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Seagle EE, Jackson BR, Lockhart SR, Jenkins EN, Revis A, Farley MM, Harrison LH, Schaffner W, Markus TM, Pierce RA, Zhang AY, Lyman MM. Recurrent Candidemia: Trends and Risk Factors Among Persons Residing in 4 US States, 2011-2018. Open Forum Infect Dis 2022; 9:ofac545. [PMID: 36324324 PMCID: PMC9620433 DOI: 10.1093/ofid/ofac545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background Candidemia is a common healthcare-associated infection with high mortality. Estimates of recurrence range from 1% to 17%. Few studies have focused on those with recurrent candidemia, who often experience more severe illness and greater treatment failure. We describe recurrent candidemia trends and risk factors. Methods We analyzed population-based candidemia surveillance data collected during 2011-2018. Persons with >1 episode (defined as the 30-day period after a positive Candida species) were classified as having recurrent candidemia. We compared factors during the initial episode between those who developed recurrent candidemia and those who did not. Results Of the 5428 persons identified with candidemia, 326 (6%) had recurrent infection. Recurrent episodes occurred 1.0 month to 7.6 years after any previous episode. In multivariable logistic regression controlling for surveillance site and year, recurrent candidemia was associated with being 19-44 years old (vs ≥65 years; adjusted odds ratio [aOR], 3.05 [95% confidence interval {CI}, 2.10-4.44]), being discharged to a private residence (vs medical facility; aOR, 1.53 [95% CI, 1.12-2.08]), hospitalization in the 90 days prior to initial episode (aOR, 1.66 [95% CI, 1.27-2.18]), receipt of total parenteral nutrition (aOR, 2.08 [95% CI, 1.58-2.73]), and hepatitis C infection (aOR, 1.65 [95% CI, 1.12-2.43]). Conclusions Candidemia recurrence >30 days after initial infection occurred in >1 in 20 persons with candidemia. Associations with younger age and hepatitis C suggest injection drug use may play a modifiable role. Prevention efforts targeting central line care and total parenteral nutrition use may help reduce the risk of recurrent candidemia.
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Affiliation(s)
- Emma E Seagle
- ASRT, Inc, Atlanta, Georgia, USA,Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan R Jackson
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shawn R Lockhart
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily N Jenkins
- Correspondence: Emily N. Jenkins, MPH, ASRT, Inc, Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS H24-9, Atlanta, GA, 30329 ()
| | - Andrew Revis
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA,Foundation for Atlanta Veterans Education and Research, Atlanta, Georgia, USA,Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | - Monica M Farley
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA,Georgia Emerging Infections Program, Atlanta, Georgia, USA,Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lee H Harrison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Rebecca A Pierce
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Alexia Y Zhang
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
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2
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Gold JAW, Seagle EE, Nadle J, Barter DM, Czaja CA, Johnston H, Farley MM, Thomas S, Harrison LH, Fischer J, Pattee B, Mody RK, Phipps EC, Shrum Davis S, Tesini BL, Zhang AY, Markus TM, Schaffner W, Lockhart SR, Vallabhaneni S, Jackson BR, Lyman M. Treatment Practices for Adults with Candidemia at Nine Active Surveillance Sites - United States, 2017-2018. Clin Infect Dis 2021; 73:1609-1616. [PMID: 34079987 DOI: 10.1093/cid/ciab512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Candidemia is a common opportunistic infection causing substantial morbidity and mortality. Because of an increasing proportion of non-albicans Candida species and rising antifungal drug resistance, the Infectious Diseases Society of America (IDSA) changed treatment guidelines in 2016 to recommend echinocandins over fluconazole as first-line treatment for adults with candidemia. We describe candidemia treatment practices and adherence to the updated guidelines. METHODS During 2017-2018, the Emerging Infections Program conducted active population-based candidemia surveillance at nine U.S. sites using a standardized case definition. We assessed factors associated with initial antifungal treatment for the first candidemia case among adults using multivariable logistic regression models. To identify instances of potentially inappropriate treatment, we compared the first antifungal drug received with species and antifungal susceptibility testing (AFST) results from initial blood cultures. RESULTS Among 1,835 patients who received antifungal treatment, 1,258 (68.6%) received an echinocandin and 543 (29.6%) received fluconazole as initial treatment. Cirrhosis (adjusted odds ratio = 2.06, 95% confidence interval: 1.29-3.29) was the only underlying medical condition significantly associated with initial receipt of an echinocandin (versus fluconazole). Over half (n = 304, 56.0%) of patients initially treated with fluconazole grew a non-albicans species. Among 265 patients initially treated with fluconazole and with fluconazole AFST results, 28 (10.6%) had a fluconazole-resistant isolate. CONCLUSIONS A substantial proportion of patients with candidemia were initially treated with fluconazole, resulting in potentially inappropriate treatment for those involving non-albicans or fluconazole-resistant species. Reasons for non-adherence to IDSA guidelines should be evaluated, and clinician education is needed.
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Affiliation(s)
- Jeremy A W Gold
- Mycotic Diseases Branch, CDC, Atlanta, Georgia, USA.,Epidemic Intelligence Service, CDC, Atlanta, Georgia, USA
| | - Emma E Seagle
- Mycotic Diseases Branch, CDC, Atlanta, Georgia, USA.,ASRT Inc., Atlanta, GA, USA
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California, USA
| | - Devra M Barter
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | | | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Monica M Farley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Stepy Thomas
- Georgia Emerging Infections, Emory University School of Medicine, Atlanta, GA, USA
| | - Lee H Harrison
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jill Fischer
- Minnesota Department of Health, Saint Paul, Minnesota, USA
| | | | - Rajal K Mody
- Minnesota Department of Health, Saint Paul, Minnesota, USA.,Division of State and Local Readiness, CDC, Atlanta, Georgia, USA
| | - Erin C Phipps
- New Mexico Emerging Infections Program, Albuquerque, New Mexico, USA
| | - Sarah Shrum Davis
- New Mexico Emerging Infections Program, Albuquerque, New Mexico, USA
| | - Brenda L Tesini
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Alexia Y Zhang
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | | | | | | | | | | | - Meghan Lyman
- Mycotic Diseases Branch, CDC, Atlanta, Georgia, USA
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3
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Magill SS, O'Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR. Antimicrobial Use in US Hospitals: Comparison of Results From Emerging Infections Program Prevalence Surveys, 2015 and 2011. Clin Infect Dis 2021; 72:1784-1792. [PMID: 32519751 PMCID: PMC7976440 DOI: 10.1093/cid/ciaa373] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In the 2011 US hospital prevalence survey of healthcare-associated infections and antimicrobial use 50% of patients received antimicrobial medications on the survey date or day before. More hospitals have since established antimicrobial stewardship programs. We repeated the survey in 2015 to determine antimicrobial use prevalence and describe changes since 2011. METHODS The Centers for Disease Control and Prevention's Emerging Infections Program sites in 10 states each recruited ≤25 general and women's and children's hospitals. Hospitals selected a survey date from May-September 2015. Medical records for a random patient sample on the survey date were reviewed to collect data on antimicrobial medications administered on the survey date or day before. Percentages of patients on antimicrobial medications were compared; multivariable log-binomial regression modeling was used to evaluate factors associated with antimicrobial use. RESULTS Of 12 299 patients in 199 hospitals, 6084 (49.5%; 95% CI, 48.6-50.4%) received antimicrobials. Among 148 hospitals in both surveys, overall antimicrobial use prevalence was similar in 2011 and 2015, although the percentage of neonatal critical care patients on antimicrobials was lower in 2015 (22.8% vs 32.0% [2011]; P = .006). Fluoroquinolone use was lower in 2015 (10.1% of patients vs 11.9% [2011]; P < .001). Third- or fourth-generation cephalosporin use was higher (12.2% vs 10.7% [2011]; P = .002), as was carbapenem use (3.7% vs 2.7% [2011]; P < .001). CONCLUSIONS Overall hospital antimicrobial use prevalence was not different in 2011 and 2015; however, differences observed in selected patient or antimicrobial groups may provide evidence of stewardship impact.
