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Righi E, Mutters NT, Guirao X, Dolores Del Toro M, Eckmann C, Friedrich AW, Giannella M, Presterl E, Christaki E, Cross ELA, Visentin A, Sganga G, Tsioutis C, Tacconelli E, Kluytmans J. European Society of Clinical Microbiology and Infectious Diseases/European Committee on infection control clinical guidelines on pre-operative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria before surgery. Clin Microbiol Infect 2024:S1198-743X(24)00341-0. [PMID: 39154859 DOI: 10.1016/j.cmi.2024.07.012] [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: 05/09/2024] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 08/20/2024]
Abstract
SCOPE The aim of these guidelines is to provide recommendations for decolonization and perioperative antibiotic prophylaxis (PAP) in multidrug-resistant Gram-positive bacteria (MDR-GPB) adult carriers before inpatient surgery. METHODS These European Society of Clinical Microbiology and Infectious Diseases/European Committee on Infection Control guidelines were developed following a systematic review of published studies targeting methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, methicillin-resistant coagulase-negative Staphylococci, and pan-drug-resistant-GPB. Critical outcomes were the occurrence of surgical site infections (SSIs) caused by the colonizing MDR-GPB and SSIs-attributable mortality. Important outcomes included the occurrence of SSIs caused by any pathogen, hospital-acquired infections, all-cause mortality, and adverse events associated with the interventions, including resistance development to the agents used and the incidence of Clostridioides difficile infections. The last search of all databases was performed on 1 November 2023. The level of evidence and the 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. RECOMMENDATIONS The guideline panel reviewed the impact of decolonization, targeted PAP, and combined interventions (e.g. decolonization and targeted PAP) on the risk of SSIs and other outcomes in MDR-GPB carriers, according to the type of bacteria and type of surgery. We recommend screening for S. aureus before high-risk operations, such as cardiothoracic and orthopaedic surgery. Decolonization with intranasal mupirocin with or without a chlorhexidine bath is recommended in patients colonized with S. aureus before cardiothoracic and orthopaedic surgery and suggested in other surgeries. The addition of vancomycin to standard prophylaxis is suggested for MRSA carriers in cardiothoracic surgery, orthopaedic surgery, and neurosurgery. Combined interventions (e.g. decolonization and targeted prophylaxis) are suggested for MRSA carriers undergoing cardiothoracic and orthopaedic surgery. No recommendation could be made regarding screening, decolonization and targeted prophylaxis for vancomycin-resistant enterococci because of the lack of data. No evidence was retrieved for methicillin-resistant coagulase-negative Staphylococci and pan-drug-resistant-GPB. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship and infection control teams are warranted before implementing screening procedures or performing changes in PAP policy. Future research should focus on novel decolonizing techniques, on the monitoring of resistance to decolonizing agents and PAP regimens, and on standardized combined interventions in high-quality studies.
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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
- Department of General Surgery, Surgical Endocrine Unit, Surgical Site Prevention Unit, Consorci Corporació Sanitària Parc Tauli, Sabadell, Spain
| | - Maria Dolores Del Toro
- Division of Infectious Diseases and Microbiology, University Hospital Virgen Macarena, Seville, Spain; Department of Medicine, University of Sevilla, Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Christian Eckmann
- Department of Klinikum Hannoversch-Muenden, Academic Hospital of Goettingen University, Göttingen, Germany
| | | | - Maddalena Giannella
- Department of Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabeth Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria (on behalf of the ESCMID Study Group on Nosocomial Infections - ESGNI), 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
- Department of 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
| | - Jan Kluytmans
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, The Netherlands.
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Mak JT, Ha S, Perloff S, Knorr JP. Perioperative daptomycin for prophylaxis of vancomycin-resistant Enterococcus infection in colonized liver transplant recipients. Transpl Infect Dis 2024; 26:e14186. [PMID: 37910593 DOI: 10.1111/tid.14186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Infection with vancomycin-resistant Enterococcus (VRE) in liver transplant recipients (LTR) has been associated with extended hospital stays, increased readmission rates, graft failure, and death. A tailored perioperative surgical prophylaxis regimen targeting VRE may reduce postoperative infections in VRE-colonized patients. This study investigated the outcomes of perioperative daptomycin in this patient population. METHODS This retrospective, single-center cohort study included LTR ≥ 18 years old who were VRE-colonized from June 2018 to November 2022. VRE colonization was identified by a VRE rectal swab screen or a positive VRE culture prior to transplant. Two groups were analyzed: daptomycin versus no daptomycin. All LTR received perioperative piperacillin-tazobactam for 24 h. If VRE-colonized, one dose of daptomycin (6 mg/kg) was given pre- and postoperatively. Demographics, clinical characteristics, risk factors for VRE infection, and daptomycin dose were collected. The primary outcome was VRE infection at 14 days and 90 days post-transplant. RESULTS There were 36 VRE-colonized LTR; 19 received daptomycin and 17 did not. Baseline characteristics and risk factors for VRE infection were similar between groups. More VRE infections occurred in the no daptomycin group within 14 days post-transplant (24% vs. 0%, p = .04), but at 90 days posttransplant there was no significant difference (29% vs. 16%, p = .43). The average daptomycin dose was 7.1 mg/kg. CONCLUSION Perioperative daptomycin reduced the rate of VRE infections in VRE-colonized LTR within 14 days posttransplant but not at 90 days. Future studies should evaluate if higher doses and/or longer duration of perioperative daptomycin can reduce VRE infections beyond 14 days post-transplant.
