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Giannella M, Rinaldi M, Viale P. Antimicrobial Resistance in Organ Transplant Recipients. Infect Dis Clin North Am 2023; 37:515-537. [PMID: 37244806 DOI: 10.1016/j.idc.2023.04.001] [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] [Indexed: 05/29/2023]
Abstract
The overall burden of the main clinically relevant bacterial multidrug-resistant organisms (MDROs) (eg, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum β-lactamase producing or extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant or carbapenemase-producing Enterobacterales, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii) in solid organ transplant (SOT) populations is summarized showing prevalence/incidence, risk factors, and impact on graft/patient outcome according to the type of SOT. The role of such bacteria in donor-derived infections is also reviewed. As for the management, the main prevention strategies and treatment options are discussed. Finally, nonantibiotic-based strategies are considered as future directions for the management of MDRO in SOT setting.
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Affiliation(s)
- Maddalena Giannella
- Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 11, Bologna 40137, Italy.
| | - Matteo Rinaldi
- Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 11, Bologna 40137, Italy
| | - Pierluigi Viale
- Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 11, Bologna 40137, Italy
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Verma N, Divakar Reddy PV, Vig S, Angrup A, Biswal M, Valsan A, Garg P, Kaur P, Rathi S, De A, Premkumar M, Taneja S, Ray P, Duseja A, Singh V. Burden, risk factors, and outcomes of multidrug-resistant bacterial colonisation at multiple sites in patients with cirrhosis. JHEP Rep 2023; 5:100788. [PMID: 37484213 PMCID: PMC10362792 DOI: 10.1016/j.jhepr.2023.100788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/25/2023] [Accepted: 04/29/2023] [Indexed: 07/25/2023] Open
Abstract
Background & Aims The reported burden of multidrug-resistant organism (MDRO) infections is highest in patients with cirrhosis from India. We evaluated whether colonisation at multiple barriers predisposes to such infections and poor outcomes in patients with cirrhosis. Methods We prospectively performed swab cultures, antimicrobial susceptibility testing (AST), and genotype testing for MDROs from various sites (rectum, nose, composite-skin, and central-line) in patients with cirrhosis (2020-2021) on admission and follow-up at a tertiary institute. We analysed clinical data, risk factors for MDROs, and patient outcomes. Results Of 125 patients aged 49 years, 85.6% males, 60.8% with acute-on-chronic liver failure, 99 (79.2%) were identified as 'colonisers'. MDRO-colonisation at rectum, nose, skin, or central line was observed in 72.7% (88/121), 30.0% (36/120), 14.9% (18/121), and 3.3% (4/121) patients, respectively. Patients were colonised with the following types of bacteria: extended-spectrum beta-lactamase (71/125), carbapenem-resistant Enterobacterales (67/125), MDR-Enterococcus (48/125), MDR-Acinetobacter (21/125), or methicillin-resistant Staphylococcus aureus (4/125). Multiple precipitants of acute-decompensation (odds ratio [OR]: 3.4, p = 0.042), norfloxacin prophylaxis (OR: 3.9, p = 0.008), and MDRO infection at admission (OR: 8.9, p = 0.041) were the independent predictors of colonisation. Colonisation increased the risk of infection by MDROs at admission (OR: 8.5, p = 0.017) and follow up (OR: 7.5, p <0.001). Although any-site colonisers were at greater risk of cerebral failure and poorer Child-Pugh scores, the nasal and skin colonisers were at higher risk of cerebral and circulatory failures than non-colonisers (p <0.05).Patients with more than one site colonisation (prevalence: 30%) developed multi-organ failure (p <0.05), MDRO infection (OR: 7.9, p <0.001), and poorer 30-day survival (hazard ratio: 2.0, p = 0.005). Conclusions A strikingly high burden of MDRO colonisation among patients with cirrhosis in India necessitates urgent control measures. Multiple-site colonisation increases the risk of MDR-infections, multi-organ failure, and mortality in patients with cirrhosis. Impact and Implications Infections by bacteria resistant to multiple antibiotics are an emerging cause of death in cirrhosis. We showed that ∼70-80% of critically ill hospitalised patients with cirrhosis carry such bacteria with the highest rate in the rectum, nose, skin, and central line port. Carbapenem-resistant and vancomycin-resistant bacteria were amongst the most common colonising bacteria. The presence of these bacteria at multiple sites increased the risk of multidrug-resistant infections, multiple organ failures, and death in patients with cirrhosis.
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Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P. Venkata Divakar Reddy
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shashi Vig
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manisha Biswal
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Valsan
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Garg
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parminder Kaur
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dolci G, Burastero GJ, Paglia F, Cervo A, Meschiari M, Guaraldi G, Chester J, Mussini C, Franceschini E. Epidemiology and Prevention of Early Infections by Multi-Drug-Resistant Organisms in Adults Undergoing Liver Transplant: A Narrative Review. Microorganisms 2023; 11:1606. [PMID: 37375108 DOI: 10.3390/microorganisms11061606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Invasive bacterial infections are a leading cause of morbidity and mortality after liver transplant (LT), especially during the first months after LT, and infections due to multi-drug-resistant organisms (MDRO) are increasing in this setting. Most of the infections in patients in intensive care unit arise from the endogenous microflora and, for this reason, pre-LT MDRO rectal colonization is a risk factor for developing MDRO infections in the post-LT. Moreover, the transplanted liver may carry an increased risk of MDRO infections due to organ transportation and preservation, to donor intensive care unit stay and previous antibiotic exposure. To date, little evidence is available about how MDRO pre-LT colonization in donors and recipients should address LT preventive and antibiotic prophylactic strategies, in order to reduce MDRO infections in the post-LT period. The present review provided an extensive overview of the recent literature on these topics, with the aim to offer a comprehensive insight about the epidemiology of MDRO colonization and infections in adult LT recipients, donor-derived MDRO infections, possible surveillance, and prophylactic strategies to reduce post-LT MDRO infections.
