Risk factors to predict drug-resistant pathogens in hemodialysis-associated pneumonia

The safety and efficacy of Chinese herbal medicine for pneumonia prevention in high-risk elder residents in the nursing home: A randomized, double-blind clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Nursing home-associated pneumonia (NHAP) is a common type of infection among long-term care residents. Moreover, the mortality of NHAP is also higher than community-acquired pneumonia (CAP). In traditional Chinese medicine (TCM), the decoctions of Banxia Houpo Tang (BHT) and Ding Chuan Tang (DCT) are two formulas supporting the lungs' natural defense systems, helps to expel mucus and promote detoxification.

AIM OF THE STUDY

We designed a concentrated Chinese herbal extract formula called BDT1, that combines the compounds of BHT and DCT. In this study, we evaluated the safety and efficacy of BDT1 for NHAP prevention in high-risk older residents in the nursing home.

MATERIALS AND METHODS

In this randomized, double-blind, placebo-controlled trial, 160 participants aged over 65 years old living in the nursing home were randomly assigned 1:1 to the BDT1 and placebo group. Besides regular medicine, participants received either BDT1 or a placebo for 12 consecutive weeks. The primary outcome was the hospitalization rate for pneumonia in the intervention period and half-year follow-up. The microscopic examination of Gram-stained sputum was also evaluated before and after the trial. Data were analyzed by using the Chi-square test and Wilcoxon Signed Ranks Test with SPSS.

RESULTS

A total of 160 participants were enrolled into two study groups in this study, which was completed with 143 participants analyzed, including 70 subjects in the BDT1 group and 73 subjects in the placebo group. After the 12-week medical treatment, the hospitalization rate for pneumonia was 10.0% and 34.2% in the BDT1 and placebo group respectively. The risk of pneumonia in half a year was lower in the BDT1 group (adjusted hazard ratio = 0.422, 95% CI = 0.226-0.791). Compared to the placebo group, the level of Gram-negative bacilli in the BDT1 group is significantly declined in sputum samples (p < 0.05).

CONCLUSION

In conclusion, the cumulative incidence of pneumonia and related-hospitalization rates declined significantly after 12-weeks of BDT1 treatment. Besides, Chinese herbal medicine BDT1 is a safe therapy without hepatotoxicity or nephrotoxicity.

Knowledge and perception of nosocomial infections among patients in a Nigerian hospital

Nosocomial infections are infections that are a leading cause of morbidity and mortality among hospitalized patients, and can lead to higher healthcare costs and longer hospital stays in both developed and developing countries. The objectives of the study were to identify the level of knowledge and perception of patients on nosocomial infection, and to determine the factors affecting the knowledge and perception of patients on nosocomial infection in Federal Medical Centre, Ebute-Metta, Lagos (FMC). A cross-sectional research design was used in carrying out the research among in-patients of FMC where an interview-based semi-structured questionnaire was used for data collection. Patients' knowledge was categorised as good (≥ 70% score), fair (50-69%) and poor (< 50% score) while perception was grouped as positive and negative. Independent sample T-test and One-way Analysis of Variance was used to assess statistical difference in knowledge scores between categorical variables with 2 and 3 groups respectively. A total of 102 patients gave consent to participate in this study of which 46.1% were male, 27.5% were aged between 38 and 47 years and 69.6% were married. About 24% did not know what is meant by nosocomial infections while 53.9% stated that all hospital-acquired infections are preventable. Less than 19% strongly disagreed that making alcohol rubs mandatory for all visitors would decrease the incidence of nosocomial infections while all strongly agreed that if left untreated, such infections can become life-threatening. Overall, 15.7% showed good knowledge while most patients showed fair knowledge (71.6%) and a negative perception (51%) of nosocomial infections. There was a significant difference in patients' knowledge of nosocomial infections based on age (0.012). There was also a statistically significant association between age and perception of patients towards nosocomial infections (p = 0.031). This study showed that most patients had fair knowledge as well as negative perception towards nosocomial infections. Age, had an influence on patients' perception and knowledge of nosocomial infection.