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Affiliation(s)
- Shelley S Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Erin O'Leary
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Lantana Consulting Group, Thetford, Vermont, USA
| | - Susan M Ray
- Department of Medicine, Emory University, Atlanta, Georgia, USA
- Georgia Emerging Infections Program, Decatur, Georgia, USA
| | | | | | - Wendy M Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Sarah J Janelle
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Tolulope Oyewumi
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Ruth Lynfield
- Minnesota Department of Health, St Paul, Minnesota, USA
| | - Jean Rainbow
- Minnesota Department of Health, St Paul, Minnesota, USA
| | - Linn Warnke
- Minnesota Department of Health, St Paul, Minnesota, USA
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California, USA
| | | | | | | | | | | | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven, Connecticut, USA
| | - Samantha Greissman
- Connecticut Emerging Infections Program, Hartford and New Haven, Connecticut, USA
| | - Lucy E Wilson
- Maryland Department of Health and University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York, USA
| | - Jonathan R Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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4
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Tsay SV, Mu Y, Williams S, Epson E, Nadle J, Bamberg WM, Barter DM, Johnston HL, Farley MM, Harb S, Thomas S, Bonner LA, Harrison LH, Hollick R, Marceaux K, Mody RK, Pattee B, Shrum Davis S, Phipps EC, Tesini BL, Gellert AB, Zhang AY, Schaffner W, Hillis S, Ndi D, Graber CR, Jackson BR, Chiller T, Magill S, Vallabhaneni S. Burden of Candidemia in the United States, 2017. Clin Infect Dis 2021; 71:e449-e453. [PMID: 32107534 DOI: 10.1093/cid/ciaa193] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/24/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Candidemia is a common healthcare-associated bloodstream infection with high morbidity and mortality. There are no current estimates of candidemia burden in the United States (US). METHODS In 2017, the Centers for Disease Control and Prevention conducted active population-based surveillance for candidemia through the Emerging Infections Program in 45 counties in 9 states encompassing approximately 17 million persons (5% of the national population). Laboratories serving the catchment area population reported all blood cultures with Candida, and a standard case definition was applied to identify cases that occurred in surveillance area residents. Burden of cases and mortality were estimated by extrapolating surveillance area cases to national numbers using 2017 national census data. RESULTS We identified 1226 candidemia cases across 9 surveillance sites in 2017. Based on this, we estimated that 22 660 (95% confidence interval [CI], 20 210-25 110) cases of candidemia occurred in the US in 2017. Overall estimated incidence was 7.0 cases per 100 000 persons, with highest rates in adults aged ≥ 65 years (20.1/100 000), males (7.9/100 000), and those of black race (12.3/100 000). An estimated 3380 (95% CI, 1318-5442) deaths occurred within 7 days of a positive Candida blood culture, and 5628 (95% CI, 2465-8791) deaths occurred during the hospitalization with candidemia. CONCLUSIONS Our analysis highlights the substantial burden of candidemia in the US. Because candidemia is only one form of invasive candidiasis, the true burden of invasive infections due to Candida is higher. Ongoing surveillance can support future burden estimates and help assess the impact of prevention interventions.
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Affiliation(s)
- Sharon V Tsay
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sabrina Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Erin Epson
- California Emerging Infections Program, Oakland, California, USA
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California, USA
| | - Wendy M Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Devra M Barter
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Helen L Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Monica M Farley
- Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Sasha Harb
- Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | - Stepy Thomas
- Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | | | - Lee H Harrison
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rosemary Hollick
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kaytlynn Marceaux
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rajal K Mody
- Minnesota Department of Health, St Paul, Minnesota, USA
| | | | - Sarah Shrum Davis
- New Mexico Emerging Infections Program, Albuquerque, New Mexico, USA
| | - Erin C Phipps
- New Mexico Emerging Infections Program, Albuquerque, New Mexico, USA
- University of New Mexico, Albuquerque, New Mexico, USA
| | - Brenda L Tesini
- University of Rochester, Rochester, New York, USA
- New York Emerging Infections Program, Rochester, New York, USA
| | - Anita B Gellert
- New York Emerging Infections Program, Rochester, New York, USA
| | | | | | - Sherry Hillis
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Danielle Ndi
- Tennessee Emerging Infections Program, Nashville, Tennessee, USA
| | | | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shelley Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Snigdha Vallabhaneni
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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Zhang AY, Shrum S, Williams S, Petnic S, Nadle J, Johnston H, Barter D, Vonbank B, Bonner L, Hollick R, Marceaux K, Harrison L, Schaffner W, Tesini BL, Farley MM, Pierce RA, Phipps E, Mody RK, Chiller TM, Jackson BR, Vallabhaneni S. The Changing Epidemiology of Candidemia in the United States: Injection Drug Use as an Increasingly Common Risk Factor-Active Surveillance in Selected Sites, United States, 2014-2017. Clin Infect Dis 2021; 71:1732-1737. [PMID: 31676903 DOI: 10.1093/cid/ciz1061] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/29/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Injection drug use (IDU) is a known, but infrequent risk factor on candidemia; however, the opioid epidemic and increases in IDU may be changing the epidemiology of candidemia. METHODS Active population-based surveillance for candidemia was conducted in selected US counties. Cases of candidemia were categorized as IDU cases if IDU was indicated in the medical records in the 12 months prior to the date of initial culture. RESULTS During 2017, 1191 candidemia cases were identified in patients aged >12 years (incidence: 6.9 per 100 000 population); 128 (10.7%) had IDU history, and this proportion was especially high (34.6%) in patients with candidemia aged 19-44. Patients with candidemia and IDU history were younger than those without (median age, 35 vs 63 years; P < .001). Candidemia cases involving recent IDU were less likely to have typical risk factors including malignancy (7.0% vs 29.4%; relative risk [RR], 0.2 [95% confidence interval {CI}, .1-.5]), abdominal surgery (3.9% vs 17.5%; RR, 0.2 [95% CI, .09-.5]), and total parenteral nutrition (3.9% vs 22.5%; RR, 0.2 [95% CI, .07-.4]). Candidemia cases with IDU occurred more commonly in smokers (68.8% vs 18.5%; RR, 3.7 [95% CI, 3.1-4.4]), those with hepatitis C (54.7% vs 6.4%; RR, 8.5 [95% CI, 6.5-11.3]), and in people who were homeless (13.3% vs 0.8%; RR, 15.7 [95% CI, 7.1-34.5]). CONCLUSIONS Clinicians should consider injection drug use as a risk factor in patients with candidemia who lack typical candidemia risk factors, especially in those with who are 19-44 years of age and have community-associated candidemia.