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Affiliation(s)
- Jordan T Mak
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - Seung Ha
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - Sarah Perloff
- Department of Internal Medicine, Division of Infectious Diseases, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
| | - John P Knorr
- Department of Pharmacy, Jefferson Einstein Hospital, Philadelphia, Pennsylvania, USA
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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: 2] [Impact Index Per Article: 2.0] [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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Multidrug-Resistant Enterococcal Infection in Surgical Patients, What Surgeons Need to Know. Microorganisms 2023; 11:microorganisms11020238. [PMID: 36838203 PMCID: PMC9968095 DOI: 10.3390/microorganisms11020238] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023] Open
Abstract
Enterococci are organisms that can be found in the normal intestinal and skin microbiota and show remarkable ability to acquire antibiotic resistance. This is an enormous challenge for surgeons when faced with surgical site infections caused by multidrug-resistant (MDR) Enterococci. Due to an increase in the prevalence of MDR Enterococcus within the last few decades, there has been a major decrease in therapeutic options, because the majority of E. faecium isolates are now resistant to ampicillin and vancomycin and exhibit high-level resistance to aminoglycosides, traditionally three of the most useful anti-enterococcal antibiotics. There is limited data regarding the magnitude and pattern of multidrug resistance among the enterococcal genus causing surgical site infections in hospitalized patients. The scope of the review is to summarize the most recent findings in the emergence of postoperative MDR Enterococci and discuss recent mechanisms of resistance and the best treatment options available.
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5
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Graziano E, Peghin M, Grossi PA. Perioperative antibiotic stewardship in the organ transplant setting. Transpl Infect Dis 2022; 24:e13895. [PMID: 35781915 PMCID: PMC9788034 DOI: 10.1111/tid.13895] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients can benefit from traditional antimicrobial stewardship (AMS) activities directed to improve judicious perioperative prescribing and management, but evidence is lacking. The aim of this expert opinion review is to provide an update on the current landscape of application of AMS practices for optimization of perioperative prophylaxis (PP). METHODS We reviewed the available literature on early postoperative infectious complications in SOT and PP management, on modified perioperative approaches in case of infection or colonization in recipients and donors and on AMS in transplantation PP. RESULTS SOT recipients are at high risk for early postoperative infectious complications due to the complexity of surgical procedures, severity of end stage organ disease, net state of immunosuppression in the posttransplant period and to the high risk for multidrug resistant organism. Moreover, SOT may be exposed to preservation fluid infections and expected or unexpected donor-derived infections. We summarize main factors to take into account when prescribing transplant PP. CONCLUSION Creating personalized PP to avoid unwanted consequences of antimicrobials while improving outcomes is an emerging and critical aspect in SOT setting. Further studies are needed to offer best PP tailored to SOT type and to evaluate interventions efficacy and safety.
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Affiliation(s)
- Elena Graziano
- Infectious and Tropical Diseases UnitDepartment of Medicine and SurgeryUniversity of Insubria‐ASST‐Sette LaghiVareseItaly
| | - Maddalena Peghin
- Infectious and Tropical Diseases UnitDepartment of Medicine and SurgeryUniversity of Insubria‐ASST‐Sette LaghiVareseItaly
| | - Paolo Antonio Grossi
- Infectious and Tropical Diseases UnitDepartment of Medicine and SurgeryUniversity of Insubria‐ASST‐Sette LaghiVareseItaly
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6
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Kinn PM, Ince D. Outpatient and peri-operative antibiotic stewardship in solid organ transplantation. Transpl Infect Dis 2022; 24:e13922. [PMID: 36254519 PMCID: PMC9788159 DOI: 10.1111/tid.13922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The consequences of inappropriate antimicrobial use including resistance are increasingly recognized as a global public health threat and many steps have been taken over the last few decades to advance antimicrobial stewardship initiatives with most organ transplant centers currently part of institutions with active antimicrobial stewardship programs. METHODS A review of the literature was conducted and articles were categorized according to the topic and relevance in the judgment of the two authors. RESULTS A summary review of the currently available literature was created with a focus on periprocedural and outpatient antimicrobial stewardship. Limitations in the data were significant and discussed in the review. CONCLUSION The principles of antimicrobial stewardship remain important throughout all phases starting with periprocedural prophylactic antimicrobial selection all the way through to discharge and subsequent healthcare encounters. Despite the broad advances in stewardship initiatives and the rapidly progressing supportive data overall there continue to be significant opportunities for additional research within various special patient populations including recipients of solid organ transplantation (SOT). The recent white paper published in the American Journal of Transplantation called to action the transplant and stewardship communities to have an increased focus and awareness of the issues that antimicrobial overuse can present in the SOT patient population. This is an important step that will hopefully generate more data in this group of patients that arguably faces the greatest vulnerability to the consequences of increased antimicrobial resistance.
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Affiliation(s)
- Patrick Michael Kinn
- Department of Pharmaceutical CareUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Dilek Ince
- Department of Internal MedicineDivision of Infectious DiseasesUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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7
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Radcliffe C, Patel KK, Azar MM, Koff A, Belfield KD, Peaper DR, Topal JE, Malinis M. Rectal screening for azole Non‐susceptible
Candida
species in patients undergoing liver transplantation. Transpl Infect Dis 2022; 24:e13811. [DOI: 10.1111/tid.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/04/2022] [Accepted: 02/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | - Kishan K. Patel
- Yale School of Medicine Section of Infectious Diseases New Haven CT USA
| | - Marwan M. Azar
- Yale School of Medicine Section of Infectious Diseases New Haven CT USA
| | - Alan Koff
- UC Davis School of Medicine Section of Infectious Diseases Sacramento CA USA
| | | | - David R. Peaper
- Yale School of Medicine Department of Laboratory Medicine New Haven CT USA
| | - Jeffrey E. Topal
- Yale School of Medicine Section of Infectious Diseases New Haven CT USA
| | - Maricar Malinis
- Yale School of Medicine Section of Infectious Diseases New Haven CT USA
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8
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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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