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2018; 2018:3747521. [PMID: 29670677 PMCID: PMC5833881 DOI: 10.1155/2018/3747521] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/28/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Highly resistant Gram-negative bacterial infections are associated with high mortality. Increasing resistance to standard therapy illustrates the need for alternatives when treating resistant organisms, especially extended-spectrum beta-lactamase- (ESBL-) producing Enterobacteriaceae. METHODS A retrospective chart review at a community hospital was performed. Patients who developed ESBL-producing infections were included. Patients less than eighteen years old, who were pregnant, or who were incarcerated were excluded. The primary outcome was hospital mortality. The secondary outcomes included intensive care unit (ICU) mortality, ICU length of stay, and hospital length of stay. RESULTS 113 patients with ESBL-producing infections met the criteria for review. Hospital mortality: carbapenem (16.6%), cefepime (0%), and levofloxacin (15.3%) (p=0.253). ICU mortality: carbapenem (4.5%), cefepime, (0%), and levofloxacin (3.7%) (p=0.616). Mean ICU and hospital length of stay: carbapenem (9.8 ± 16, 12.1 ± 1 days), cefepime (7.8 ± 6, 11.1 ± 10.5 days), and levofloxacin (5.4 ± 4.1, 11.1 ± 10.4 days) (p=0.805, 0.685). No predictors were clearly found between the source of infection and mortality. CONCLUSION Cefepime or levofloxacin can be a potential alternative agent for infections with ESBL-producing Enterobacteriaceae, and larger clinical trials investigating these outcomes are warranted.
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Affiliation(s)
| | - Young R. Lee
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, 1718 Pine St., Abilene, TX 79601, USA
| | - Amanda R. Klar
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, 1718 Pine St., Abilene, TX 79601, USA
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An Improved Extended-Spectrum-β-Lactamase Detection Test Utilizing Aztreonam plus Clavulanate. J Clin Microbiol 2018; 56:JCM.01309-17. [DOI: 10.1128/jcm.01309-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 10/04/2017] [Indexed: 11/20/2022] Open
Abstract
ABSTRACT
Clinical laboratories test for extended-spectrum β-lactamases (ESBLs) for epidemiological and infection control purposes and also for the potential of cephalosporins to cause therapeutic failures. Testing can be problematic, because the CLSI does not recommend the testing of all producers of ESBLs and also falsely negative results may occur with isolates that coproduce AmpC. Boronic acid-supplemented tests can enhance ESBL detection in AmpC producers. Because aztreonam inhibits AmpCs, a study was designed to compare ESBL detection by the CLSI disk test (CLSI), a boronic acid-supplemented CLSI disk test (CLSI plus BA), and an aztreonam plus clavulanate disk test (ATM plus CA). The study tested 100 well-characterized
Enterobacteriaceae
,
Acinetobacter baumannii
, and
Pseudomonas aeruginosa
isolates. Seventy produced TEM, SHV, or CTX-M ESBLs, with 15 coproducing an AmpC and 11 coproducing a metallo-β-lactamase. Thirty ESBL-negative isolates were also tested. Tests were inoculated by CLSI methodology and interpreted as positive if an inhibitor caused a zone diameter increase of ≥5 mm. The percentages of ESBL producers detected were as follows: ATM plus CA, 95.7%; CLSI plus BA, 88.6%; and CLSI, 78.6%. When AmpC was coproduced, the sensitivities of the tests were as follows: ATM plus CA, 100%; CLSI plus BA, 93.3%; and CLSI, 60%. ATM plus CA also detected an ESBL in 90.1% of isolates that coproduced a metallo-β-lactamase. Falsely positive tests occurred only with the CLSI and CLSI plus BA tests. Overall, the ATM plus CA test detected ESBLs more accurately than the CLSI and CLSI plus BA tests, especially with isolates coproducing an AmpC or metallo-β-lactamase.
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Bork JT, Heil EL, Leekha S, Fowler RC, Hanson ND, Majumdar A, Johnson JK. Impact of CLSI and EUCAST Cefepime breakpoint changes on the susceptibility reporting for Enterobacteriaceae. Diagn Microbiol Infect Dis 2017; 89:328-333. [PMID: 29031525 DOI: 10.1016/j.diagmicrobio.2017.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/19/2017] [Accepted: 08/23/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We analyzed the effects of different cefepime MIC breakpoints on Enterobacteriaceae cefepime susceptibility and the presence of AmpC and extended-spectrum β-lactamase (ESBL) genes within the cefepime MIC interpretative categories. METHODS Using Enterobacteriaceae susceptibility data from 2013 comparisons of MIC breakpoints were performed using Pearson's chi-squared test. Molecular testing on a subset of isolates was done. RESULTS Among 3784 non-duplicate clinical isolates, cefepime susceptibility decreased from 97.6% to 96.1% to 93.7% for CLSI 2013, CLSI 2014, and EUCAST 2011, respectively. In ceftriaxone non-susceptible isolates, cefepime susceptibility decreased from 79% to 66% (P<0.0001) using CLSI 2013 and 2014, respectively, which was greater and statistically significant for Escherichia coli and Klebsiella spp. but not for Enterobacter spp. (P=0.06). Isolates with MIC ≤1μg/mL more often harbored AmpC (77%) than ESBL (18%) genes. CONCLUSIONS Lower cefepime MIC breakpoints decrease cefepime susceptibility for isolates harboring ESBLs, while sparing the majority of those with AmpCs.