Prevalence, Microbial Etiology and Risk Factors Associated With Healthcare Associated Infections Among End Stage Renal Disease Patients on Renal Replacement Therapy

End stage renal disease (ESRD) patients on renal replacement therapy (RRT) have an increased risk of morbidity and mortality due to healthcare associated infections (HCAIs). The aim of this study is to determine the prevalence, microbial etiology, and risk factors associated with HCAIs among ESRD patients on RRT. A multicenter, retrospective study was conducted from June to December 2019. ESRD patients with minimum of 6 months on RRT were included, while pregnant patients and patients <18 years were excluded. To reduce the risk of selection bias, all patients were randomly selected using a simple random sampling technique. The prevalence showing the proportion of patients that acquired HCAI since the initiation of dialysis until 2019 was calculated using the European patients' academy (EUPATI) formula. Risk factors were assessed using univariate and multivariate regression analysis. The prevalence of HCAI among ESRD patients was 174/400 (43.5%). Catheter related bloodstream infection (CRBSI) was the most common infection [64(36.8%)], followed by peritonitis [45(25.8%)] and pneumonia [37(21.2%)]. Out of 382 total pathogens identified, 204 (53.4%) were Gram positive and 162 (42.4%) were Gram negative. Both methicillin sensitive staphylococcus aureus (MSSA) and methicillin resistant staphylococcus aureus (MRSA) showed statistically significant associations (p<0.05) with CRBSI. Use of multiple accesses, increased blood sugar levels, low serum sodium levels and higher CRP concentration increased the occurrence of HCAIs. The burden of HCAIs among the patients undergoing RRT is high. Preventive strategies and optimum empirical therapy of antibiotics should be used to reduce the risk of these infections among ESRD patients.

Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy

Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).

A Novel Dosing Strategy of Ceftolozane/Tazobactam in a Patient Receiving Intermittent Hemodialysis

We describe the case of a 54-year-old male receiving intermittent hemodialysis (iHD) who was found to have Pseudomonas aeruginosa bacteremia secondary to osteomyelitis of the calcaneus bone. The patient was clinically cured without recurrence using a ceftolozane/tazobactam (CTZ) dosing strategy of 100/50 mg every 8 hours (standard dosing) and 1000/500 mg thrice weekly following iHD. Utilizing a susceptibility breakpoint of ≤4 µg/mL for P. aeruginosa, the T > MIC for standard dosing and the 1000/500-mg thrice-weekly following iHD regimen were calculated to be 92.7% and 94.1%, respectively. Ceftolozane total body clearance for the standard q 8 h dosing and the 1000/500-mg thrice-weekly following iHD regimen were calculated to be 0.196 L/h and 0.199 L/h, respectively. To our knowledge, this is the first report to illustrate the administration of CTZ at a dose of 1000/500 mg thrice weekly following iHD.

Early Screening of Risk for Multidrug-Resistant Organisms in the Emergency Department in Patients With Pneumonia and Early Septic Shock: Single-Center, Retrospective Cohort Study

OBJECTIVES

Pneumonia is the fourth leading cause of death globally, with rapid progression during sepsis. Multidrug-resistant organisms (MDROs) are becoming more common with some healthcare-associated pneumonia events. Early detection of MDRO risk improves the outcomes; however, MDROs risk in pneumonia with sepsis is unknown. This study investigated the disease outcomes of pneumonia with septic shock in patients admitted in the emergency department (ED) intensive care unit (ICU), a population with a high prevalence of MDROs, after early screening of MDROs risk.

METHODS

In this retrospective cohort study, patients with pneumonia and early septic shock (n = 533) admitted to the ED at the Taipei Tzu Chi Hospital from 2013 to 2019 were selected. The study population was divided into four subgroups after the MDROs risk and screening procedure were completed within 1 or 6 h of admission. ICU mortality and multidrug antibiotic therapy were compared.