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Affiliation(s)
- Giovanni Dolci
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giulia Jole Burastero
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Francesca Paglia
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Adriana Cervo
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Johanna Chester
- Department of Dermatology, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
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Righi E, Scudeller L, Mirandola M, Visentin A, Mutters NT, Meroi M, Schwabe A, Erbogasto A, Vantini G, Cross ELA, Giannella M, Guirao X, Tacconelli E. Colonisation with Extended-Spectrum Cephalosporin-Resistant Enterobacterales and Infection Risk in Surgical Patients: A Systematic Review and Meta-analysis. Infect Dis Ther 2023; 12:623-636. [PMID: 36633819 PMCID: PMC9925622 DOI: 10.1007/s40121-022-00756-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/21/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Limited evidence has been reported for surgical site infections (SSIs) in patients undergoing surgery who are carriers of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E). A systematic review and meta-analysis were conducted to evaluate the risk of postoperative infections in adult inpatients colonised with ESCR-E before surgery. METHODS The Medline, Embase and Cochrane databases were searched between January 2011 and April 2022, following PRISMA indications. Random effects meta-analysis was used to quantify the association between ESCR-E colonisation and infection. RESULTS Among the 467 articles reviewed, 9 observational studies encompassing 7219 adult patients undergoing surgery were included. The ESCR-E colonisation rate was 13.7% (95% CI 7.7-19.7). The most commonly reported surgeries included abdominal surgery (44%) and liver transplantation (LT; 33%). The SSI rate was 23.2% (95% CI 13.2-33.1). Pooled incidence risk was 0.36 (95% CI 0.22-0.50) vs 0.13 (95% CI 0.02-0.24) for any postoperative infection and 0.28 (95% CI 0.18-0.38) vs 0.17 (95% CI 0.07-0.26) for SSIs in ESCR-E carriers vs noncarriers, respectively. In ESCR-E carriers, the ESCR-E infection ratio was 7 times higher than noncarriers. Postoperative infection risk was higher in carriers versus noncarriers following LT. Sources of detected heterogeneity between studies included ESCR-E colonisation and the geographic region of origin. CONCLUSIONS Patients colonised with ESCR-E before surgery had increased incidence rates of post-surgical infections and SSIs compared to noncarriers. Our results suggest considering the implementation of pre-surgical screening for detecting ESCR-E colonisation status according to the type of surgery and the local epidemiology.
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Affiliation(s)
- Elda Righi
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy.
| | - Luigia Scudeller
- Research and Innovation Unit, IRCCS Bologna University Hospital, Bologna, Italy
| | - Massimo Mirandola
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Alessandro Visentin
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Nico T Mutters
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Marco Meroi
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Anna Schwabe
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Anna Erbogasto
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | | | - Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Xavier Guirao
- Surgical Endocrine Unit, Department of General Surgery, Surgical Site Prevention Unit, Parc Tauli University Hospital, Sabadell, Spain
| | - Evelina Tacconelli
- Infectious Diseases Division, Diagnostics and Public Health Department, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
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Pilmis B, Weiss E, Scemla A, Le Monnier A, Grossi PA, Slavin MA, Van Delden C, Lortholary O, Paugam-Burtz C, Zahar JR. Multidrug-resistant Enterobacterales infections in abdominal solid organ transplantation. Clin Microbiol Infect 2023; 29:38-43. [PMID: 35716912 DOI: 10.1016/j.cmi.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Transplant recipients are highly susceptible to multidrug-resistant (MDR) related infections. The lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. OBJECTIVES In this review, we present the current state of knowledge concerning multidrug-resistant Gram negative bacilli's risk management in the care of solid-organ transplant recipients and suggest control strategies. SOURCES We searched for studies treating MDR g-negative bacilli related infections in the renal and hepatic transplant patient population. We included randomized and observational studies. CONTENT Solid-organ transplant is the best therapeutic option for patients diagnosed with end-stage organ disease. While the incidence of opportunistic infections is decreasing due to better prevention, the burden of "classical" infections related to MDR bacteria especially related to Gram-negative bacteria is constantly increasing. Over the last two decades, various MDR pathogens have emerged as a relevant cause of infection in this specific population associated with significant mortality. Several factors related to the management of transplant donor candidates and recipients increase the risk of MDR infections in transplant recipients. The awareness of this high susceptibility of transplant recipients to MDR-related infections challenges the choice of empirical therapy, while its appropriateness can only be validated a posteriori. Indeed, the lack of early appropriate antimicrobial treatment may contribute to the high mortality due to MDR-related infections in transplant recipients especially in case of metallo-β-lactamases. IMPLICATIONS Multidrug-resistant Gram-negative bacteria are associated with high morbidity and mortality in solid organ transplant recipients. It seems important to identify patients at risk of colonization/MDR bacteria to evaluate strategies to limit the risk of secondary infections and to minimize the inappropriate use of broad-spectrum antibiotics.
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Affiliation(s)
- Benoît Pilmis
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France; Équipe mobile de microbiologie Clinique, Groupe Hospitalier Paris Saint Joseph, Paris, France; Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France.
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Anne Scemla
- Departement of Nephrology-Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - Alban Le Monnier
- Institut Micalis, UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Chatenay-Malabry, France; Service de Microbiologie Clinique et Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Paolo Antonio Grossi
- Department of Medicine and Surgery, University of Insubria and ASST Sette Laghi, Ospedale di Circolo of Varese, Varese, Italy
| | - Monica A Slavin
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia; National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Olivier Lortholary
- Centre d'infectiologie Necker-Pasteur, Hôpital Necker Enfants-Malades, Centre médical de l'institut Pasteur, Université de Paris, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Université de Paris, Paris, France; Inserm UMR S1149, Centre de recherche sur l'inflammation
| | - Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, France; Service de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, Bobigny, France
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6
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Righi E, Mutters NT, Guirao X, Del Toro MD, Eckmann C, Friedrich AW, Giannella M, Kluytmans J, Presterl E, Christaki E, Cross ELA, Visentin A, Sganga G, Tsioutis C, Tacconelli E. ESCMID/EUCIC clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant Gram-negative bacteria before surgery. Clin Microbiol Infect 2022; 29:463-479. [PMID: 36566836 DOI: 10.1016/j.cmi.2022.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/10/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
SCOPE The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery. METHODS These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development. RECOMMENDATIONS The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.
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Affiliation(s)
- Elda Righi
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- University Hospital Bonn, Institute for Hygiene and Public Health, Bonn, Germany
| | - Xavier Guirao
- Surgical Endocrine Unit, Department of General Surgery, Surgical Site Prevention Unit, Parc Tauli, Hospital Universitari Sabadell, Spain
| | - Maria Dolores Del Toro
- Division of Infectious Diseases and Microbiology, University Hospital Virgen Macarena, Seville, Spain; Department of Medicine, University of Sevilla. Biomedicine Institute of Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas, Spain
| | - Christian Eckmann
- Klinikum Hannoversch-Muenden, Academic Hospital of Goettingen University, Germany
| | - Alex W Friedrich
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Groningen, the Netherlands; Institute for European Prevention Networks in Infection Control, University Hospital Münster, Münster, Germany
| | - Maddalena Giannella
- Infectious Diseases Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Eirini Christaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Alessandro Visentin
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; Division of Infectious Diseases, Department of Internal Medicine I, University of Tübingen, Tübingen, Germany.