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Affiliation(s)
- Jacqueline T Bork
- University of Maryland School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, MD.
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, MD
| | - Surbhi Leekha
- University of Maryland School of Medicine, Department of Medicine, Division of Infectious Diseases, Baltimore, MD; Department of Public Health and Epidemiology, University of Maryland School of Medicine, Baltimore, MD
| | - Randal C Fowler
- University of Nebraska Medical Center, Department of Pathology and Microbiology, Omaha, NE
| | - Nancy D Hanson
- Creighton School of Medicine, Department of Microbiology and Immunology, Omaha, NE
| | - Anjali Majumdar
- MedStar Washington Hospital Center, Department of Medicine, Division of Infectious Diseases, Washington, DC
| | - J Kristie Johnson
- University of Maryland School of Medicine, Department of Pathology, Baltimore, MD
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Diene SM, Abat C, Rolain JM, Raoult D. How artificial is the antibiotic resistance definition? THE LANCET. INFECTIOUS DISEASES 2017; 17:690. [PMID: 28653629 DOI: 10.1016/s1473-3099(17)30338-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/16/2017] [Accepted: 05/16/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Seydina M Diene
- URMITE (Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, Marseille Cedex 05, France
| | - Cédric Abat
- URMITE (Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, Marseille Cedex 05, France
| | - Jean-Marc Rolain
- URMITE (Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, Marseille Cedex 05, France
| | - Didier Raoult
- URMITE (Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, IHU-Méditerranée Infection, Marseille Cedex 05, France.
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El-Jade MR, Parcina M, Schmithausen RM, Stein C, Meilaender A, Hoerauf A, Molitor E, Bekeredjian-Ding I. ESBL Detection: Comparison of a Commercially Available Chromogenic Test for Third Generation Cephalosporine Resistance and Automated Susceptibility Testing in Enterobactericeae. PLoS One 2016; 11:e0160203. [PMID: 27494134 PMCID: PMC4975492 DOI: 10.1371/journal.pone.0160203] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 07/17/2016] [Indexed: 11/24/2022] Open
Abstract
Rapid detection and reporting of third generation cephalosporine resistance (3GC-R) and of extended spectrum betalactamases in Enterobacteriaceae (ESBL-E) is a diagnostic and therapeutic priority to avoid inefficacy of the initial antibiotic regimen. In this study we evaluated a commercially available chromogenic screen for 3GC-R as a predictive and/or confirmatory test for ESBL and AmpC activity in clinical and veterinary Enterobacteriaceae isolates. The test was highly reliable in the prediction of cefotaxime and cefpodoxime resistance, but there was no correlation with ceftazidime and piperacillin/tazobactam minimal inhibitory concentrations. All human and porcine ESBL-E tested were detected with exception of one genetically positive but phenotypically negative isolate. By contrast, AmpC detection rates lay below 30%. Notably, exclusion of piperacillin/tazobactam resistant, 3GC susceptible K1+ Klebsiella isolates increased the sensitivity and specificity of the test for ESBL detection. Our data further imply that in regions with low prevalence of AmpC and K1 positive E. coli strains chromogenic testing for 3GC-R can substitute for more time consuming ESBL confirmative testing in E. coli isolates tested positive by Phoenix or VITEK2 ESBL screen. We, therefore, suggest a diagnostic algorithm that distinguishes 3GC-R screening from primary culture and species-dependent confirmatory ESBL testing by βLACTATM and discuss the implications of MIC distribution results on the choice of antibiotic regimen.
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Affiliation(s)
- Mohamed Ramadan El-Jade
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Marijo Parcina
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Ricarda Maria Schmithausen
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
- Institute of Animal Science, Preventive Health Management Group, University of Bonn, Katzenburgweg 7–9, D-53115, Bonn, Germany
| | - Christoph Stein
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
- Division of Microbiology, Paul-Ehrlich-Institut, Paul-Ehrlich-Str. 51–59, D-63225, Langen, Germany
| | - Alina Meilaender
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Achim Hoerauf
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Ernst Molitor
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Isabelle Bekeredjian-Ding
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Sigmund-Freud-Str. 25, D-53105, Bonn, Germany
- Division of Microbiology, Paul-Ehrlich-Institut, Paul-Ehrlich-Str. 51–59, D-63225, Langen, Germany
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25
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Miller S, Humphries RM. Clinical laboratory detection of carbapenem-resistant and carbapenemase-producingEnterobacteriaceae. Expert Rev Anti Infect Ther 2016; 14:705-17. [DOI: 10.1080/14787210.2016.1206815] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Banerjee R, Humphries R. Clinical and laboratory considerations for the rapid detection of carbapenem-resistant Enterobacteriaceae. Virulence 2016; 8:427-439. [PMID: 27168451 DOI: 10.1080/21505594.2016.1185577] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Carbapenem resistance among the Enterobacteriaceae has become a significant clinical and public health dilemma. Rapid administration of effective antimicrobials and implementation of supplemental infection control practices is required to both improve patient outcomes and limit the spread of these highly resistant organisms. However, carbapenem-resistant Enterobacteriaceae (CRE)-infected patients are predominantly identified by routine culture methods, which take days to perform. Rapid genomic and phenotypic methods are currently available to accelerate the identification of carbapenemase-producing CRE. Effective use of these technologies is reliant on close collaboration between clinical microbiology, infection prevention, antimicrobial stewardship and infectious diseases specialists. This review discusses the performance characteristics of these technologies to date, and describes strategies for their optimal implementation.