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Affiliation(s)
- Alexia Y Zhang
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Sarah Shrum
- New Mexico Department of Health, Santa Fe, New Mexico, USA
| | - Sabrina Williams
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Petnic
- California Emerging Infections Program, Oakland, California, USA
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California, USA
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | | | - Lindsay Bonner
- Maryland Emerging Infections Program, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Rosemary Hollick
- Maryland Emerging Infections Program, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Kaytlynn Marceaux
- Maryland Emerging Infections Program, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Lee Harrison
- Maryland Emerging Infections Program, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | | | - Brenda L Tesini
- University of Rochester School of Medicine, Rochester, New York, USA
| | - Monica M Farley
- Emory University School of Medicine and Atlanta Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Rebecca A Pierce
- Oregon Public Health Division, Oregon Health Authority, Portland, Oregon, USA
| | - Erin Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico, USA
| | - Rajal K Mody
- Minnesota Department of Health, St Paul, Minnesota, USA.,Division of State and Local Readiness, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tom M Chiller
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brendan R Jackson
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Snigdha Vallabhaneni
- Mycotic Disease Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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6
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Thompson ND, Stone ND, Brown CJ, Penna AR, Eure TR, Bamberg WM, Barney GR, Barter D, Clogher P, DeSilva MB, Dumyati G, Frank L, Felsen CB, Godine D, Irizarry L, Kainer MA, Li L, Lynfield R, Mahoehney JP, Maloney M, Nadle J, Ocampo VLS, Pierce R, Ray SM, Davis SS, Sievers M, Srinivasan K, Wilson LE, Zhang AY, Magill SS. Antimicrobial Use in a Cohort of US Nursing Homes, 2017. JAMA 2021; 325:1286-1295. [PMID: 33821897 PMCID: PMC8025112 DOI: 10.1001/jama.2021.2900] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. OBJECTIVE To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. EXPOSURES Residence in one of the participating nursing homes at the time of the survey. MAIN OUTCOMES AND MEASURES Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. RESULTS Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. CONCLUSIONS AND RELEVANCE In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.
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Affiliation(s)
- Nicola D. Thompson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D. Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cedric J. Brown
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Austin R. Penna
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Taniece R. Eure
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Now with Medical Epidemiology Consulting, Denver, Colorado
| | - Grant R. Barney
- New York Emerging Infections Program, Rochester
- Now with New York State Department of Health, Albany
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver
| | - Paula Clogher
- Connecticut Emerging Infections Program, New Haven
- Yale School of Public Health, New Haven, Connecticut
| | - Malini B. DeSilva
- Minnesota Department of Health, St Paul
- Now with HealthPartners Institute, Minneapolis, Minnesota
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester, Rochester, New York
| | - Linda Frank
- California Emerging Infections Program, Oakland
| | - Christina B. Felsen
- New York Emerging Infections Program, Rochester
- University of Rochester, Rochester, New York
| | | | | | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Now with Western Health, Melbourne, Australia
| | - Linda Li
- Maryland Emerging Infections Program, Maryland Department of Health, Baltimore
| | | | | | | | | | | | | | - Susan M. Ray
- Georgia Emerging Infections Program, Atlanta
- Emory University, Atlanta, Georgia
| | | | | | | | - Lucy E. Wilson
- Maryland Emerging Infections Program, Maryland Department of Health, Baltimore
- Now with Maryland Emerging Infections Program, University of Maryland Baltimore County, Baltimore
| | | | - Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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7
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Magill SS, O’Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR, Chea N, Neuhauser MM. Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4:e212007. [PMID: 33734417 PMCID: PMC7974639 DOI: 10.1001/jamanetworkopen.2021.2007] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.
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Affiliation(s)
- Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin O’Leary
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Lantana Consulting Group, Thetford, Vermont
| | - Susan M. Ray
- Department of Medicine, Emory University, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur
| | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Infectious Diseases, Western Health, Melbourne, Victoria, Australia
| | | | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Medical Epidemiology Consulting, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver
| | | | - Tolulope Oyewumi
- Colorado Department of Public Health and Environment, Denver
- Department of Healthcare Management, University of Denver, Colorado
| | | | | | - Linn Warnke
- Minnesota Department of Health, St Paul
- Hennepin County Public Health, Minneapolis, Minnesota
| | | | - Deborah L. Thompson
- New Mexico Department of Health, Santa Fe
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Shamima Sharmin
- New Mexico Department of Health, Santa Fe
- Infection Prevention and Control Department, University of New Mexico Hospital, Albuquerque
| | | | | | | | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven
| | - Samantha Greissman
- Connecticut Emerging Infections Program, Hartford and New Haven
- Department of Medicine, Columbia–New York Presbyterian Hospital
| | - Lucy E. Wilson
- Maryland Department of Health, Baltimore
- University of Maryland Baltimore County, Baltimore
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester Medical Center, Rochester, New York
| | - Jonathan R. Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Chea
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melinda M. Neuhauser
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Tesini BL, Lyman M, Jackson BR, Gellert A, Schaffner W, Farley MM, Shrum S, Phipps EC, Zhang AY, Pattee B, Fischer J, Johnston H, Barter D, Harrison L, Marceaux K, Nadle J. 146. antifungal Susceptibility Patterns of candida Parapsilosis Bloodstream Isolates in the US, 2008–2018. Open Forum Infect Dis 2020. [PMCID: PMC7778318 DOI: 10.1093/ofid/ofaa439.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Multidrug resistant Candida is an increasing concern. C. parapsilosis in particular has decreased in vitro susceptibility to echinocandins. As a result, fluconazole had been favored for C. parapsilosis treatment. However, there is growing concern about increasing azole resistance among Candida species. We report on antifungal susceptibility patterns of C. parapsilosis in the US from 2008 through 2018. Methods Active, population-based surveillance for candidemia through the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program was conducted between 2008–2018, eventually encompassing 9 states (GA, MD,OR, TN, NY, CA, CO, MN, NM). Each incident isolate was sent to the CDC for species confirmation and antifungal susceptibility testing (AFST). Frequency of resistance was calculated and stratified by year and state using SAS 9.4 Results Of the 8,704 incident candidemia isolates identified, 1,471 (15%) were C. parapsilosis; the third most common species after C. albicans and C. glabrata. AFST results were available for 1,340 C. parapsilosis isolates. No resistance was detected to caspofungin (MIC50 0.25) or micafungin (MIC50 1.00) with only one (< 1%) isolate resistant to anidulafungin (MIC50 1.00). In contrast, 84 (6.3%) isolates were resistant to fluconazole and another 44 (3.3%) isolates had dose-dependent susceptibility to fluconazole (MIC50 1.00). Fluconazole resistance increased sharply from an average of 4% during 2008–2014 to a peak of 14% in 2016 with a subsequent decline to 6% in 2018 (see figure). Regional variation is also observed with fluconazole resistance ranging from 0% (CO, MN, NM) to 42% (NY) of isolates by site. ![]()
Conclusion The recent marked increase in fluconazole resistance among C. parapsilosis highlights this pathogen as an emerging drug resistant pathogen of concern and the need for ongoing antifungal resistance surveillance among Candida species. Our data support the empiric use of echinocandins for C. parapsilosis bloodstream infections and underscore the need to obtain AFST prior to fluconazole treatment. Furthermore, regional variation in fluconazole resistance emphasizes the importance of understanding local Candida susceptibility patterns. Disclosures Lee Harrison, MD, GSK (Consultant)Merck (Consultant)Pfizer (Consultant)Sanofi Pasteur (Consultant)
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Affiliation(s)
| | | | | | | | | | | | - Sarah Shrum
- New Mexico Emerging Infectious Program, Albuquerque, New Mexico
| | | | - Alexia Y Zhang
- Oregon Public Health Division-Acute and Communicable Disease Prevention, Portland, Oregon
| | | | - Jill Fischer
- Minnesota Department of Health, St. Paul, Minnesota
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Lee Harrison
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Joelle Nadle
- California Emerging Infections Program, Oakland, California
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Oh DH, Seagle E, Lockhart SR, Nadle J, Barter D, Johnston H, Farley MM, Revis A, Pattee B, Phipps EC, Tesini BL, Zhang AY, Schaffner W, Jackson BR, Lyman M. 1424. Factors Associated with Failure to Clear Candidemia Infection: Surveillance Data from Eight States, 2017. Open Forum Infect Dis 2020. [PMCID: PMC7776766 DOI: 10.1093/ofid/ofaa439.1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Candidemia is a bloodstream infection commonly associated with high morbidity and mortality. Failure to clear candidemia can lengthen hospitalization and treatment. Factors associated with candidemia clearance are unknown.