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7
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Prado V, Hernández-Tejero M, Mücke MM, Marco F, Gu W, Amoros A, Toapanta D, Reverter E, Peña-Ramirez CDL, Altenpeter L, Bassegoda O, Mezzano G, Aziz F, Juanola A, Rodríguez-Tajes S, Chamorro V, López D, Reyes M, Hogardt M, Kempf VAJ, Ferstl PG, Zeuzem S, Martínez JA, Vila J, Arroyo V, Trebicka J, Fernandez J. Rectal colonization by resistant bacteria increases the risk of infection by the colonizing strain in critically ill patients with cirrhosis. J Hepatol 2022; 76:1079-1089. [PMID: 35074475 DOI: 10.1016/j.jhep.2021.12.042] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/01/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS It remains unclear whether rectal colonization with multidrug-resistant organisms (MDROs) is prevalent and predisposes to infections by the same pathogens in patients with cirrhosis. METHODS Two series of critically ill patients were evaluated. In the Barcelona cohort, 486 consecutive patients were prospectively evaluated, 129 with and 357 without cirrhosis (2015-2016). Rectal swabs were performed at admission and weekly thereafter (until intensive care unit [ICU] discharge) to detect MDRO colonization. Risk factors for colonization and infection by MDROs were evaluated. A retrospective cohort from Frankfurt (421 patients with cirrhosis; 2010-2018) was investigated to evaluate MDRO rectal colonization in another epidemiological scenario. RESULTS In the Barcelona cohort, 159 patients were colonized by MDROs (32.7%), 102 (64.2%) at admission and 57 (35.8%) during follow-up. Patients with cirrhosis showed higher rates of rectal colonization at admission than those without cirrhosis (28.7% vs. 18.2%, p = 0.01) but similar colonization rates during ICU stay. Extended-spectrum beta-lactamase-Enterobacterales were the most frequent MDROs isolated in both groups. Colonization by MDROs independently increased the risk of infection by MDROs at admission and during follow-up. Risk of new infection by the colonizing strain was also significantly increased in patients with (hazard ratio [HR] 7.41) and without (HR 5.65) cirrhosis. Rectal colonization by MDROs was also highly prevalent in Frankfurt (n = 198; 47%; 131 at admission [66.2%] and 67 [33.8%] during follow-up), with vancomycin-resistant enterococci being the most frequent colonizing organism. Rectal colonization by MDROs was also associated with an increased risk of infection by MDROs in this cohort. Infections occurring in MDR carriers were mainly caused by the colonizing strain. CONCLUSION Rectal colonization by MDROs is extremely frequent in critically ill patients with cirrhosis. Colonization increases the risk of infection by the colonizing resistant strain. LAY SUMMARY Rectal colonization by multidrug-resistant organisms (MDROs) is a prevalent problem in patients with cirrhosis requiring critical care. The pattern of colonizing bacteria is heterogeneous with relevant differences between centers. Colonization by MDROs is associated with increased risk of infection by the colonizing bacteria in the short term. This finding suggests that colonization data could be used to guide empirical antibiotic therapy and de-escalation policies in patients with cirrhosis.
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Affiliation(s)
- Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; Hepato-Gastro-enterology Department, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - María Hernández-Tejero
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Marcus M Mücke
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Francesc Marco
- Microbiology Department, Hospital Clinic, University of Barcelona, Spain; ISGlobal, Hospital Clínic - University of Barcelona, Spain
| | - Wenyi Gu
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Alex Amoros
- EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | | | - Laura Altenpeter
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Gabriel Mezzano
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Fátima Aziz
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Adria Juanola
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Sergio Rodríguez-Tajes
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Vanessa Chamorro
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - David López
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Marta Reyes
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Volkhard A J Kempf
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, Germany; University Center for Infectious Diseases, University Hospital Frankfurt, Germany; University Center of Competence for Infection Control, State of Hesse, Germany
| | - Philip G Ferstl
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | - Stefan Zeuzem
- Department for Internal Medicine I, Goethe University Frankfurt, Germany
| | | | - Jordi Vila
- Microbiology Department, Hospital Clinic, University of Barcelona, Spain; ISGlobal, Hospital Clínic - University of Barcelona, Spain
| | | | - Jonel Trebicka
- Department for Internal Medicine I, Goethe University Frankfurt, Germany; EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
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8
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Abstract
The World Health Organization describes antimicrobial resistance as one of the biggest threats to global health, food security, and development with indiscriminate use of antimicrobials globally driving the emergence of multidrug-resistant bacteria, resistant to 60% of antimicrobials in some countries. Infections with multidrug-resistant organisms (MDROs) have increased in recent decades in patients with cirrhosis, who are frequently prescribed antibiotics, regularly undergo invasive procedures such as large volume paracentesis, and have recurrent hospitalizations, posing a particular risk in this already immunocompromised cohort of patients. In this review, we explore mechanisms underlying this vulnerability to MDRO infection; the effect of bacterial infections on disease course in cirrhosis; prevalence of MDROs in patients with cirrhosis; outcomes following MDRO infection; fungal infections; antibiotics and their efficacy; and management of MDRO infections in terms of detection, antimicrobial and nonantimicrobial treatments, prophylaxis, antibiotic stewardship, the gut microbiome, and technological interventions.
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Affiliation(s)
- Charles E Gallaher
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Debbie L Shawcross
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom.,Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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9
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Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc07. [PMID: 35707229 PMCID: PMC9174886 DOI: 10.3205/dgkh000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.
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10
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Molina KC, Bajrovic V, Bonomo RA. Carbapenemase-producing Enterobacterales in solid organ transplantation: Tip of the iceberg? Transpl Infect Dis 2021; 24:e13780. [PMID: 34962337 DOI: 10.1111/tid.13780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
A liver transplant recipient developed a urinary tract infection with Citrobacter freundii complex and Klebsiella aerogenes, both producing dual carbapenemases (KPC-3/NDM-1). Whole genome sequencing suggested plasmid transfer between organisms. Silent plasmid transmission highlights emergent threats to infection prevention, with implications for screening and antimicrobial stewardship. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kyle C Molina
- Department of Pharmacy Services, University of Colorado Hospital, Aurora, CO, USA.,Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Division of Infectious Disease, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Valida Bajrovic
- Division of Infectious Disease, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA, Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA, CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
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11
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Colonization with Multidrug-resistant Organisms in Patients with Ventricular Assist Devices. ASAIO J 2021; 68:1048-1053. [PMID: 34967790 DOI: 10.1097/mat.0000000000001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infection is a leading cause of morbidity and mortality in patients with ventricular assist devices (VAD). The impact of colonization with multidrug-resistant organisms (MDRO) on outcomes in this cohort is unknown. Patients on VAD support from July 2008 to September 2018 at a single site were evaluated for MDRO colonization after implantation. MDROs included methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus species, and extended-spectrum beta-lactamase producing gram-negative bacteria. 378 patients with 433 VADs were included. 42.6% (n = 161) of patients were colonized with an MDRO throughout the duration of VAD support. Eighty-two VAD infections occurred, 74.4% (n = 61) of whom were MDRO colonized before infection. MDRO colonization was associated with an increased risk of a subsequent VAD infection (hazard ratio 3.704, p < 0.001). MDRO colonization is common after VAD implantation and is associated with future VAD infections. Further study is needed to determine best management strategies for VAD recipients with MDRO colonization given this increased risk.