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Affiliation(s)
- Ritu Banerjee
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
| | - Romney Humphries
- b Department of Pathology and Laboratory Medicine , University of California , Los Angeles , CA , USA
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Humphries RM, Hindler JA. Emerging Resistance, New Antimicrobial Agents … but No Tests! The Challenge of Antimicrobial Susceptibility Testing in the Current US Regulatory Landscape. Clin Infect Dis 2016; 63:83-8. [PMID: 27025822 DOI: 10.1093/cid/ciw201] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/19/2016] [Indexed: 11/12/2022] Open
Abstract
Accurate and timely performance of antimicrobial susceptibility testing (AST) by the clinical laboratory is paramount to combating antimicrobial resistance. The ability of laboratories in the United States to effectively perform ASTs is challenged by several factors. Some, such as new resistance mechanisms and the associated evolution of testing recommendations and breakpoints, are inevitable. Others are entirely man-made. These include unnecessarily strict US Food and Drug Administration (FDA) limitations on how commercial AST systems can be used for diagnostic testing, the absence of up-to-date performance data on these systems, and the lack of commercially available FDA-cleared tests for newer antimicrobial agents or for older agents with updated breakpoints. This viewpoint will highlight contemporary AST challenges faced by the clinical laboratory, and propose some solutions.
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Affiliation(s)
- R M Humphries
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - J A Hindler
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles
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Stillwell T, Green M, Barbadora K, Ferrelli JG, Roberts TL, Weissman SJ, Nowalk A. Outbreak of KPC-3 Producing Carbapenem-Resistant Klebsiella pneumoniae in a US Pediatric Hospital. J Pediatric Infect Dis Soc 2015; 4:330-8. [PMID: 26582872 DOI: 10.1093/jpids/piu080] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 07/06/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND The increase in carbapenem-resistant Enterobacteriaceae (CRE) infections is a critical public health issue. We recently experienced the largest single-center pediatric outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) at our hospital. The objective of this study was to describe the molecular epidemiology of this outbreak before and after infection-prevention interventions. METHODS All positive cultures and associated clinical conditions were reviewed to determine whether health care-associated infections (HAIs) exist. HAIs were defined using Centers for Disease Control and Prevention guidelines. CRKP isolates were collected and screened for the presence of β-lactamase genes. Strain relatedness of CRKP isolates was determined by field-inversion gel electrophoresis (FIGE) and multilocus sequence typing (MLST). Polymerase chain reaction (PCR) amplification and sequencing of blaTEM, blaSHV, and blaKPC genes were performed on representative isolates. RESULTS During March-July 2010, 18 CRKP isolates were recovered from 15 unique patients. Six isolates were considered HAIs; all were central-line-associated bloodstream infections. All isolates testing positive by PCR for blaKPC were found to carry KPC-3 in transposon Tn4401 isotype "b." FIGE revealed 2 prevalent patterns (accounting for 10 and 3 CRKP isolates, respectively) that MLST demonstrated to consist entirely of strains from ST730; the remaining FIGE types corresponded to ST14, ST15, and ST1559 (a single-locus variant of ST730), with these alternate backgrounds appearing later in the outbreak. New CRKP cases decreased after the implementation of infection-control interventions. All isolates were ciprofloxacin sensitive. CONCLUSIONS Molecular analyses document the introduction of a KPC-3-producing CRKP clone into our hospital setting, though some isolates appear to have other mechanisms of carbapenem resistance. The transition to a polyclonal epidemiology suggests that the initial outbreak was due to nosocomial spread of a single ST730 clone, while latter isolates may have been secondary to the introduction of a blaKPC-3/Tn4401 isotype "b"-containing plasmid into other K pneumoniae strain backgrounds versus new carbapenemase-producing bacteria.
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Affiliation(s)
| | - Michael Green
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
| | - Karen Barbadora
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
| | - Juliet G Ferrelli
- Infection Control Department, University of Pittsburgh Medical Center Mercy
| | - Terri L Roberts
- Infection Control Department, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pennsylvania
| | - Scott J Weissman
- Department of Pediatrics, Seattle Children's Hospital, Washington
| | - Andrew Nowalk
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center
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29
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Lee CH, Su LH, Chen FJ, Tang YF, Li CC, Chien CC, Liu JW. Comparative effectiveness of flomoxef versus carbapenems in the treatment of bacteraemia due to extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae with emphasis on minimum inhibitory concentration of flomoxef: a retrospective study. Int J Antimicrob Agents 2015; 46:610-5. [PMID: 26387064 DOI: 10.1016/j.ijantimicag.2015.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/26/2015] [Accepted: 07/20/2015] [Indexed: 11/26/2022]
Abstract
This study compared treatment outcomes of adult patients with bacteraemia due to extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella pneumoniae (ESBL-EK) receiving flomoxef versus those receiving a carbapenem as definitive therapy. In propensity score matching (PSM) analysis, case patients receiving flomoxef shown to be active in vitro against ESBL-EK were matched with controls who received a carbapenem. The primary endpoint was 30-day crude mortality. The flomoxef group had statistically significantly higher sepsis-related mortality (27.3% vs. 10.5%) and 30-day mortality (28.8% vs. 12.8%) than the carbapenem group. Of the bacteraemic episodes caused by isolates with a MICflomoxef of ≤1 mg/L, sepsis-related mortality rates were similar between the two treatment groups (8.7% vs. 6.4%; P=0.73). The sepsis-related mortality rate of the flomoxef group increased to 29.6% and 50.0% of episodes caused by isolates with a MICflomoxef of 2-4 mg/L and 8 mg/L, respectively, which was significantly higher than the carbapenem group (12.3%). In the PSM analysis of 86 case-control pairs infected with strains with a MICflomoxef of 2-8 mg/L, case patients had a significantly higher 30-day mortality rate (38.4% vs. 18.6%). Multivariate regression analysis revealed that flomoxef therapy for isolates with a MICflomoxef of 2-8 mg/L, concurrent pneumonia or urosepsis, and a Pitt bacteraemia score ≥4 were independently associated with 30-day mortality. Definitive flomoxef therapy appears to be inferior to carbapenems in treating ESBL-EK bacteraemia, particularly for isolates with a MICflomoxef of 2-8 mg/L, even though the currently suggested MIC breakpoint of flomoxef is ≤8 mg/L.