RESULTS

The high-risk MDROs groups had higher percentage of P aeruginosa than the low-risk group. Furthermore, the appropriate ED first antibiotics were higher in the 1-h subgroup than in the 6-h subgroup of the high-risk MDROs group. In multivariate analysis, the 6-h high-risk MDROs group had an adjusted odds ratio of 7.191 (95% CI: 2.911-17.767, P < 0.001) and 2.917 (95% CI: 1.456-5.847, P = 0.003) for ICU mortality and multidrug therapy in the ICU, respectively, after adjusting for other confounding factors.

CONCLUSIONS

MDRO screening within 1 h is recommended following admission of patients with pneumonia and early septic shock in the ED, especially in areas with a high prevalence of MDROs.

Risk factors, antimicrobial susceptibility pattern and patient outcomes of Pseudomonas aeruginosa infection: A matched case-control study

BACKGROUND

Pseudomonas aeruginosa is a leading nosocomial Gram-negative bacteria associated with prolonged hospitalization, and increased morbidity and mortality. Limited data exist regarding P. aeruginosa infection and outcome in patients managed in intensive care units (ICUs) in the Gulf countries. We aimed to determine the risk factors, antimicrobial susceptibility pattern and patient outcomes of P. aeruginosa infection in ICU.

METHODS

In this matched case-control study, all P. aeruginosa infections that occurred >48 h after hospital admission between January 31st 2016 and December 31st 2018 at ICUs affiliated with King Abdulaziz Medical City, Riyadh were included. P. aeruginosa was identified using MALDI-TOF (Vitek-MS) by biomérieux, and the antimicrobial susceptibility testing was performed using an automated biomérieux VITEK^®️ 2 Antimicrobial Susceptibility card.

RESULTS

The study included 90 cases and 90 controls. Compared with controls, cases had significantly higher mean ICU stay and higher proportions with previous history of antimicrobial therapy, coronary artery disease, malignancy, hemodialysis, previous surgery, use of central line, urethral catheterization, nasogastric tube, and tracheostomy. In a multivariate conditional logistic regression analysis, factors independently associated with P. aeruginosa infection were ICU duration [Odds Ratio (OR) 9.05, 95%CI 2.53-32.27, p = .001], previous surgery (OR = 7.33, 95%CI 1.66-32.36, p = .009), tracheostomy (OR = 11.13, 95%CI 1.05-118.59, p = .046), urethral catheterization (OR = 7.38, 95%CI 1.21-45.11, p = .030) and use of aminoglycosides (OR = 10.59, 95%CI 1.14-98.13, p = .038). Approximately 41% of P. aeruginosa isolates were resistant to imipenem, while 36.7% were multidrug-resistant. Mortality was similar in both groups: 54(60%) cases and 51(56.7%) controls; p = .650.

CONCLUSIONS

The study identifies several potentially modifiable factors associated with P. aeruginosa infection in ICUs. Identification of these factors could facilitate case identification and enhance control measures.

Risk factors associated with nosocomial infections among end stage renal disease patients undergoing hemodialysis: A systematic review

Background

Profound healthcare challenges confront societies with an increase in prevalence of end-stage renal disease (ESRD), which is one of the leading causes of morbidity and mortality worldwide. Due to several facility and patient related factors, ESRD is significantly associated with increased morbidity and mortality attributed to infections.

Aims and objective

The aim of this study was to assess systematically the characteristics of patients and risk factors associated with nosocomial infections among ESRD patients undergoing hemodialysis.

Methods

A systematic literature search was performed to identify eligible studies published during the period from inception to December 2018 pertaining to risk factors associated with nosocomial infections among hemodialysis patients. The relevant studies were generated through a computerized search on five databases (PubMed, EBSCOhost, Google Scholar, ScienceDirect and Scopus) using the Mesh Words: nosocomial infections, hospital acquired infections, healthcare associated infections, end stage renal disease, end stage renal failure, hemodialysis, and risk factors. The complete protocol has been registered under PROSPERO (CRD42019124099).

Results

Initially, 1411 articles were retrieved. Out of these, 24 were duplicates and hence were removed. Out of 1387 remaining articles, 1337 were removed based on irrelevant titles and/or abstracts. Subsequently, the full texts of 50 articles were reviewed and 41 studies were excluded at this stage due to lack of relevant information. Finally, nine articles were selected for this review. Longer hospital stay, longer duration on hemodialysis, multiple catheter sites, longer catheterization, age group, lower white blood cell count, history of blood transfusion, and diabetes were identified as the major risk factors for nosocomial infections among hemodialysis patients.