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12
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Malekzadegan Y, Amanati A, Bazargani A, Ramzi M, Motamedifar M. Fecal colonization, phenotypic and genotypic characterization of ESBL-producing Escherichia coli isolates in transplant patients in Shiraz Nemazee and Abu Ali Sina Hospitals. GENE REPORTS 2021. [DOI: 10.1016/j.genrep.2021.101321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Fernández J, Piano S, Bartoletti M, Wey EQ. Management of bacterial and fungal infections in cirrhosis: The MDRO challenge. J Hepatol 2021; 75 Suppl 1:S101-S117. [PMID: 34039482 DOI: 10.1016/j.jhep.2020.11.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
Bacterial infections are frequent in cirrhotic patients with acute decompensation or acute-on-chronic liver failure and can complicate the clinical course. Delayed diagnosis and inappropriate empirical treatments are associated with poor prognosis and increased mortality. Fungal infections are much less frequent, usually nosocomial and associated with extremely high short-term mortality. Early diagnosis and adequate empirical treatment of infections is therefore key in the management of these patients. In recent decades, antibiotic resistance has become a major worldwide problem in patients with cirrhosis, warranting a more complex approach to antibiotic treatment that includes the use of broad-spectrum antibiotics, new administration strategies, novel drugs and de-escalation policies. Herein, we review epidemiological changes, the main types of multidrug-resistant organisms, mechanisms of resistance, new rapid diagnostic tools and currently available therapeutic options for bacterial and fungal infections in cirrhosis.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Michele Bartoletti
- Infectious Disease Unit- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emmanuel Q Wey
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom; Centre for Clinical Microbiology, Division of Infection & Immunity, UCL, London, United Kingdom; Department of Infection, Royal Free London NHS Trust London, United Kingdom
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14
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Chea N, Sapiano MRP, Zhou L, Epstein L, Guh A, Edwards JR, Allen-Bridson K, Russo V, Watkins J, Pouch SM, Magill SS. Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015-2018. Transpl Infect Dis 2021; 23:e13589. [PMID: 33617680 PMCID: PMC8380253 DOI: 10.1111/tid.13589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 01/22/2023]
Abstract
Liver transplant recipients are at high risk for surgical site infections (SSIs). Limited data are available on SSI epidemiology following liver transplant procedures (LTPs). We analyzed data on SSIs from 2015 to 2018 reported to CDC's National Healthcare Safety Network to determine rates, pathogen distribution, and antimicrobial resistance after LTPs and other hepatic, biliary, or pancreatic procedures (BILIs). LTP and BILI SSI rates were 5.7% and 5.9%, respectively. The odds of SSI after LTP were lower than after BILI (adjusted odds ratio = 0.70, 95% confidence interval 0.57-0.85). Among LTP SSIs, 43.1% were caused by Enterococcus spp., 17.2% by Candida spp., and 15.0% by coagulase-negative Staphylococcus spp. (CNS). Percentages of SSIs caused by Enterococcus faecium or CNS were higher after LTPs than BILIs, whereas percentages of SSIs caused by Enterobacteriaceae, Enterococcus faecalis, or viridans streptococci were higher after BILIs. Antimicrobial resistance was common in LTP SSI pathogens, including E. faecium (69.4% vancomycin resistant); Escherichia coli (68.8% fluoroquinolone non-susceptible and 44.7% extended spectrum cephalosporin [ESC] non-susceptible); and Klebsiella pneumoniae and K. oxytoca (39.4% fluoroquinolone non-susceptible and 54.5% ESC non-susceptible). National LTP SSI pathogen and resistance data can help prioritize studies to determine effective interventions to prevent SSIs and reduce antimicrobial resistance in liver transplant recipients.
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Affiliation(s)
- Nora Chea
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mathew R P Sapiano
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Lantana Consulting Group, Inc, East Thetford, VT, USA
| | - Liang Zhou
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.,CACI Inc., Atlanta, GA, USA
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alice Guh
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jonathan R Edwards
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Katherine Allen-Bridson
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria Russo
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.,CACI Inc., Atlanta, GA, USA
| | - Jennifer Watkins
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.,CACI Inc., Atlanta, GA, USA
| | | | - Shelley S Magill
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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15
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Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:232-264. [PMID: 33394069 PMCID: PMC7780910 DOI: 10.1007/s00103-020-03265-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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16
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Logre E, Bert F, Khoy-Ear L, Janny S, Giabicani M, Grigoresco B, Toussaint A, Dondero F, Dokmak S, Roux O, Francoz C, Soubrane O, Durand F, Paugam-Burtz C, Weiss E. Risk Factors and Impact of Perioperative Prophylaxis on the Risk of Extended-spectrum β-Lactamase-producing Enterobacteriaceae-related Infection Among Carriers Following Liver Transplantation. Transplantation 2021; 105:338-345. [PMID: 32217945 DOI: 10.1097/tp.0000000000003231] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage is frequent among liver transplant (LT) recipients, thereby fostering a large empirical carbapenem prescription. However, ESBL-E infections occur in only 10%-25% of critically ill patients with rectal colonization. Our aim was to identify risk factors for post-LT ESBL-E infection in colonized patients. The effect of perioperative antimicrobial prophylaxis (AP) was also analyzed in patients with prophylaxis lasting <48 hours and without proven intraoperative infection. METHODS Retrospective study from a prospective database including patients with a positive ESBL-E rectal screening transplanted between 2010 and 2016. RESULTS Among the 749 patients transplanted, 100 (13.3%) were colonized with an ESBL-E strain. Thirty-nine (39%) patients developed an infection related to the same ESBL-E (10 pulmonary, 11 surgical site, 13 urinary, 5 bloodstream) within 11 postoperative days in median. Klebsiella pneumoniae carriage, model for end-stage liver disease ≥25, preoperative spontaneous bacterial peritonitis prophylaxis, and antimicrobial exposure during the previous month were independent predictors of ESBL-E infection. We propose a colonization to infection risk score built on these variables. The prevalence of infection for colonization to infection score of 0, 1, 2, and ≥3 were 7.4%, 26.3%, 61.9%, and 91.3%, respectively. Of note, the incidence of post-LT ESBL-E infection was lower in case of perioperative AP targeting colonizing ESBL-E (P = 0.04). CONCLUSIONS Thirty-nine percentage of ESBL-E carriers develop a related infection after LT. We identified predictors for ESBL-E infection in carriers that may help in rationalizing carbapenem prescription. Perioperative AP targeting colonizing ESBL-E may be associated with a reduced risk of post-LT ESBL-E infections.