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Affiliation(s)
- Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan; Chang Gung University, College of Medicine, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan.
| | - Lin-Hui Su
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kweishan, Taoyuan 333, Taiwan; Chang Gung University College of Medicine, 259 Wenhua 1st Road, Kweishan, Taoyuan 333, Taiwan
| | - Fang-Ju Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Ya-Feng Tang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Chia-Chin Li
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
| | - Jien-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan; Chang Gung University, College of Medicine, 123 Ta-Pei Road, Niao Sung District, Kaohsiung 833, Taiwan
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30
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Kahlmeter G. The 2014 Garrod Lecture: EUCAST – are we heading towards international agreement? J Antimicrob Chemother 2015; 70:2427-39. [DOI: 10.1093/jac/dkv145] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Impact of borderline minimum inhibitory concentration on the outcome of invasive infections caused by Enterobacteriaceae treated with β-lactams: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2015; 34:1751-8. [DOI: 10.1007/s10096-015-2408-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/10/2015] [Indexed: 01/06/2023]
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Asín-Prieto E, Soraluce A, Trocóniz IF, Campo Cimarras E, Sáenz de Ugarte Sobrón J, Rodríguez-Gascón A, Isla A. Population pharmacokinetic models for cefuroxime and metronidazole used in combination as prophylactic agents in colorectal surgery: Model-based evaluation of standard dosing regimens. Int J Antimicrob Agents 2015; 45:504-11. [DOI: 10.1016/j.ijantimicag.2015.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/08/2015] [Accepted: 01/10/2015] [Indexed: 01/22/2023]
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Clouzeau B, Boyer A, M’Zali F, Kann M, Gruson D. Nouvelles stratégies thérapeutiques contre les entérobactéries productrices de β-lactamases à spectre étendu. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shaikh S, Fatima J, Shakil S, Rizvi SMD, Kamal MA. Antibiotic resistance and extended spectrum beta-lactamases: Types, epidemiology and treatment. Saudi J Biol Sci 2014; 22:90-101. [PMID: 25561890 DOI: 10.1016/j.sjbs.2014.08.002] [Citation(s) in RCA: 391] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 08/09/2014] [Accepted: 08/10/2014] [Indexed: 12/25/2022] Open
Abstract
Antibiotic resistance is a problem of deep scientific concern both in hospital and community settings. Rapid detection in clinical laboratories is essential for the judicious recognition of antimicrobial resistant organisms. Production of extended-spectrum β-lactamases (ESBLs) is a significant resistance-mechanism that impedes the antimicrobial treatment of infections caused by Enterobacteriaceae and is a serious threat to the currently available antibiotic armory. ESBLs are classified into several groups according to their amino acid sequence homology. Proper infection control practices and barriers are essential to prevent spread and outbreaks of ESBL producing bacteria. As bacteria have developed different strategies to counter the effects of antibiotics, the identification of the resistance mechanism may help in the discovery and design of new antimicrobial agents. The carbapenems are widely regarded as the drugs of choice for the treatment of severe infections caused by ESBL-producing Enterobacteriaceae, although comparative clinical trials are scarce. Hence, more expeditious diagnostic testing of ESBL-producing bacteria and the feasible modification of guidelines for community-onset bacteremia associated with different infections are prescribed.