Methods
We analyzed 2017 candidemia surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program. Data from eight sites (counties in California, Colorado, Georgia, Minnesota, New Mexico, New York, Oregon, and Tennessee) were included. Clearance was defined as having a blood culture negative for Candida ≤30 days after initial culture date (ICD). Cases with unknown clearance, unknown survival outcome, or death ≤30 days of ICD were excluded. Demographic and clinical factors associated with clearance were assessed with bivariate analysis using chi-square tests and multivariable logistic regression to calculate adjusted odds ratios (aOR) using backward selection (p-value< 0.10).
Results
Of 1,024 candidemia cases, 737 were included and 582 (79%) demonstrated clearance, of which 79% had evidence of clearance ≤5 days after ICD. In bivariate analysis, clearance was associated with central venous catheter (CVC) ≤2 days before ICD, CVC removal ≤7 days after ICD, and systemic antifungal medication within 14 days before ICD. Clearance was inversely associated with black race and admission from another hospital. In multivariable analysis, only race and admission from another hospital were significant predictors; age, sex, and CVC presence and subsequent removal were also retained for their clinical relevance. In the final model, clearance was less likely among black patients (aOR 0.51, 95% confidence interval [CI] 0.29-0.91) and those admitted from another hospital (aOR 0.28, 95% CI 0.11-0.75).
Table 1. Bivariate associations for select variables between individuals with documented candidemia clearance and those without documented clearance in eight Emerging Infections Program surveillance sites, 2017
Conclusion
We found failure to clear candidemia infection to be associated with black race and prior hospital exposure, but not other factors previously shown to be associated (e.g., comorbidities, CVC presence). These associations could reflect illness severity, access to care, or other obstacles to effective treatment. Additional research is needed to investigate these associations further and identify other factors (e.g., treatment type and timing) to improve outcomes.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- David H Oh
- Tufts University School of Medicine, San Leandro, California
| | - Emma Seagle
- Centers for Disease Control and Prevention, Mycotic Disease Branch, Atlanta, Georgia
| | | | - Joelle Nadle
- California Emerging Infections Program, Oakland, California
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | - Andrew Revis
- Foundation for Atlanta Veterans Education and Research/VA Health System, Georgia Emerging Infections Program, Atlanta, Georgia
| | | | | | | | - Alexia Y Zhang
- Oregon Public Health Division-Acute and Communicable Disease Prevention, Portland, Oregon
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Thompson ND, Penna A, Eure TR, Bamberg WM, Barney G, Barter D, Clogher P, DeSilva MB, Dumyati G, Epson E, Frank L, Godine D, Irizarry L, Kainer MA, Li L, Lynfield R, Mahoehney JP, Nadle J, Ocampo V, Perry L, Ray SM, Davis SS, Sievers M, Wilson LE, Zhang AY, Stone ND, Magill SS. Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents. J Am Med Dir Assoc 2019; 21:91-96. [PMID: 31822391 DOI: 10.1016/j.jamda.2019.11.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/01/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. DESIGN Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. SETTING AND PARTICIPANTS Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). METHODS EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home-specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. RESULTS Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home-specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used. CONCLUSIONS AND IMPLICATIONS One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home-specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.
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Affiliation(s)
- Nicola D Thompson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Austin Penna
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Taniece R Eure
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Wendy M Bamberg
- Colorado Department of Public Health and Environment, Denver, CO
| | - Grant Barney
- New York Emerging Infections Program, Rochester, NY
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver, CO
| | - Paula Clogher
- Connecticut Emerging Infections Program and the Yale School of Public Health, New Haven, CT
| | | | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester, NY; University of Rochester, Rochester, NY
| | - Erin Epson
- California Department of Health, Richmond, CA
| | - Linda Frank
- California Emerging Infections Program, Oakland, CA
| | | | | | | | - Linda Li
- Maryland Department of Health, Baltimore, MD
| | | | | | - Joelle Nadle
- California Emerging Infections Program, Oakland, CA
| | | | - Lewis Perry
- Georgia Emerging Infections Program, Atlanta, GA
| | - Susan M Ray
- Georgia Emerging Infections Program, Atlanta, GA; Emory University, Atlanta, GA
| | | | | | | | | | - Nimalie D Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shelley S Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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Gokhale RH, Sapiano M, Dantes R, Abanyie-Bimbo F, Wilson LE, Thompson N, Perlmuter R, Nadle J, Frank L, Brousseau G, Johnston H, Bamberg WM, Dumyati G, Lynfield R, DaSilva M, Kainer MA, Zhang AY, Ocampo V, Samper M, Irizarry L, Sievers MM, Maloney M, Ray S, Magill S, Katz D, Epstein L. 111. Pediatric and Adolescent Sepsis Epidemiology and Clinical Characteristics, Emerging Infections Program, 2014–2015. Open Forum Infect Dis 2019. [PMCID: PMC6809396 DOI: 10.1093/ofid/ofz360.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Sepsis is an important contributor to mortality among children and young adults. However, recent studies focused on hospital management and burden estimation do not provide critical data to inform prevention efforts. We conducted detailed medical record reviews to describe the epidemiology and clinical characteristics of children and young adults with sepsis to inform prevention and early recognition targets. Methods We utilized the Emerging Infections Program (EIP) to collect comprehensive data via retrospective record review for patients with severe sepsis or septic shock discharge diagnosis codes from a nonrandom sample of hospitals across 10 states. Children and young adults, aged 30 days through 21 years, discharged between September 30, 2014 and October 1, 2015, were randomly selected for inclusion. We performed a descriptive analysis of these data. Results Among 734 patients hospitalized with sepsis, 92% were living in a private residence 4 days before admission, 38% had an outpatient medical encounter in the 7 days before admission, 14% had sepsis onset after hospital day 3, and 11% died within 90 days of sepsis diagnosis. The most frequently identified infection was lower respiratory tract infection (14%); for 317 (43%) no infection was documented as a cause of sepsis. The most frequently identified pathogen was Staphylococcus aureus (10%); for 326 (44%) no pathogen was identified as a cause of sepsis. Among 394 (54%) patients with ≥1 chronic underlying medical condition (CUMC), the most common were pulmonary disease (35%), hematologic/oncologic disease (31%), immune compromise (24%), and cardiovascular disease (20%). Patients with CUMC had a higher percentage of their sepsis onset after hospital day 3, death within 90 days of sepsis diagnosis, and Pseudomonas aeruginosa as a cause of sepsis (table). The percentage of patients with no pathogen identified was similar between those with CUMC and those without. Conclusion In our large cohort of children and young adults with sepsis, most had sepsis onset outside of the hospital and over half had chronic conditions. Our data suggest that distinct approaches may be needed to develop effective prevention and early recognition strategies for children and young adults depending on the presence of chronic conditions. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Matthew Sapiano
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Raymund Dantes
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Lucy E Wilson
- University of Maryland Baltimore County, Baltimore, Maryland
| | - Nicola Thompson
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joelle Nadle
- California Emerging Infections Program, Oakland, California
| | - Linda Frank
- California Emerging Infections Program, Oakland, California
| | - Geoff Brousseau
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Wendy M Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Ghinwa Dumyati
- New York Rochester Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York
| | - Ruth Lynfield
- Minnesota Department of Health, Saint Paul, Minnesota
| | | | | | - Alexia Y Zhang
- Oregon Public Health Division-Acute and Communicable Disease Prevention, Portland, Oregon
| | | | | | | | | | | | - Susan Ray
- Emory University School of Medicine, Atlanta, Georgia
| | - Shelley Magill
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David Katz
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauren Epstein
- Centers for Disease Control and Prevention, Atlanta, Georgia
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12