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Affiliation(s)
- Elsa Logre
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Frédéric Bert
- Department of Microbiology, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Linda Khoy-Ear
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Sylvie Janny
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Mikhaël Giabicani
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Bénédicte Grigoresco
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Amélie Toussaint
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Fédérica Dondero
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Safi Dokmak
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Olivier Roux
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
| | - Claire Francoz
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - François Durand
- Department of Hepatology, Beaujon Hospital, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de recherche sur l'inflammation, Paris, France
- Université de Paris, Paris, France
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17
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Magro B, Mazzola A, Munteanu M, Goumard C, Martinez V, Bernard D, Scatton O, Battaglia S, Celsa C, Cammà C, Conti F. Consequences of Extended Spectrum Beta-Lactamase-Producing Enterobacteriaceae and Methicillin-Resistant Staphylococcus aureus Carriage in Awaiting Liver Transplant Patients. Liver Transpl 2021; 27:43-54. [PMID: 32955790 DOI: 10.1002/lt.25897] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 01/13/2023]
Abstract
Infections in patients with cirrhosis are associated with liver-related complications (LRCs), especially in patients awaiting liver transplantation (LT). The aim of this study was to evaluate the impact of methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase colonization on infections and LRCs for patients on the wait list and on infections after LT. We retrospectively included 250 of 483 patients with cirrhosis who were placed on the wait list for LT from December 2015 to January 2018. These patients were screened for MRSA or extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) at the time of wait-list placement and after LT. Of the patients, 76% were male with a mean age of 57.5 ± 10 years, and the most frequent cause of liver disease was alcohol (39%). Median Model for End-Stage Liver Disease (MELD) score was 19 (12-28). Only 1 patient was positive for MRSA; 19% of patients (n = 47) had ESBLE fecal carriage at the time of wait-list placement and 15% (n = 37) had it after LT. Infection-free survival on the wait list and after LT, according to fecal carriage status, was not statistically different between 2 groups. LRC-free survival at 6 and 12 months was significantly lower in ESBLE fecal carriage (HR, 1.6; P = 0.04). MELD score >19 (HR, 3.0; P = 0.01) and occurrence of infection during the first 3 months on the wait list (HR, 4.13; P < 0.001) were independent risk factors for LRC occurrence in the multivariate analysis. Our study is the first showing that in a cohort of patients with cirrhosis waiting for LT LRC-free survival was lower in patients with ESBLE fecal carriage but that infection-free survival was not different between the 2 groups.
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Affiliation(s)
- Bianca Magro
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Research Center of Saint-Antoine, INSERM U938, Sorbonne Université, Paris, France
| | - Mona Munteanu
- Nutrition Institute, INSERM, Sorbonne Université, Paris, France
| | - Claire Goumard
- Hepato-Biliary and Liver Transplantation Surgical Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Valerie Martinez
- Infectious Diseases Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Denis Bernard
- Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Olivier Scatton
- Hepato-Biliary and Liver Transplantation Surgical Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Salvatore Battaglia
- Department of Economics, Business and Statistics, University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.,Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Filomena Conti
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Research Center of Saint-Antoine, INSERM U938, Sorbonne Université, Paris, France.,Nutrition Institute, INSERM, Sorbonne Université, Paris, France
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18
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Phichaphop C, Apiwattanakul N, Techasaensiri C, Lertudomphonwanit C, Treepongkaruna S, Thirapattaraphan C, Boonsathorn S. High prevalence of multidrug-resistant gram-negative bacterial infection following pediatric liver transplantation. Medicine (Baltimore) 2020; 99:e23169. [PMID: 33158003 PMCID: PMC7647589 DOI: 10.1097/md.0000000000023169] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Bacterial infection has been identified as one of the most significant complications of liver transplantation (LT). Multidrug-resistant (MDR) gram-negative bacteria (GNB) infection remains problematic issue following LT in the adults. However, data in children are scarce. We aimed to examine the prevalence and associated factors of MDR-GNB infection among pediatric LT recipients.We performed a single-center retrospectively study of 118 children who underwent LT between January 2010 and December 2018. Data on the prevalence, clinical characteristics, types, and sites of MDR-GNB infection within 3 months after LT as well as the treatment outcomes were collected. Multidrug resistance was defined as acquired non-susceptibility to at least 1 agent in 3 or more antibiotic classes.In total, 64 (53.7%) patients developed 96 episodes of culture-proven bacterial infection with 93 GNB isolates. Moreover, there were 58 (62.4%) MDR-GNB isolates, with a predominance of Klebsiella pneumoniae (32.7%), Escherichia coli (31%), and Pseudomonas aeruginosa (10.3%). Interestingly, 10 (17.2%) isolates were determined to be carbapenem-resistant Enterobacteriaceae. The median time to MDR-GNB infection was 9 (interquartile range: 5-33) days. The most common type of infection was intra-abdominal infection (47.9%). In the multivariate analysis, the significant variables associated with post-LT MDR-GNB infection include exposure to third-generation cephalosporins (hazard ratio [HR]: 2.16, P = .023), operative time (hazard ratio [HR] 1.20, P = .009), and length of intensive care unit stay (HR 1.03, P = .049). With a focus on carbapenem-resistant Enterobacteriaceae infection, a pediatric end-stage liver disease score >21 was the only significant 6 variable in the multivariate analysis (HR 11.48, P = .024). The overall 3-month mortality rate was 6.8%.This study has highlighted the high prevalence rate of MDR-GNB infection after pediatric LT. Therefore, caution on the emergence of MDR-GNB infection should be paid in at-risk children. Moreover, knowledge regarding the prevalence of MDR-GNB infection and resistant patterns is essential for guideline development to prevent and minimize the risk of MDR-GNB infection in this group of patients.
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19
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Donor-Derived Disease Transmission in Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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High Heterogeneity of Multidrug-Resistant Enterobacteriaceae Fecal Levels in Hospitalized Patients Is Partially Driven by Intravenous β-Lactams. Antimicrob Agents Chemother 2020; 64:AAC.01415-19. [PMID: 31767720 DOI: 10.1128/aac.01415-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/12/2019] [Indexed: 11/20/2022] Open
Abstract
Multidrug-resistant Enterobacteriaceae (MRE) colonize the intestine asymptomatically from where they can breach into the bloodstream and cause life-threatening infections, especially in heavily colonized patients. Despite the clinical relevance of MRE colonization levels, we know little about how they vary in hospitalized patients and the clinical factors that determine those levels. Here, we conducted one of the largest studies of MRE fecal levels by tracking longitudinally 133 acute leukemia patients and monitoring their MRE levels over time through extensive culturing. MRE were defined as Enterobacteriaceae species that acquired nonsusceptibility to ≥1 agent in ≥3 antimicrobial categories. In addition, due to the selective media used, the MRE had to be resistant to third-generation cephalosporins. MRE were detected in 60% of the patients, but their fecal levels varied considerably among patients and within the same patient (>6 and 4 orders of magnitude, respectively). Multivariate analysis of clinical metadata revealed an impact of intravenous beta-lactams (i.e., meropenem and piperacillin-tazobactam), which significantly diminished the fecal MRE levels in hospitalized patients. Consistent with a direct action of beta-lactams, we found an effect only when the patient was colonized with strains sensitive to the administered beta-lactam (P < 0.001) but not with nonsusceptible strains. We report previously unobserved inter- and intraindividual heterogeneity in MRE fecal levels, suggesting that quantitative surveillance is more informative than qualitative surveillance of hospitalized patients. In addition, our study highlights the relevance of incorporating antibiotic treatment and susceptibility data of gut-colonizing pathogens for future clinical studies and in clinical decision-making.