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Affiliation(s)
| | - Jamale Fatima
- Department of Bio-engineering, Integral University, Lucknow 226026, India
| | - Shazi Shakil
- Department of Bio-engineering, Integral University, Lucknow 226026, India
| | | | - Mohammad Amjad Kamal
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia ; Enzymoic, 7 Peterlee Pl, Hebersham, NSW 2770, Australia
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Costa PDO, Atta EH, Silva ARAD. Predictors of 7- and 30-day mortality in pediatric intensive care unit patients with cancer and hematologic malignancy infected with Gram-negative bacteria. Braz J Infect Dis 2014; 18:591-9. [PMID: 25051279 PMCID: PMC9425202 DOI: 10.1016/j.bjid.2014.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/19/2014] [Indexed: 11/18/2022] Open
Abstract
Background Infection with Gram-negative bacteria is associated with increased morbidity and mortality. The aim of this study was to evaluate the predictors of 7- and 30-day mortality in pediatric patients in an intensive care unit with cancer and/or hematologic diseases and Gram-negative bacteria infection. Methods Data were collected relating to all episodes of Gram-negative bacteria infection that occurred in a pediatric intensive care unit between January 2009 and December 2012, and these cases were divided into two groups: those who were deceased seven and 30 days after the date of a positive culture and those who survived the same time frames. Variables of interest included age, gender, presence of solid tumor or hematologic disease, cancer status, central venous catheter use, previous Pseudomonas aeruginosa infection, infection by multidrug resistant-Gram-negative bacteria, colonization by multidrug resistant-Gram-negative bacteria, neutropenia in the preceding seven days, neutropenia duration ≥3 days, healthcare-associated infection, length of stay before intensive care unit admission, length of intensive care unit stay >3 days, appropriate empirical antimicrobial treatment, definitive inadequate antimicrobial treatment, time to initiate adequate antibiotic therapy, appropriate antibiotic duration ≤3 days, and shock. In addition, use of antimicrobial agents, corticosteroids, chemotherapy, or radiation therapy in the previous 30 days was noted. Results Multivariate logistic regression analysis resulted in significant relationship between shock and both 7-day mortality (odds ratio 12.397; 95% confidence interval 1.291–119.016; p = 0.029) and 30-day mortality (odds ratio 6.174; 95% confidence interval 1.760–21.664; p = 0.004), between antibiotic duration ≤3 days and 7-day mortality (odds ratio 21.328; 95% confidence interval 2.834-160.536; p = 0.003), and between colonization by multidrug resistant-Gram-negative bacteria and 30-day mortality (odds ratio 12.002; 95% confidence interval 1.578–91.286; p = 0.016). Conclusions Shock was a predictor of 7- and 30-day mortality, and colonization by multidrug resistant-Gram-negative bacteria was an important risk factor for 30-day mortality.
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Affiliation(s)
- Patrícia de Oliveira Costa
- Center of Haematopoietic Stem Cell Transplantation, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil.
| | - Elias Hallack Atta
- Center of Haematopoietic Stem Cell Transplantation, Instituto Nacional do Câncer (INCA), Rio de Janeiro, RJ, Brazil
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36
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Papich MG. Pharmacokinetic-pharmacodynamic (PK-PD) modeling and the rational selection of dosage regimes for the prudent use of antimicrobial drugs. Vet Microbiol 2014; 171:480-6. [PMID: 24513278 DOI: 10.1016/j.vetmic.2013.12.021] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 12/23/2013] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
Abstract
One of the strategies to decrease inappropriate antimicrobial use in veterinary medicine is to apply pharmacokinetic-pharmacodynamic (PK-PD) principles to dosing regimens. If antimicrobials are used appropriately by applying these principles to attain targets for area-under-the-curve to MIC ratio (AUC/MIC), peak concentration to MIC ratio (CMAX/MIC), and time above MIC (T>MIC), more effective antibiotic therapy is possible, thus avoiding ineffective administration. Another mechanism whereby inappropriate antibiotic administration can be avoided is to use accurate Interpretive Criteria established by the Clinical Laboratory Standards Institute (CLSI) for breakpoint selection. Inaccurate breakpoints will encourage antibiotic administration that is likely to be ineffective. For newly approved antimicrobials, three criteria are used for determining breakpoints: PK-PD criteria, MIC distributions, and clinical response. For older (often generic drugs) evaluated by the CLSI, recent clinical data may not be available and breakpoints are derived from PK-PD principles, wild-type distributions, and Monte Carlo simulations. It is the goal of the CLSI subcommittee that these revised breakpoints will encourage more effective antimicrobial use and avoid unnecessary antimicrobial administration.
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Affiliation(s)
- Mark G Papich
- North Carolina State University, College of Veterinary Medicine, 1060 William Moore Drive, Raleigh, NC 27607, USA.
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37
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Yilmaz E, Akalin H, Özbey S, Kordan Y, Sinirtaş M, Gürcüoglu E, Özakin C, Heper Y, Mistik R, Helvaci S. Risk Factors in Community-Acquired/Onset Urinary Tract Infections Due to Extended-Spectrum Beta-Lactamase-ProducingEscherichia coliandKlebsiella pneumoniae. J Chemother 2013; 20:581-5. [DOI: 10.1179/joc.2008.20.5.581] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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38
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Nguyen HM, Shier KL, Graber CJ. Determining a clinical framework for use of cefepime and -lactam/ -lactamase inhibitors in the treatment of infections caused by extended-spectrum- -lactamase-producing Enterobacteriaceae. J Antimicrob Chemother 2013; 69:871-80. [DOI: 10.1093/jac/dkt450] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Tham J, Odenholt I, Walder M, Andersson L, Melander E. Risk factors for infections with extended-spectrum beta-lactamase-producing Escherichia coli in a county of Southern Sweden. Infect Drug Resist 2013; 6:93-7. [PMID: 24082789 PMCID: PMC3785393 DOI: 10.2147/idr.s46290] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background It is important to identify patients who are at risk for infections with extended-spectrum β-lactamase (ESBL)-producing bacteria in order to reduce mortality, to avoid spread of resistant bacteria in hospitals, and to minimize the number of patients receiving unnecessary treatment with broad-spectrum antibiotics. A case-control survey among Swedish patients was performed at Skåne University Hospital to identify risk factors for developing an infection with ESBL-producing Escherichia coli in a low endemic country. Methods We used a computerized database to identify patients with growth of ESBL-producing E. coli (n = 109) in urine or blood cultures and an equal number of controls matched for age and gender with non ESBL-producing E. coli in urine and blood diagnosed between January and October 2008. We used unadjusted P-values. Results Patients with ESBL-producing E. coli had a significantly (P < 0.05) higher likelihood of having traveled to Asia including Turkey and the Middle East including Egypt (14/58) than the non-ESBL-positive group (4/53). Hospital stay during the previous year (P < 0.04), especially for more than one month, was another significant (P = 0.01) risk factor for infection with ESBL-producing E. coli (8/58). A stay in the surgical department was a further risk factor (P < 0.01). Conclusion In this study, we identified 22 of 58 (38%) patients with ESBL-producing E. coli by considered significant risk factors before starting antibiotics.