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Magill SS, O’Leary E, Nadle J, Johnston H, Janelle SJ, Maloney M, Ray S, Wilson LE, Lynfield R, Rainbow J, Sievers MM, Dumyati G, Ocampo V, Samper M, Zhang AY, Evans CD, Kainer MA, Edwards JR, Chea N, Neuhauser MM. 1009. Measuring the quality of fluoroquinolone prescribing in hospitals: results from the Emerging Infections Program Hospital Prevalence Survey Antimicrobial Quality Assessment. Open Forum Infect Dis 2019. [PMCID: PMC6811286 DOI: 10.1093/ofid/ofz360.873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Improving antimicrobial use is a key component of controlling antimicrobial resistance. Multiple factors influence inpatient provider antimicrobial prescribing decisions, making it challenging to develop standard methods to evaluate prescribing quality in hospitals. In 2015, CDC’s Emerging Infections Program (EIP) conducted a hospital antimicrobial use prevalence survey and collected data to assess prescribing quality in selected scenarios, including fluoroquinolone (FQ) treatment. Methods EIP sites (CA, CO, CT, GA, MD, MN, NM, NY, OR, TN) each recruited up to 25 hospitals for the survey. Each hospital selected a survey date during May–September 2015. Among randomly selected inpatients on the survey date, EIP staff identified those ≥18 years old who received FQ treatment on the survey date or the day prior and reviewed medical records to gather data on underlying conditions, infections, and diagnostic tests. We used these data to update a previously developed prescribing quality assessment pathway that categorized FQ treatment as supported or unsupported based on medical record documentation. Results Among 12,299 patients in 199 hospitals, 1084 (8.7%) received FQ treatment; 756 (70%) were treated for a single infection type during their hospitalization and were ≥18 years old. The pathway categorized FQ treatment as supported for 646 (85.4%) and unsupported for 110 patients (14.6%) (figure). Almost half of unsupported treatment was due to a lack of compatible signs or symptoms of infection in a patient from whom an organism susceptible or likely susceptible to an FQ was identified from a nonsterile site (49/110 patients, 44.5%), suggesting colonization. Conclusion Utilization of a pathway that incorporates detailed clinical data enabled us to apply a standard approach to assess FQ prescribing quality in hospitals. A high percentage of FQ treatment was supported, possibly reflecting efforts in recent years to reduce inappropriate use. Our assessment approach also identified opportunities for further improvements in inpatient FQ stewardship. Incorporation of additional elements in the pathway, such as the availability of other antibiotic choices in clinical scenarios where FQ use is currently supported (e.g., pneumonia) could further enhance the pathway’s performance. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Erin O’Leary
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Sarah J Janelle
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | - Susan Ray
- Emory University School of Medicine, Atlanta, Georgia
| | - Lucy E Wilson
- University of Maryland Baltimore County, Baltimore, Maryland
| | - Ruth Lynfield
- Minnesota Department of Health, Saint Paul, Minnesota
| | - Jean Rainbow
- Minnesota Department of Health, Saint Paul, Minnesota
| | | | - Ghinwa Dumyati
- New York Rochester Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York
| | | | | | - Alexia Y Zhang
- Oregon Public Health Division-Acute and Communicable Disease Prevention, Portland, Oregon
| | | | | | | | - Nora Chea
- Center for Disease Control and Prevention, Atlanta, Georgia
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Toda M, Williams SR, Berkow EL, Farley MM, Harrison LH, Bonner L, Marceaux KM, Hollick R, Zhang AY, Schaffner W, Lockhart SR, Jackson BR, Vallabhaneni S. Population-Based Active Surveillance for Culture-Confirmed Candidemia - Four Sites, United States, 2012-2016. MMWR Surveill Summ 2019; 68:1-15. [PMID: 31557145 PMCID: PMC6772189 DOI: 10.15585/mmwr.ss6808a1] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PROBLEM/CONDITION Candidemia is a bloodstream infection (BSI) caused by yeasts in the genus Candida. Candidemia is one of the most common health care-associated BSIs in the United States, with all-cause in-hospital mortality of up to 30%. PERIOD COVERED 2012-2016. DESCRIPTION OF SYSTEM CDC's Emerging Infections Program (EIP), a collaboration among CDC, state health departments, and academic partners that was established in 1995, was used to conduct active, population-based laboratory surveillance for candidemia in 22 counties in four states (Georgia, Maryland, Oregon, and Tennessee) with a combined population of approximately 8 million persons. Laboratories serving the catchment areas were recruited to report candidemia cases to the local EIP program staff. A case was defined as a blood culture that was positive for a Candida species collected from a surveillance area resident during 2012-2016. Isolates were sent to CDC for species confirmation and antifungal susceptibility testing. Any subsequent blood cultures with Candida within 30 days of the initial positive culture in the same patient were considered part of the same case. Trained surveillance officers collected clinical information from the medical chart for all cases, and isolates were sent to CDC for species confirmation and antifungal susceptibility testing. RESULTS Across all sites and surveillance years (2012-2016), 3,492 cases of candidemia were identified. The crude candidemia incidence averaged across sites and years during 2012-2016 was 8.7 per 100,000 population; important differences in incidence were found by site, age group, sex, and race. The crude annual incidence was the highest in Maryland (14.1 per 100,000 population) and lowest in Oregon (4.0 per 100,000 population). The crude annual incidence of candidemia was highest among adults aged ≥65 years (25.5 per 100,000 population) followed by infants aged <1 year (15.8). The crude annual incidence was higher among males (9.4) than among females (8.0) and was approximately 2 times greater among blacks than among nonblacks (13.7 versus 5.8). Ninety-six percent of cases occurred in patients who were hospitalized at the time of or during the week after having a positive culture. One third of cases occurred in patients who had undergone a surgical procedure in the 90 days before the candidemia diagnosis, 77% occurred in patients who had received systemic antibiotics in the 14 days before the diagnosis, and 73% occurred in patients who had had a central venous catheter (CVC) in place within 2 days before the diagnosis. Ten percent were in patients who had used injection drugs in the past 12 months. The median time from admission to candidemia diagnosis was 5 days (interquartile range [IQR]: 0-16 days). Among 2,662 cases that were treated in adults aged >18 years, 34% were treated with fluconazole alone, 30% with echinocandins alone, and 34% with both. The all-cause, in-hospital case-fatality ratio was 25% for any time after admission; the all-cause in-hospital case-fatality ratio was 8% for <48 hours after a positive culture for Candida species. Candida albicans accounted for 39% of cases, followed by Candida glabrata (28%) and Candida parapsilosis (15%). Overall, 7% of isolates were resistant to fluconazole and 1.6% were resistant to echinocandins, with no clear trends in resistance over the 5-year surveillance period. INTERPRETATION Approximately nine out of 100,000 persons developed culture-positive candidemia annually in four U.S. sites. The youngest and oldest persons, men, and blacks had the highest incidences of candidemia. Patients with candidemia identified in the surveillance program had many of the typical risk factors for candidemia, including recent surgery, exposure to broad-spectrum antibiotics, and presence of a CVC. However, an unexpectedly high proportion of candidemia cases (10%) occurred in patients with a history of injection drug use (IDU), suggesting that IDU has become a common risk factor for candidemia. Deaths associated with candidemia remain high, with one in four cases resulting in death during hospitalization. PUBLIC HEALTH ACTION Active surveillance for candidemia yielded important information about the disease incidence and death rate and persons at greatest risk. The surveillance was expanded to nine sites in 2017, which will improve understanding of the geographic variability in candidemia incidence and associated clinical and demographic features. This surveillance will help monitor incidence trends, track emergence of resistance and species distribution, monitor changes in underlying conditions and predisposing factors, assess trends in antifungal treatment and outcomes, and be helpful for those developing prevention efforts. IDU has emerged as an important risk factor for candidemia, and interventions to prevent invasive fungal infections in this population are needed. Surveillance data documenting that approximately two thirds of candidemia cases were caused by species other than C. albicans, which are generally associated with greater antifungal resistance than C. albicans, and the presence of substantial fluconazole resistance supports 2016 clinical guidelines recommending a switch from fluconazole to echinocandins as the initial treatment for candidemia in most patients.