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21
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Martin Mateos R, Albillos A. Sepsis in Patients With Cirrhosis Awaiting Liver Transplantation: New Trends and Management. Liver Transpl 2019; 25:1700-1709. [PMID: 31408581 DOI: 10.1002/lt.25621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023]
Abstract
Bacterial infections are more frequent and severe in patients with advanced liver disease and, therefore, in liver transplant candidates. The increased risk of infection in these patients parallels the severity of the immune dysfunction associated with cirrhosis, which is related to systemic inflammation and progressive immunodeficiency. Other factors contribute to this risk, such as genetic polymorphisms, proton pump inhibitor overuse, the numerous invasive procedures and hospitalizations these patients go through, or the immunosuppressive effects of malnutrition or alcohol abuse. Bacterial infections have a great impact on disease progression and significantly increase mortality rates before and after liver transplantation. Mechanisms leading to organ failure in sepsis are associated not only with the hemodynamic derangement but also with an excessive inflammatory response triggered by infection. Furthermore, prophylactic and empirical antibiotic treatment strategies in patients with cirrhosis are being modified according to the growing prevalence of multidrug-resistant bacteria in the past decade. Also, new criteria have been introduced for the diagnosis of sepsis and septic shock. These new definitions have been validated in patients with cirrhosis and show a better accuracy to predict in-hospital mortality than previous criteria based on systemic inflammatory response syndrome. Accurate prophylaxis and early identification and treatment of bacterial infections are key to reducing the burden of sepsis in patients with cirrhosis awaiting liver transplantation.
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Affiliation(s)
- Rosa Martin Mateos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
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Colonization by fecal extended-spectrum β-lactamase-producing Enterobacteriaceae and surgical site infections in patients with cancer undergoing gastrointestinal and gynecologic surgery. Am J Infect Control 2019; 47:916-921. [PMID: 30850249 DOI: 10.1016/j.ajic.2019.01.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/27/2019] [Accepted: 01/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cancer patients are at increased risk of infection. Fecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) may increase this risk. There are few studies on the prevalence of ESBL-PE colonization and surgical site infections (SSIs). METHODS This prospective cohort study included patients with gastrointestinal and gynecological malignancies who were admitted to the hospital for elective surgery. Rectal swab cultures were obtained on the day of admission and during the postoperative period every 5 days. Prevalence of ESBL-PE fecal colonization and risk factors for the development of SSI were assessed. RESULTS We included 171 patients, 30 (17.5%) of whom were colonized with ESBL-PE at admission. This proportion increased to 21% (37 of 171) of the samples during the hospital stay. Incidence of SSI was 14.6% (n = 25). Ten of 37 (27%) patients colonized by ESBL-PE developed SSI versus 15 of 134 (11%) of the non-ESBL-PE (relative risk [RR], 2.163; 95% confidence interval [CI], 1.201-3.897; P = .016). Five patients developed a bloodstream infection, and 4 patients were colonized with ESBL-PE (RR = 4.02; 95% CI, 1.2-3.89; P = .008). CONCLUSIONS The rate of ESBL-PE fecal colonization in surgical patients was 17.5%. Colonization of ESBL-PE duplicated the risk of SSI by the same strain and, by a factor of 4, the risk of bloodstream infections.
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Pouch SM, Patel G. Multidrug-resistant Gram-negative bacterial infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13594. [PMID: 31102483 DOI: 10.1111/ctr.13594] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of infections due to multidrug-resistant (MDR) Gram-negative bacilli in the pre- and post-transplant period. MDR Gram-negative bacilli, including carbapenem-resistant Enterobacteriaceae, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii, remain a threat to successful organ transplantation. Clinicians now have access to at least five novel agents with activity against some of these organisms, with others in the advanced stages of clinical development. No agent, however, provides universal and predictable activity against any of these pathogens, and very little is available to treat infections with MDR nonfermenting Gram-negative bacilli including A baumannii. Despite advances, empiric antibiotics should be tailored to local microbiology and targeted regimens should be tailored to susceptibilities. Source control remains an important part of the therapeutic armamentarium. Morbidity and mortality associated with infections due to MDR Gram-negative organisms remain unacceptably high. Heightened infection control and antimicrobial stewardship initiatives are needed to prevent these infections, curtail their transmission, and limit the evolution of MDR Gram-negative pathogens, especially in the setting of organ transplantation.
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Affiliation(s)
| | - Gopi Patel
- Icahn School of Medicine at Mount Sinai, New York, New York
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24
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Fernández J, Prado V, Trebicka J, Amoros A, Gustot T, Wiest R, Deulofeu C, Garcia E, Acevedo J, Fuhrmann V, Durand F, Sánchez C, Papp M, Caraceni P, Vargas V, Bañares R, Piano S, Janicko M, Albillos A, Alessandria C, Soriano G, Welzel TM, Laleman W, Gerbes A, De Gottardi A, Merli M, Coenraad M, Saliba F, Pavesi M, Jalan R, Ginès P, Angeli P, Arroyo V. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019; 70:398-411. [PMID: 30391380 DOI: 10.1016/j.jhep.2018.10.027] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. METHODS This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018. RESULTS A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. CONCLUSIONS MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. LAY SUMMARY Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jonel Trebicka
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; University of Bonn, Germany
| | - Alex Amoros
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital, Brussels, Belgium
| | - Reiner Wiest
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Carme Deulofeu
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elisabet Garcia
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | | | | | | - Cristina Sánchez
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Hungary
| | | | - Victor Vargas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Vall d'Hebron, Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | | | - German Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital of Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Andrea De Gottardi
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Faouzi Saliba
- Centre Hepato-Biliare, Hòpital Paul Brousse, Paris, France
| | - Marco Pavesi
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rajiv Jalan
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom
| | - Pere Ginès
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain
| | | | - Vicente Arroyo
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
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Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24:4311-4329. [PMID: 30344417 PMCID: PMC6189843 DOI: 10.3748/wjg.v24.i38.4311] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/11/2018] [Accepted: 10/05/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.
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Affiliation(s)
- Elda Righi
- Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
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26
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Salomão MC, Guimarães T, Duailibi DF, Perondi MBM, Letaif LSH, Montal AC, Rossi F, Cury AP, Duarte AJS, Levin AS, Boszczowski I. Carbapenem-resistant Enterobacteriaceae in patients admitted to the emergency department: prevalence, risk factors, and acquisition rate. J Hosp Infect 2017; 97:241-246. [PMID: 28826688 DOI: 10.1016/j.jhin.2017.08.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/14/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) have been reported worldwide and are associated with high mortality rates. Intestinal colonization acts as a reservoir and fosters exchange of resistance mechanisms. AIM To investigate the prevalence of patients harbouring CRE on hospital admission, risk factors associated, and the acquisition rate within the emergency department (ED). METHODS This was a cross-sectional survey with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain reaction (PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE. FINDINGS Forty-six patients were colonized; all positive PCR were Klebsiella pneumoniae carbapenemase. The acquisition rate was 18%. Previous exposure to healthcare in the last year, liver disease, and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community. CONCLUSION Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.
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Affiliation(s)
- M C Salomão
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, Brazil; Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil.
| | - T Guimarães
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - D F Duailibi
- Department of Infectious Diseases, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - M B M Perondi
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - L S H Letaif
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A C Montal
- Emergency Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - F Rossi
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A P Cury
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A J S Duarte
- Central Laboratory Division, Hospital das Clínicas, Universidade de São Paulo, Brazil
| | - A S Levin
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, Brazil; Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil; LIM54, Faculdade de Medicina, Universidade de São Paulo, Brazil
| | - I Boszczowski
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, Brazil
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Dumford DM, Skalweit M. Antibiotic-Resistant Infections and Treatment Challenges in the Immunocompromised Host. Infect Dis Clin North Am 2017; 30:465-489. [PMID: 27208768 DOI: 10.1016/j.idc.2016.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This article reviews antibiotic resistance and treatment of bacterial infections in the growing number of patients who are immunocompromised: solid organ transplant recipients, the neutropenic host, and persons with human immunodeficiency virus and AIDS. Specific mechanisms of resistance in both gram-negative and gram-positive bacteria, as well as newer treatment options are addressed elsewhere, and are only briefly discussed in the context of the immunocompromised host.