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Affiliation(s)
- Johan Tham
- Infectious Diseases Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Antimicrobials, Susceptibility Testing, and Minimum Inhibitory Concentrations (MIC) in Veterinary Infection Treatment. Vet Clin North Am Small Anim Pract 2013; 43:1079-89. [DOI: 10.1016/j.cvsm.2013.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Schulz LT, Fox BC, Polk RE. Can the antibiogram be used to assess microbiologic outcomes after antimicrobial stewardship interventions? A critical review of the literature. Pharmacotherapy 2013; 32:668-76. [PMID: 23307516 DOI: 10.1002/j.1875-9114.2012.01163.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hospitals are implementing antimicrobial stewardship programs (ASPs) in response to national guidelines to improve the use and to extend the utility of antiinfective drugs. An often implied purpose of ASPs is to curb or reverse the emergence of resistant bacteria. Because antibiotic use causes antibiotic resistance, there is a natural tendency to link local measures of antibiotic use to local measures of bacterial resistance, and the hospital antibiogram is a readily available measure of resistance. We performed a literature review to identify published reports that used hospitalwide and unit-specific antibiograms to assess the relationship of ASP interventions to changes in resistance. Eight studies were identified and reviewed. The relationship between hospital antibiotic use and resistance is complex, and the existing literature has several limitations. Furthermore, the antibiogram itself is neither designed nor well suited to reflect changes in hospital antimicrobial drug use. The literature on the effectiveness of ASPs in reducing resistance continues to emerge, but at this time the antibiogram bears an inconsistent relationship with changes in hospital antibiotic use and cannot be recommended to reliably evaluate an ASP intervention. Interrupted time series analysis is a superior strategy to assess the effect of an ASP intervention on bacterial resistance, but it is not widely used because of its complexity and greater data requirements. Nevertheless, before ASP efforts can be convincingly demonstrated to have a favorable impact on resistance, a more sophisticated approach that links drug use to resistance should become a priority, at least for hospitals that have sufficient resources.
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Affiliation(s)
- Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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van Duin D, van Delden C. Multidrug-resistant gram-negative bacteria infections in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:31-41. [PMID: 23464996 DOI: 10.1111/ajt.12096] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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To KK, Lo WU, Chan JF, Tse H, Cheng VC, Ho PL. Clinical outcome of extended-spectrum beta-lactamase-producing Escherichia coli bacteremia in an area with high endemicity. Int J Infect Dis 2013; 17:e120-4. [DOI: 10.1016/j.ijid.2012.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 08/21/2012] [Accepted: 09/25/2012] [Indexed: 10/27/2022] Open
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Kurihara Y, Hitomi S, Oishi T, Kondo T, Ebihara T, Funayama Y, Kawakami Y. Characteristics of bacteremia caused by extended-spectrum beta-lactamase-producing Proteus mirabilis. J Infect Chemother 2013; 19:799-805. [DOI: 10.1007/s10156-013-0563-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
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Lee NY, Lee CC, Huang WH, Tsui KC, Hsueh PR, Ko WC. Cefepime therapy for monomicrobial bacteremia caused by cefepime-susceptible extended-spectrum beta-lactamase-producing Enterobacteriaceae: MIC matters. Clin Infect Dis 2012; 56:488-95. [PMID: 23090931 DOI: 10.1093/cid/cis916] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae isolates are important clinical pathogens. In addition, the efficacy of cefepime for such infections is controversial. METHODS We performed a retrospective study of monomicrobial bacteremia caused by ESBL producers at 2 medical centers between May 2002 and August 2007. The patients definitively treated with in vitro active cefepime (cases) were compared with those treated with a carbapenem (controls) in a propensity score-matched analysis to assess therapeutic effectiveness. The 30-day crude mortality is the primary endpoint. RESULTS A total of 178 patients were eligible for the study. Patients who received cefepime (n = 17) as definitive therapy were more likely to have a clinical failure (odds ratio [OR] 6.2; 95% confidence interval [CI], 1.7-22.5; P = .002), microbiological failure (OR 5.5; 95% CI, 1.3-25.6; P = .04), and 30-day mortality (OR 7.1; 95% CI, 2.5-20.3; P < .001) than those who received carbapenem therapy (n = 161). Multivariate regression revealed that a critical illness with a Pitt bacteremia score ≥ 4 points (OR 5.4; 95% CI, 1.4-20.9; P = .016), a rapidly fatal underlying disease (OR 4.4; 95% CI, 1.5-12.6; P = .006), and definitive cefepime therapy (OR 9.9; 95% CI, 2.8-31.9; P < .001) were independently associated with 30-day crude mortality. There were 17 case-control pairs in the propensity scores matched analysis. The survival analysis consistently found that individuals who received cefepime therapy had a lower survival rate (log-rank test, P = .016). CONCLUSIONS Based on the current Clinical and Laboratory Standards Institute susceptible breakpoint of cefepime (minimum inhibitory concentration ≤ 8 μg/mL), cefepime definitive therapy is inferior to carbapenem therapy in treating patients with so-called cefepime-susceptible ESBL-producer bacteremia.