Conclusion

The results of this review indicate an information gap and potential benefits of additional preventive measures to further reduce the risk of infections in hemodialysis population. Moreover, several patient-related and facility-related risk factors were consistently observed in the studies included in this review, which require optimal control measures.

Risk Factor Evaluation for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Community-Acquired Pneumonia

BACKGROUND

The 2019 community-acquired pneumonia guidelines recommend using recent respiratory cultures and locally validated epidemiology plus risk factor assessment to determine empirical coverage of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa.

OBJECTIVE

To develop a methodology for evaluating local epidemiology and validating local risk factors for P aeruginosa and MRSA.

METHODS

This multicenter, retrospective cohort evaluated adult patients admitted for pneumonia. Risk factors for MRSA and P aeruginosa were evaluated using multivariable logistic regression and reported as adjusted odds ratios (aORs).

RESULTS

There were 10 723 cases evaluated. Lung abscess/empyema had the highest odds associated with MRSA (aOR = 4.24; P < 0.0001), followed by influenza (aOR = 2.34; P = 0.01), end-stage renal disease (ESRD; aOR = 2.09; P = 0.006), illicit substance use (aOR = 1.7; P = 0.007), and chronic obstructive pulmonary disease (COPD; aOR = 1.26; P = 0.04). For P aeruginosa, the highest odds were in bronchiectasis (aOR = 6.13; P < 0.0001), lung abscess/empyema (aOR = 3.36; P = 0.005), and COPD (aOR = 1.84; P < 0.0001). Isolated COPD without other risk factors did not pose an increased risk of either organism.

CONCLUSION AND RELEVANCE

Influenza, ESRD, lung abscess/empyema, and illicit substance use were local risk factors for MRSA. Bronchiectasis and lung abscess/empyema were risk factors for Pseudomonas. COPD was associated with MRSA and Pseudomonas. However, isolated COPD had similar rates of MRSA and Pseudomonas pneumonia compared with the total population. This study established a feasible methodology for evaluating local risk factors.

Positive nasal Staphylococcus aureus polymerase chain reaction assay is not sensitive in predicting concurrent or subsequent Staphylococcus aureus infection in critically ill patients

Staphylococcal infection is associated with significant morbidity and mortality in critically ill patients. Using data from 16,681 patients who had a nasal Staphylococcus aureus polymerase chain reaction (PCR) assay on admission to the intensive care unit (ICU) of Royal Perth Hospital between March 2006 and September 2016, this retrospective cohort study assessed whether nasal S. aureus colonisation on admission to an ICU was predictive of concurrent or subsequent S. aureus infections. Culture-proven S. aureus infections were identified using the hospital microbiology database. Of the 16,681 patients included, 565 (3.4%) had a positive methicillin-resistant S. aureus (MRSA) assay, 146 (0.9%) had a positive methicillin-sensitive S. aureus (MSSA) assay and eight (0.05%) had both positive MRSA and MSSA assays. Of those 565 patients with a positive MRSA PCR assay, 79 (13.8%) had concurrent or subsequent MRSA infections. Of those 146 patients with a positive MSSA PCR assay, only 5 (3.4%) had MSSA infection. The sensitivity and specificity for the MRSA PCR assay in predicting concurrent or subsequent MRSA infection were 72.7% (95% confidence intervals (CI) 63.4%-80.8%) and 97.0% (95% CI 96.8%-97.3%), respectively. The sensitivity and specificity for the MSSA PCR assay in predicting concurrent or subsequent MSSA infection were 3.3% (95% CI 1.1%-7.6%) and 99.1% (95% CI 98.9%-99.2%), respectively. Both nasal MRSA and MSSA PCR assays had a high specificity and negative predictive value in predicting MRSA and MSSA infections, respectively, suggesting that in centres without endemic S. aureus infections, a negative nasal MRSA or MSSA PCR assay may be useful to reduce unnecessary empirical antibiotic therapy against S. aureus.