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Affiliation(s)
- Donald M Dumford
- Akron General Medical Center, 1 Akron General Way, Akron, OH 44302, USA; Northeast Ohio Medical University, 4209 St. Rt. 44, PO Box 95, Rootstown, Ohio 44272, USA.
| | - Marion Skalweit
- Louis Stokes Cleveland Department of Veterans Affairs, 10701 East Blvd 111(W), Cleveland, OH 44106, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, OH 44106, USA
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Alevizakos M, Kallias A, Flokas ME, Mylonakis E. Colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae in solid organ transplantation: A meta-analysis and review. Transpl Infect Dis 2017; 19. [PMID: 28470983 DOI: 10.1111/tid.12718] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/12/2017] [Accepted: 02/07/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) may cause severe infections, often preceded by ESBL-E gastrointestinal (GI) colonization. METHODS We conducted a review of the literature, investigating the prevalence of ESBL-E GI colonization in solid organ transplant (SOT) patients and the risk for subsequent ESBL-E infection. We searched the PubMed and EMBASE databases (to April 1, 2016) looking for studies that contained data on ESBL-E colonization among transplant patients. RESULTS Of 341 non-duplicate citations, four studies reporting data on 1089 patients fulfilled our inclusion criteria. Among them, the pooled prevalence for ESBL-E colonization was 18% (95% confidence interval [CI] 5%-36%). Stratifying by transplant type, we identified an ESBL-E colonization rate of 17% (95% CI 3%-39%) among liver transplant recipients and 24% (single report) among kidney transplant recipients. CONCLUSIONS Among SOT patients, approximately one in five patients is colonized with ESBL-E, although this finding may be skewed by reporting bias from centers with high ESBL-E prevalence. ESBL-E screening in SOT patients should be considered and evaluated in future studies.
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Affiliation(s)
- Michail Alevizakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Athanasios Kallias
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Myrto Eleni Flokas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
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29
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Freire MP, Oshiro ICVS, Pierrotti LC, Bonazzi PR, de Oliveira LM, Song ATW, Camargo CH, van der Heijden IM, Rossi F, Costa SF, DʼAlbuquerque LAC, Abdala E. Carbapenem-Resistant Enterobacteriaceae Acquired Before Liver Transplantation: Impact on Recipient Outcomes. Transplantation 2017; 101:811-820. [PMID: 28009779 DOI: 10.1097/tp.0000000000001620] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) is an emergent microorganism of infections after liver transplant (LT). The aim of this study was to analyze the risk factors for CRE acquisition and infection after LT. METHODS This was a prospective cohort study involving patients who underwent LT in the 2010 to 2014 period. Surveillance cultures for CRE were collected immediately before LT and weekly thereafter until hospital discharge. RESULTS We analyzed 386 patients undergoing a total of 407 LTs. Before LT, 68 (17.6%) patients tested positive for CRE, 11 (16.2%) of those patients having CRE infection, whereas 119 (30.8%) patients acquired CRE after LT. Post-LT CRE infection was identified in 59 (15.7%) patients: Klebsiella pneumoniae was isolated in 83.2%; surgical site infection was the most common type of infection (46.7%). Multivariate analysis showed that post-LT dialysis was the only risk factor for post-LT CRE acquisition. Eighty-two percent of patients who underwent 3 or more post-LT dialysis sessions and acquired CRE before LT evolved with post-LT CRE infection. Other risk factors for CRE infection were acquisition of CRE post-LT, Model for End-Stage Liver Disease score greater than 32, combined transplantation, and reoperation. Patients who acquired CRE before LT had a high risk of developing CRE infection (P < 0.001). CONCLUSIONS Measures for minimizing that risk, including altering the antibiotic prophylaxis, should be investigated and implemented.
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Affiliation(s)
- Maristela Pinheiro Freire
- 1 Infection Control Team, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil. 2 Department of Infectious Diseases, University of São Paulo School of Medicine, São Paulo, Brazil. 3 Liver and Intestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil. 4 Microbiology Research Laboratory-LIM54, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil. 5 Centro de Bacteriologia, Instituto Adolfo Lutz, São Paulo, Brazil. 6 Microbiology Laboratory, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
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Surveillance culture for multidrug-resistant gram-negative bacteria: Performance in liver transplant recipients. Am J Infect Control 2017; 45:e40-e44. [PMID: 28254253 DOI: 10.1016/j.ajic.2016.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/13/2016] [Accepted: 12/13/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The prevalence of infection with multidrug-resistant gram-negative bacteria (MDR-GNB) after solid-organ transplantation is increasing. Surveillance culture (SC) seems to be an important tool for MDR-GNB control. The goal of this study was to analyze the performance of SC for MDR-GNB among liver transplant (LT) recipients. METHODS This was a prospective cohort study involving patients who underwent LT between November 2009 and November 2011. We screened patients for extended spectrum β-lactamase-producing Escherichia coli, extended spectrum β-lactamase-producing Klebsiella pneumoniae, and carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa (CRPA), and carbapenem-resistant Acinetobacter baumannii (CRAB). We collected SC samples immediately before LT and weekly thereafter, until hospital discharge. Samples were collected from the inguinal-rectal area, axilla, and throat. The performance of SC was evaluated through analysis of its sensitivity, negative predictive value, and accuracy. RESULTS During the study period, 181 patients were evaluated and 4,110 SC samples were collected. The GNB most often identified was CRAB, in 45.9% of patients, followed by CRKP in 40.3%. For all microorganisms, the positivity rate was highest among the inguinal-rectal samples. If only samples collected from this area were considered, the SC would fail to identify 34.9% of the cases of CRAB colonization. The sensitivity of SC for CRKP was 92.5%. The performance of SC was poorest for CRAB (sensitivity, 80.6%). CONCLUSIONS Our data indicate that SC is a sensitive tool to identify LT recipients colonized by MDR-GNB.