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Affiliation(s)
- Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital and Medical College, Tainan, Taiwan
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van der Bij AK, van Dijk K, Muilwijk J, Thijsen SFT, Notermans DW, de Greeff S, van de Sande-Bruinsma N. Clinical breakpoint changes and their impact on surveillance of antimicrobial resistance in Escherichia coli causing bacteraemia. Clin Microbiol Infect 2012; 18:E466-72. [PMID: 22925456 DOI: 10.1111/j.1469-0691.2012.03996.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dutch laboratories are currently changing their breakpoint criteria from mostly Clinical Laboratory and Standards Institute (CLSI) breakpoints to European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints. To evaluate the impact of these changes, we studied antimicrobial resistance trends of Escherichia coli in blood specimens from January 2008 to January 2012 using CLSI and EUCAST breakpoints and compared them with the antimicrobial susceptibility test (AST) interpretations reported by Dutch laboratories participating in the Infectious Disease Surveillance Information System for Antibiotic Resistance (ISIS-AR). ISIS-AR collects AST interpretations, including underlying minimal inhibitory concentrations (MICs) of routinely cultured bacterial species on a monthly basis from Dutch laboratories. MICs of Etests or automated systems were reinterpreted according to the CLSI 2009 and EUCAST 2010 guidelines. Trends in non-susceptibility (i.e. intermediate resistant and resistant) over time were analysed by the Cochran-Armitage test for trend. The effects of the change from CLSI to EUCAST breakpoints on non-susceptibility were small. There were no differences in non-susceptibility to amoxicillin, amoxicillin/clavulanic acid, cefuroxim, gentamicin and co-trimoxazol and only small differences (1-1.5%) for ciprofloxacin between AST interpretations by CLSI or EUCAST. However, for ceftazidime, and cefotaxime/ceftriaxone the proportion of non-susceptibility was substantially higher when EUCAST breakpoints were used (2-3%). The effects on time trends of the change in guidelines were limited, with only substantial differences for the oxymino-cephalosporins. Our study shows that the implementation of EUCAST breakpoints has a limited effect on the proportion of non-susceptible isolates and time trends in E. coli for most, but not all, antimicrobial agents.
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Affiliation(s)
- A K van der Bij
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
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Schultsz C, Geerlings S. Plasmid-mediated resistance in Enterobacteriaceae: changing landscape and implications for therapy. Drugs 2012; 72:1-16. [PMID: 22191792 DOI: 10.2165/11597960-000000000-00000] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antimicrobial resistance is increasing worldwide, and pathogenic microorganisms that are resistant to all available antimicrobial agents are increasingly reported. Emerging plasmid-encoded extended-spectrum β-lactamases (ESBLs) and carbapenemases are increasingly reported worldwide. Carbapenemase production encoded by genes located on mobile genetic elements is typically accompanied by genes encoding resistance to other drug classes, often but not necessarily located on the same mobile element. Multiple plasmid-mediated mechanisms of resistance against the fluoroquinolones and aminoglycosides have been described, and the combination of plasmid-mediated resistance with chromosomally encoded resistance mechanisms of multiple drug classes now results in strains that are resistant to all of the main classes of commonly used antimicrobial drugs. Clinical studies of antimicrobial therapy and outcome of patients infected with ESBL- or carbapenemase-producing strains of Enterobacteriaceae compared with patients infected with susceptible strains are limited in their design but suggest a worse outcome after infection with resistant strains. Alternative options for the treatment of infections caused by carbapenem-resistant strains of Enterobacteriaceae are limited. Current strategies include colistin, fosfomycin, tigecycline and temocillin. Although in vitro testing suggests strong activity for each of these drugs against a large proportion of carbapenem-resistant strains of Enterobacteriaceae, clinical evaluations do not provide strong evidence for equivalent or improved outcome. Oral treatment with fosfomycin tromethamine is effective against lower urinary tract infections (UTIs) caused by ESBL-producing Escherichia coli. Intravenous fosfomycin may be beneficial and safe for patients when used as part of a combination therapy in the management of severe infections caused by carbapenem-resistant Klebsiella pneumoniae. Tigecycline is only indicated for the treatment of complicated skin and skin structure infections and complicated intra-abdominal infections in Europe, and is also approved for treatment of community-acquired pneumonia in the US. Clearly, further research on the clinical and safety outcomes in the treatment of multidrug-resistant Enterobacteriaceae with these existing alternative drugs, and the development of new and unrelated drugs, are urgently warranted.