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Magill SS, O’Leary E, Ray SM, Morabit S, Perry L, Kainer MA, Beard RH, Bamberg W, Johnston HL, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sievers MM, Sharmin S, Hancock EB, Pierce R, Zhang AY, Maloney M, Wilson LE, Buhr N, Richards K, Dumyati G, Edwards JR. 1859. Prevalence of Antimicrobial Use in US Hospital Patients, 2011 vs. 2015. Open Forum Infect Dis 2018. [PMCID: PMC6252926 DOI: 10.1093/ofid/ofy210.1515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Antimicrobial stewardship (AS) is increasingly recognized as an essential component of patient safety programs. In a US hospital prevalence survey in 2011, 50% of patients received antimicrobial drugs (ADs). The survey was repeated in 2015 to describe changes in inpatient antimicrobial use, approximately one year after CDC published the “Core Elements of Hospital Antibiotic Stewardship Programs.” Methods Emerging Infections Program (EIP) sites in 10 states recruited up to 25 hospitals each, seeking to re-engage hospitals that participated in the 2011 survey. Hospitals selected survey dates from May to September 2015 and completed AS questionnaires. Patients were randomly sampled from the hospital census on the survey date. EIP staff retrospectively reviewed medical records to collect AD data. Percentages of patients on ADs on the survey date or the day before were compared using chi-square tests (SAS 9.4, OpenEpi 3.01). Results In 2015, among 148 hospitals participating in both surveys, 29 (19.6%) reported having no AS team (AST); 63 (42.6%) had ASTs for <4 years, and 56 (37.8%) had ASTs for ≥4 years. Antimicrobial use prevalence in 2015 was approximately 50% in hospitals with and without ASTs. Percentages of patients on ADs was not different in 2015 (4,590/9,169, 50.1%) compared with 2011 (4,606/9,283, 49.6%, P = 0.55). Antimicrobial use prevalence in most hospital locations did not change, although the percentage of neonatal intensive and special care unit patients on ADs was lower in 2015 compared with 2011 (22.1% vs. 30.7%, P = 0.005). The percentage of patients on fluoroquinolones was lower in 2015, while percentages of patients on carbapenems or cephalosporins were higher in 2015 than in 2011 (figure). ![]()
Conclusion Some observed differences between 2011 and 2015 provide evidence of stewardship impact. The decrease in antimicrobial use in selected neonatal locations may reflect implementation of tools to improve neonatal sepsis prescribing, while decreases in fluoroquinolone use may reflect efforts to prevent Clostridium difficile infections. However, our data also suggest that reductions in some ADs are offset by increases in others, supporting the need for ongoing work to identify the most effective AS strategies. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Erin O’Leary
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan M Ray
- Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur, Georgia
| | - Susan Morabit
- Georgia Emerging Infections Program, Decatur, Georgia
| | - Lewis Perry
- Georgia Emerging Infections Program, Decatur, Georgia
| | | | | | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Helen L Johnston
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | - Jean Rainbow
- Minnesota Department of Health, St. Paul, Minnesota
| | - Linn Warnke
- Minnesota Department of Health, St. Paul, Minnesota
| | - Joelle Nadle
- California Emerging Infections Program, Oakland, California
| | - Deborah L Thompson
- Presbyterian Healthcare Services, Albuquerque, New Mexico
- New Mexico Department of Health, Santa Fe, New Mexico
| | | | | | | | | | | | | | | | - Nicolai Buhr
- Maryland Department of Health, Baltimore, Maryland
| | | | - Ghinwa Dumyati
- New York Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York
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15
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Zhang AY, Shrum S, Williams S, Vonbank B, Hillis S, Barter D, Petnic S, Harrison LH, Dumyati G, Phipps EC, Pierce R, Schaffner W, Farley MM, Mody RK, Chiller T, Jackson BR, Vallabhaneni S. 1722. The Changing Epidemiology of Candidemia in the United States: Injection Drug Use as an Emerging Risk Factor for Candidemia. Open Forum Infect Dis 2018. [PMCID: PMC6253027 DOI: 10.1093/ofid/ofy209.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Known risk factors for candidemia include diabetes, malignancy, antibiotics, total parenteral nutrition (TPN), prolonged hospitalization, abdominal surgery, and central venous catheters. Injection drug use (IDU) is not a common risk factor. We used data from CDC Emerging Infections Program’s candidemia surveillance to assess prevalence of IDU among candidemia cases and compare IDU and non-IDU cases. Methods Active, population-based candidemia surveillance was conducted in 45 counties in 9 states during January–December 2017. Data from 2014 to 2016 were available from 4 states and were used to look for trends. A case was defined as blood culture with Candida in a surveillance area resident. We collected clinical information, including IDU in the past 12 months. Differences between IDU and non-IDU cases were tested using logistic regression. Results Of 1,018 candidemia cases in 2017, 123 (12%) occurred in the context of recent IDU (1% in Minnesota and 27% in New Mexico) (Figure 1). In the 4 states with pre-2017 data, the proportion of IDU cases increased from 7% in 2014 to 15% in 2017, with the proportion in Tennessee nearly tripling from 7% to 18% (Figure 2). IDU cases were younger than non-IDU cases (median 34 vs. 62 years, P < 0.001). Compared with non-IDU cases, IDU cases were less likely to have diabetes (16% vs. 35%; OR 0.4, CI 0.2–0.6), malignancies (7% vs. 30%; OR 0.2, CI 0.1–0.3), abdominal surgery (6% vs. 19%; OR 0.3, CI 0.1–0.6), receive TPN (6% vs. 27%; OR 0.2, CI 0.1–0.4) and were more likely to have hepatitis C (96% vs. 47%; OR 16.1, CI 10.4–24.9), be homeless (13% vs. 1%; OR 17.8, CI 7.1–44.6), and have polymicrobial blood cultures (33% vs. 17%; OR 2.4, CI 1.6–3.6). Median time from admission to candidemia was 0.5 vs. 3 days and in-hospital mortality was 7% vs. 28% for IDU and non-IDU cases, respectively. Conclusion In 2017, 1 in 8 candidemia cases had a history of IDU, including a quarter of cases in some sites. The proportion of such cases increased since 2014. IDU cases lacked many of the typical risk factors for candidemia, suggesting that IDU may be an independent risk factor. Given the growing opioid epidemic, further study is necessary to elucidate how people who inject drugs acquire candidemia and design effective interventions for prevention. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Alexia Y Zhang
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, Oregon
| | - Sarah Shrum
- New Mexico Department of Health, Santa Fe, New Mexico
| | - Sabrina Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Sherry Hillis
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Devra Barter
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - Sarah Petnic
- California Emerging Infections Program, Oakland, California
| | | | - Ghinwa Dumyati
- NY Emerging Infections Program, Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, New York
| | - Erin C Phipps
- New Mexico Emerging Infections Program, University of New Mexico, Albuquerque, New Mexico
| | - Rebecca Pierce
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, Oregon
| | | | - Monica M Farley
- Department of Medicine, Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia
| | - Rajal K Mody
- Minnesota Department of Health, St. Paul, Minnesota
- Division of State and Local Readiness, Office of Public Health Preparedness and Response, CDC, Atlanta, Georgia
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Snigdha Vallabhaneni