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Fernández J, Bert F, Nicolas-Chanoine MH. The challenges of multi-drug-resistance in hepatology. J Hepatol 2016; 65:1043-1054. [PMID: 27544545 DOI: 10.1016/j.jhep.2016.08.006] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/05/2016] [Accepted: 08/10/2016] [Indexed: 02/08/2023]
Abstract
Antimicrobial resistance has become a major global public health security problem that needs coordinated approaches at regional, national and international levels. Antibiotic overuse and the failure of control measures to prevent the spread of resistant bacteria in the healthcare environment have led to an alarming increase in the number of infections caused by resistant bacteria, organisms that resist many (multi-drug and extensively drug-resistant strains), if not all (pan-drug-resistant bacteria) currently available antibiotics. While Gram-positive cocci resistance (methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci) shows a heterogeneous geographical distribution, extended-spectrum β-lactamase-producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae have become pandemic worldwide and endemic in some parts of the world, respectively. Moreover, currently available therapeutic options for resistant bacteria are very limited, with very few new agents in development. Antimicrobial resistance is especially relevant in decompensated cirrhosis. Firstly, cirrhotic patients are highly susceptible to develop infections caused by resistant bacteria as risk factors of multiresistance concentrate in this population (mainly repeated hospitalizations and antibiotic exposure). Secondly, inappropriate empirical antibiotic schedules easily translate into increased morbidity (acute kidney injury, acute-on-chronic liver failure, septic shock) and hospital mortality in advanced cirrhosis. Therefore, hepatologists must face nowadays a complex clinical scenario that requires new empirical antibiotic strategies that may further spread resistance. Global, regional and local preventive measures should therefore be implemented to combat antimicrobial resistance in cirrhosis including the restriction of antibiotic prophylaxis to high-risk populations, investigation on non-antibiotic prophylaxis, stewardship programs on adequate antibiotic prescription and on increasing awareness of the problem among health professionals, and well-defined early de-escalation policies based on rapid microbiological diagnostic tests. Other infection control practices such as hand hygiene and barrier precautions are also important. Clinical impact and cost-effectiveness of epidemiological surveillance programs (periodic rectal and nasal swabs) should also be explored.
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Affiliation(s)
- Javier Fernández
- Liver Unit, Hospital Clínic Barcelona, University of Barcelona, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain.
| | - Frédéric Bert
- Service de Microbiologie, Hôpital Beaujon, AP-HP, Clichy, France; INSERM UMR 1149, Université Paris 7, Paris, France
| | - Marie-Hélène Nicolas-Chanoine
- Service de Microbiologie, Hôpital Beaujon, AP-HP, Clichy, France; INSERM UMR 1149, Université Paris 7, Paris, France; Faculté de Médecine Paris Diderot, Paris, France
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Hand J, Patel G. Multidrug-resistant organisms in liver transplant: Mitigating risk and managing infections. Liver Transpl 2016; 22:1143-53. [PMID: 27228555 DOI: 10.1002/lt.24486] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/05/2016] [Accepted: 05/12/2016] [Indexed: 12/17/2022]
Abstract
Liver transplant (LT) recipients are vulnerable to infections with multidrug-resistant (MDR) pathogens. Risk factors for colonization and infection with resistant bacteria are ubiquitous and unavoidable in transplantation. During the past decade, progress in transplantation and infection prevention has contributed to the decreased incidence of infections with methicillin-resistant Staphylococcus aureus. However, even in the face of potentially effective antibiotics, vancomycin-resistant enterococci continue to plague LT. Gram-negative bacilli prove to be more problematic and are responsible for high rates of both morbidity and mortality. Despite the licensure of novel antibiotics, there is no universal agent available to safely and effectively treat infections with MDR gram-negative organisms. Currently, efforts dedicated toward prevention and treatment require involvement of multiple disciplines including transplant providers, specialists in infectious diseases and infection prevention, and researchers dedicated to the development of rapid diagnostics and safe and effective antibiotics with novel mechanisms of action. Liver Transplantation 22 1143-1153 2016 AASLD.
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Affiliation(s)
- Jonathan Hand
- Department of Infectious Diseases, Ochsner Clinic Foundation, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Gopi Patel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Prieto J, Medina J, López M, Rando K, Iglesias C, Harguindeguy M, Leites A, Etlin A, Menéndez J, Valverde M, Scalone P, Castelli J, Grecco G, Abelleira M, González L, Gerona S. Impact of a Multimodal Approach in Prevention of Surgical Site Infection in Hepatic Transplant Recipients. Transplant Proc 2016; 48:658-64. [DOI: 10.1016/j.transproceed.2016.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
The number of patients undergoing hematopoietic cell and solid organ transplantation are increasing every year, as are the number of centers both transplanting and caring for these patients. Improvements in transplant procedures, immunosuppressive regimens, and prevention of transplant-associated complications have led to marked improvements in survival in both populations. Infections remain one of the most important sources of excess morbidity and mortality in transplant, and therefore, infection prevention strategies are a critical element for avoiding these complications in centers caring for high-risk patients. This manuscript aims to provide an update of recent data on prevention of major healthcare-associated infections unique to transplantation, reviews the emergence of antimicrobial resistant infections, and discusses updated strategies to both identify and prevent transmission of these pathogens in transplant recipients.
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Asir J, Nair S, Devi S, Prashanth K, Saranathan R, Kanungo R. Simultaneous gut colonisation and infection by ESBL-producing Escherichia coli in hospitalised patients. Australas Med J 2015. [PMID: 26213583 DOI: 10.4066/amj.2015.2358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Extended spectrum betalactamase (ESBL)-producing organisms are a major cause of hospital-acquired infections. ESBL-producing Escherichia coli (E. coli) have been recovered from the hospital environment. These drug-resistant organisms have also been found to be present in humans as commensals. The present investigation intended to isolate ESBL-producing E. coli from the gut of already infected patients; to date, only a few studies have shown evidence of the gut microflora as a major source of infection. AIMS This study aimed to detect the presence of ESBL genes in E.coli that are isolated from the gut of patients who have already been infected with the same organism. METHODS A total of 70 non-repetitive faecal samples were collected from in-patients of our hospital. These in-patients were clinically diagnosed and were culture-positive for ESBL-producing E. coli either from blood, urine, or pus. Standard microbiological methods were used to detect ESBL from clinical and gut isolates. Genes coding for major betalactamase enzymes such as bla CTX-M , bla TEM, and bla SHV were investigated by polymerase chain reaction (PCR). RESULTS ESBL-producing E. coli was isolated from 15 (21 per cent) faecal samples of the 70 samples that were cultured. PCR revealed that out of these 15 isolates, the bla CTX-M gene was found in 13 (86.6 per cent) isolates, the bla TEM was present in 11 (73.3 per cent) isolates, and bla SHV only in eight (53.3 per cent) isolates. All 15 clinical and gut isolates had similar phenotypic characters and eight of the 15 patients had similar pattern of genes (bla TEM, bla CTX-M, and bla SHV) in their clinical and gut isolates. CONCLUSION Strains with multiple betalactamase genes that colonise the gut of hospitalised patients are a potential threat and it may be a potential source of infection.
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Affiliation(s)
- Johny Asir
- Department of Clinical Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Shashikala Nair
- Department of Clinical Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Sheela Devi
- Department of Clinical Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | | | | | - Reba Kanungo
- Department of Clinical Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
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Cervera C, van Delden C, Gavaldà J, Welte T, Akova M, Carratalà J. Multidrug-resistant bacteria in solid organ transplant recipients. Clin Microbiol Infect 2014; 20 Suppl 7:49-73. [DOI: 10.1111/1469-0691.12687] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 05/16/2014] [Accepted: 05/18/2014] [Indexed: 12/23/2022]
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