Recommendations and guidelines for the treatment of pneumonia in Taiwan

Pneumonia is a leading cause of death worldwide, ranking third both globally and in Taiwan. This guideline was prepared by the 2017 Guidelines Recommendations for Evidence-based Antimicrobial agents use in Taiwan (GREAT) working group, formed under the auspices of the Infectious Diseases Society of Taiwan (IDST). A consensus meeting was held jointly by the IDST, Taiwan Society of Pulmonary and Critical Care Medicine (TSPCCM), the Medical Foundation in Memory of Dr. Deh-Lin Cheng, the Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Education and CY Lee's Research Foundation for Pediatric Infectious Diseases and Vaccines. The final guideline was endorsed by the IDST and TSPCCM. The major differences between this guideline and the 2007 version include the following: the use of GRADE methodology for the evaluation of available evidence whenever applicable, the specific inclusion of healthcare-associated pneumonia as a category due to the unique medical system in Taiwan and inclusion of recommendations for treatment of pediatric pneumonia. This guideline includes the epidemiology and recommendations of antimicrobial treatment of community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, healthcare-associated pneumonia in adults and pediatric pneumonia.

Proposed risk factors for infection with multidrug-resistant pathogens in hemodialysis patients hospitalized with pneumonia

BACKGROUND

In patients with hemodialysis-associated pneumonia (HDAP), information on both microbiologic features and antimicrobial strategies is limited. The aim of this study is to investigate predictive factors of infection with multidrug-resistant (MDR) pathogens in HDAP patients.

METHODS

This was a multicenter, retrospective, and observational study. Enrolled patients were classified into MDR or non-MDR pathogens groups according to culture results. We examined risk factors of infection with MDR pathogens and created a decision support tool using these risk factors.

RESULTS

MDR pathogens were identified in 24 (22.8%) out of a total of 105 HDAP patients. The most common MDR pathogens were methicillin-resistant Staphylococcus aureus (10 patients, 9.5%) and the isolation rate of Pseudomonas aeruginosa was 6.6%. Logistic regression showed two variables were associated with the isolation of MDR pathogens: recent hospitalization (adjusted odds ratio [OR]: 2.951, 95% confidence interval [CI]: 1.022-8.518) and PSI (Pneumonia Severity Index) score (adjusted OR: 1.023, 95% CI: 1.005-1.041). The optimal cut-off value for PSI score using a receiver operating characteristic curve analysis was 147. According to the presence of 0, 1, or 2 of the identified risk factors, the prevalence of MDR pathogens was 7.6, 28.2 and 64.2%, respectively (p < 0.001 for trend). The area under the curve of the prediction tool was 0.764 (95% CI: 0.652-0.875).

CONCLUSIONS

We demonstrated that recent hospitalization and PSI > 147 are risk factors of infection with MDR pathogens in HDAP patients. This simple proposed tool would facilitate more accurate identification of MDR pathogens in these patients.

Newly approved antibiotics and antibiotics reserved for resistant infections: Implications for emergency medicine

Millions of patients are evaluated every year in the emergency department (ED) for bacterial infections. Emergency physicians often diagnose and prescribe initial antibiotic therapy for a variety of bacterial infections, ranging from simple urinary tract infections to severe sepsis. In life-threatening infections, inappropriate choice of initial antibiotic has been shown to increase morbidity and mortality. As such, initiation of appropriate antibiotic therapy on the part of the emergency physician is critical. Increasing rates of antibiotic resistance, drug allergies, and antibiotic shortages further complicates the choice of antibiotics. Patients may have a history of prior resistant infections or culture data indicating that common first-line antibiotics used in the ED may be ineffective. In recent years, there have been several new antibiotic approvals as well as renewed interest in second and third line antibiotics because of the aforementioned concerns. In addition, several newly approved antibiotics have the advantage of being administered once weekly or even as a single infusion, which has the potential to decrease hospitalizations and healthcare costs. This article reviews newly approved antibiotics and antibiotics used to treat resistant infections with a focus on implications for emergency medicine.