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Benedict K, Roy M, Kabbani S, Anderson EJ, Farley MM, Harb S, Harrison LH, Bonner L, Wadu VL, Marceaux K, Hollick R, Beldavs ZG, Zhang AY, Schaffner W, Graber CR, Derado G, Chiller TM, Lockhart SR, Vallabhaneni S. Neonatal and Pediatric Candidemia: Results From Population-Based Active Laboratory Surveillance in Four US Locations, 2009-2015. J Pediatric Infect Dis Soc 2018. [PMID: 29522195 DOI: 10.1093/jpids/piy009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Candida is a leading cause of healthcare-associated bloodstream infections in the United States. Infants and children have unique risk factors for candidemia, and the Candida species distribution in this group is different that among adults; however, candidemia epidemiology in this population has not been described recently. METHODS We conducted active population-based candidemia surveillance in 4 US metropolitan areas between 2009 and 2015. We calculated incidences among neonates (0-30 days old), infants (0-364 days old), and noninfant children (1-19 years old), documented their clinical features and antifungal drug resistance. RESULTS We identified 307 pediatric candidemia cases. Incidence trends varied according to site, but overall, the incidence in neonates decreased from 31.5 cases/100000 births in 2009 to 10.7 to 11.8 cases/100000 births between 2012 and 2015, the incidence in infants decreased from 52.1 cases/100000 in 2009 to 15.7 to 17.5 between 2012 and 2015, and the incidence in noninfant children decreased steadily from 1.8 cases/100000 in 2009 to 0.8 in 2014. Common underlying conditions were prematurity in neonates (78%), surgery in nonneonate infants (38%), and malignancy in noninfant children (28%). Most neonate cases were caused by C albicans (67%), whereas non-C. albicans species accounted for 60% of cases in nonneonate infants and noninfant children. Fluconazole and echinocandin resistance rates were low overall. Thirty-day crude mortality was 13%. CONCLUSIONS The incidence of candidemia among neonates and infants declined after 2009 but remained stable from 2012 to 2015. Antifungal drug resistance is uncommon. Reasons for the lack of recent declines in neonatal and infant candidemia deserve further exploration. In this article, we describe the epidemiology of candidemia in children in the United States and on the basis of data collected as part of US Centers for Disease Control and Prevention active population-based surveillance. Trends in incidence, clinical characteristics, species distribution, and resistance rates are presented.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monika Roy
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Evan J Anderson
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Monica M Farley
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Sasha Harb
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Lee H Harrison
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lindsay Bonner
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vijitha Lahanda Wadu
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kaytlyn Marceaux
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rosemary Hollick
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Zintar G Beldavs
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland
| | - Alexia Y Zhang
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland
| | | | | | - Gordana Derado
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tom M Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Snigdha Vallabhaneni
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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17
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Zhang AY, Judson I, Benson C, Wunder JS, Ray-Coquard I, Grimer RJ, Quek R, Wong E, Miah AB, Ferguson PC, Dufresne A, Teh JYH, Stockler M, Tattersall MHN. Author Correction: Chemotherapy with radiotherapy influences time-to-development of radiation-induced sarcomas: a multicenter study. Br J Cancer 2018; 118:1682. [PMID: 29808016 PMCID: PMC6008468 DOI: 10.1038/s41416-018-0079-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Since the publication of this paper, the authors noticed an error in Fig. 1. The X-axis on all the figure panels should read 'Time (years)', not 'Time (months)'. The corrected Fig. 1 is shown below.
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Affiliation(s)
- A Y Zhang
- The University of Sydney, Sydney, 2006, Australia. .,Chris O'Brien Lifehouse, Sydney, 2050, Australia.
| | - I Judson
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - C Benson
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - J S Wunder
- Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada.,Department of Surgery, University of Toronto, Toronto, ON, M5S, Canada
| | - I Ray-Coquard
- Centre Léon Bérard, University Claude Bernard, Lyon, 69100, France
| | - R J Grimer
- The Royal Orthopaedic Hospital NHS Trust, Birmingham, B31 2AP, UK
| | - R Quek
- National Cancer Centre, Singapore, 169610, Singapore
| | - E Wong
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - A B Miah
- Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - P C Ferguson
- Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada.,Department of Surgery, University of Toronto, Toronto, ON, M5S, Canada
| | - A Dufresne
- Centre Léon Bérard, University Claude Bernard, Lyon, 69100, France
| | - J Y H Teh
- National Cancer Centre, Singapore, 169610, Singapore
| | - M Stockler
- Chris O'Brien Lifehouse, Sydney, 2050, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, 2006, Australia
| | - M H N Tattersall
- The University of Sydney, Sydney, 2006, Australia.,Chris O'Brien Lifehouse, Sydney, 2050, Australia
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18
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Zhang AY, Grogan JS, Mahon KL, Rasiah K, Sved P, Eisinger DR, Boulas J, Vasilaris A, Henshall SM, Stricker PD, Kench JG, Horvath LG. A prospective multicentre phase III validation study of AZGP1 as a biomarker in localized prostate cancer. Ann Oncol 2018; 28:1903-1909. [PMID: 28486686 DOI: 10.1093/annonc/mdx247] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Prostate cancers (PCs) with similar characteristics at the time of diagnosis can have very different disease outcomes. Conventional biomarkers of PC still lack precision in identifying individuals at high risk of PC recurrence. While many candidate biomarkers are proposed in the literature, few are in clinical practice as they lack rigorous validation. This study prospectively enrolled an independent phase III cohort to evaluate the clinical utility of zinc-alpha 2-glycoprotein (AZGP1) as a prognostic biomarker in localized PC. Patients and methods In our multicentre, prospective phase III study, AZGP1 status in 347 radical prostatectomy specimens was assayed by immunohistochemistry in a NATA-accredited laboratory. The AZGP1 score was assessed in a multivariable model incorporating established prognostic factors. We also report extended outcomes from our previous phase II study. The primary endpoint was biochemical relapse-free survival (BRFS). Secondary endpoints were metastasis-free survival (MFS) and PC-specific survival (PCSS). Results In the phase II cohort, with a median follow-up of 15.8 years, low/absent AZGP1 expression was an independent predictor of poor BRFS (HR, 1.4; 95% CI, 1.1-1.9; P = 0.03), MFS (HR, 2.8; 95% CI, 1.2-6.6; P = 0.02) and PCSS (HR, 3.8; 95% CI, 1.5-9.5; P = 0.005). These results were validated in our prospective phase III cohort. Low/absent AZGP1 expression independently predicted for BRFS (HR, 1.9; 95% CI, 1.1-3.3; P = 0.02), with shorter MFS (HR, 2.0; 95% CI, 1.1-3.4; P = 0.02). AZGP1 improved the discriminatory value when incorporated into existing prognostic risk models. Conclusion Our study provides prospective phase III validation that absent/low AZGP1 expression provides independent prognostic value in PC. This study provides robust evidence for the incorporation of this biomarker into clinical practice.