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Affiliation(s)
- Constance Schultsz
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Carbapenem therapy for bacteremia due to extended-spectrum-β-lactamase-producing Escherichia coli or Klebsiella pneumoniae: implications of ertapenem susceptibility. Antimicrob Agents Chemother 2012; 56:2888-93. [PMID: 22430969 DOI: 10.1128/aac.06301-11] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
A retrospective study was conducted at two medical centers in Taiwan to evaluate the clinical characteristics, outcomes, and risk factors for mortality among patients treated with a carbapenem for bacteremia caused by extended-spectrum-beta-lactamase (ESBL)-producing organisms. A total of 251 patients with bacteremia caused by ESBL-producing Escherichia coli and Klebsiella pneumoniae isolates treated by a carbapenem were identified. Among these ESBL-producing isolates, rates of susceptibility to ertapenem (MICs ≤ 0.25 μg/ml) were 83.8% and 76.4%, respectively; those to meropenem were 100% and 99.3%, respectively; and those to imipenem were 100% and 97.9%, respectively. There were no significant differences in the critical illness rate (P = 0.1) or sepsis-related mortality rate (P = 0.2) for patients with bacteremia caused by ESBL-producing K. pneumoniae (140 isolates, 55.8%) and E. coli (111 isolates, 44.2%). Multivariate analysis of variables related to sepsis-related mortality revealed that the presence of severe sepsis (odds ratio [OR], 15.9; 95% confidence interval [CI], 5.84 to 43.34; P < 0.001), hospital-onset bacteremia (OR, 4.65; 95% CI, 1.42 to 15.24; P = 0.01), and ertapenem-nonsusceptible isolates (OR, 5.12; 95% CI, 2.04 to 12.88; P = 0.001) were independent risk factors. The patients receiving inappropriate therapy had a higher sepsis-related mortality than those with appropriate therapy (P = 0.002), irrespective of ertapenem, imipenem, or meropenem therapy. Infections due to the ertapenem-susceptible isolates (MICs ≤ 0.25 μg/ml) were associated with a more favorable outcome than those due to ertapenem-nonsusceptible isolates (MICs > 0.25 μg/ml), if treated by a carbapenem. However, the mortality for patients with bacteremic episodes due to isolates with MICs of ≤ 0.5 μg/ml was similar to the mortality for those whose isolates had MICs of >0.5 μg/ml (P = 0.8). Such a finding supports the rationale of the current CLSI 2011 criteria for carbapenems for Enterobacteriaceae.
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Lenhard-Vidal A, Cardoso RF, Pádua RAFD, Siqueira VLD. High prevalence rate of extended-spectrum beta-lactamases (ESBL) among Enterobacteriaceae in a small Brazilian public hospital. BRAZ J PHARM SCI 2011. [DOI: 10.1590/s1984-82502011000400006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The production of extended-spectrum beta-lactamases (ESBL) is considered one of the most important resistance mechanisms that impair antimicrobial treatment of infections caused by Enterobacteriaceae. Data on culture and susceptibility tests were collected from the Clinical Analyses and Research Laboratory charts reporting on patients admitted to the University Hospital of Maringá (HUM) from January 2004 to December 2009. The following Enterobacteriaceae were selected: Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter spp. and Proteus mirabilis. All tests were performed according to the recommendations of the Clinical and Laboratory Standards Institute (biochemical identification; susceptibility tests; initial screening and phenotypic confirmatory tests for ESBL). For Enterobacter spp. isolates, a disk approximation test was carried out, adding a cefepime disk. Seven hundred samples were analyzed, and E. coli was the most prevalent bacteria (n= 356). ESBLs were detected phenotypically in 7.3% of E. coli, 61.7% of K. pneumoniae, 33.3% of K. oxytoca, 7.1% of P. mirabilis, and 13.4% of Enterobacter spp samples. Overall ESBL prevalence reached 22% when all producers were taken together. Although HUM is considered a small-sized hospital, it showed high levels of resistance to antimicrobial agents, similar to those observed in bigger hospitals, which demonstrated the need for careful epidemiological surveillance.
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Leclercq R, Cantón R, Brown DFJ, Giske CG, Heisig P, MacGowan AP, Mouton JW, Nordmann P, Rodloff AC, Rossolini GM, Soussy CJ, Steinbakk M, Winstanley TG, Kahlmeter G. EUCAST expert rules in antimicrobial susceptibility testing. Clin Microbiol Infect 2011; 19:141-60. [PMID: 22117544 DOI: 10.1111/j.1469-0691.2011.03703.x] [Citation(s) in RCA: 434] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
EUCAST expert rules have been developed to assist clinical microbiologists and describe actions to be taken in response to specific antimicrobial susceptibility test results. They include recommendations on reporting, such as inferring susceptibility to other agents from results with one, suppression of results that may be inappropriate, and editing of results from susceptible to intermediate or resistant or from intermediate to resistant on the basis of an inferred resistance mechanism. They are based on current clinical and/or microbiological evidence. EUCAST expert rules also include intrinsic resistance phenotypes and exceptional resistance phenotypes, which have not yet been reported or are very rare. The applicability of EUCAST expert rules depends on the MIC breakpoints used to define the rules. Setting appropriate clinical breakpoints, based on treating patients and not on the detection of resistance mechanisms, may lead to modification of some expert rules in the future.
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Affiliation(s)
- R Leclercq
- Laboratoire de Microbiologie, CHU Côte de Nacre, Caen, France
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