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Affiliation(s)
- A Y Zhang
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown.,Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst.,Sydney Medical School, University of Sydney, Camperdown
| | - J S Grogan
- Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst
| | - K L Mahon
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown.,Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst
| | - K Rasiah
- Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst.,Sydney Medical School, University of Sydney, Camperdown.,Department of Urology, Royal North Shore Hospital, Crows Nest
| | - P Sved
- Sydney Medical School, University of Sydney, Camperdown.,Department of Urology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - D R Eisinger
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - J Boulas
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - A Vasilaris
- Department of Urology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - S M Henshall
- Three Stories Consulting - Global Health Advocacy, USA
| | - P D Stricker
- Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst.,Sydney Medical School, University of Sydney, Camperdown.,Department of Urology, St Vincent's Clinic, Darlinghurst.,Discipline of Medicine, University of New South Wales
| | - J G Kench
- Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst.,Sydney Medical School, University of Sydney, Camperdown.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - L G Horvath
- Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown.,Cancer Division, Garvan Institute of Medical Research/The Kinghorn Cancer Centre, Darlinghurst.,Sydney Medical School, University of Sydney, Camperdown.,Discipline of Medicine, University of New South Wales.,Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, Australia
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19
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Buser GL, Mató S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the Field: Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta - Oregon, 2016. MMWR Morb Mortal Wkly Rep 2017; 66:677-678. [PMID: 28662016 PMCID: PMC5687501 DOI: 10.15585/mmwr.mm6625a4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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20
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Abstract
As an anti-inflammatory cytokine, interleukin-37 (IL-37) provides certain protective effects against inflammatory and autoimmune diseases. Recent reports indicate that IL-37 is expressed in foam cells of atherosclerotic plaques in both the coronary and carotid arteries of humans, suggesting the possible involvement of IL-37 in the pathogenesis and progression of atherosclerosis. Current evidence supports the protective role that IL-37 plays against atherosclerosis via the regulation of different subtypes of macrophage. Atherosclerosis was induced in apolipoprotein E -/- mice through diet, and the mice were then given IL-37 to observe patterns in the aorta plaque. Furthermore, human peripheral blood-derived monocytes were cultured for seven days to induce the differentiation of macrophages. Specifically, we observed the effect of IL-37 on oxygenated low density lipoprotein (ox-LDL)-induced macrophage polarity, in addition to conducting an expressional assay of the M1 cell markers tumor necrosis factor (TNF)-α and CD86 and the M2 marker CD206. IL-37 effectively decreased the area ratio between the aorta plaque and vascular cavity. We also observed that M1 macrophages can be induced from peripheral monocytes by ox-LDL, with significant elevation of marker molecules TNF-α and CD86. The co-stimulation of IL-37 and ox-LDL, however, inhibited the induction of M1 cells and facilitated the transformation of macrophages into M2 cells, as supported by the elevation of cell-specific marker CD206. These results indicate that IL-37 can prevent atherosclerosis by modulating macrophage polarity.
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Affiliation(s)
- J Huang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China
| | - F L Hou
- Department of Health, Weifang People's Hospital, Weifang, Shandong, China
| | - A Y Zhang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shandong, China
| | - Z L Li
- Department of Health, Weifang People's Hospital, Weifang, Shandong, China
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21
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Lee HJ, Yoon C, Schmidt B, Park DJ, Zhang AY, Erkizan HV, Toretsky JA, Kirsch DG, Yoon SS. Combining PARP-1 inhibition and radiation in Ewing sarcoma results in lethal DNA damage. Mol Cancer Ther 2013; 12:2591-600. [PMID: 23966622 DOI: 10.1158/1535-7163.mct-13-0338] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ewing sarcomas (ES) harbor a chromosomal translocation that fuses the EWS gene to an ETS transcription factor, most commonly Friend leukemia integration 1 (FLI1). The EWS-FLI1 fusion protein acts in a positive feedback loop to maintain the expression of PARP-1, which is involved in repair of DNA damage. Here, we examine the effects of PARP-1 inhibition and radiation therapy on Ewing sarcomas. In proliferation assays, the Ewing sarcoma cell lines RD-ES and SK-N-MC were much more sensitive than non-Ewing sarcoma cell lines to the PARP-1 inhibitor olaparib (Ola; IC50 0.5-1 μmol/L vs. >5 μmol/L) and to radiation (IC50 2-4 Gy vs. >6 Gy). PARP-1 inhibition with short hairpin RNA (shRNA) or Ola sensitized Ewing sarcoma cells, but not non-Ewing sarcoma cells, to radiation therapy in both proliferation and colony formation assays. Using the Comet assay, radiation of Ewing sarcoma cells with Ola, compared to without Ola, resulted in more DNA damage at 1 hour (mean tail moment 36-54 vs. 26-28) and sustained DNA damage at 24 hours (24-29 vs. 6-8). This DNA damage led to a 2.9- to 4.0-fold increase in apoptosis and a 1.6- to 2.4-fold increase in cell death. The effect of PARP-1 inhibition and radiation therapy on Ewing sarcoma cells was lost when EWS-FLI1 was silenced by shRNA. A small dose of radiation therapy (4 Gy), when combined with PARP-1 inhibition, stopped the growth of SK-N-MC flank tumors xenografts. In conclusion, PARP-1 inhibition in Ewing sarcomas amplifies the level and duration of DNA damage caused by radiation therapy, leading to synergistic increases in apoptosis and cell death in a EWS-FLI1-dependent manner.
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Affiliation(s)
- Hae-June Lee
- Corresponding Author: Sam S. Yoon, Department of Surgery, Memorial Sloan-Kettering Cancer Center, H-1209, 1275 York Avenue, New York, NY 10065.
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22
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Schmidt B, Kim YJ, Zhang AY, Kim TM, Eisinger-Mathason KT, Park PJ, Simon CM, Yoon SS, Lee HJ. Overcoming evasive resistance from vascular endothelial growth factor A inhibition in sarcomas by genetic or pharmacologic targeting of hypoxia inducible factor 1 alpha. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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23
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Kim YJ, Lee HJ, Kim TM, Eisinger-Mathason TSK, Zhang AY, Schmidt B, Karl DL, Nakazawa MS, Park PJ, Simon MC, Yoon SS. Overcoming evasive resistance from vascular endothelial growth factor a inhibition in sarcomas by genetic or pharmacologic targeting of hypoxia-inducible factor 1α. Int J Cancer 2012; 132:29-41. [PMID: 22684860 PMCID: PMC3677782 DOI: 10.1002/ijc.27666] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 05/10/2012] [Indexed: 12/11/2022]
Abstract
Increased levels of hypoxia and hypoxia-inducible factor 1α (HIF-1α) in human sarcomas correlate with tumor progression and radiation resistance. Prolonged antiangiogenic therapy of tumors not only delays tumor growth but may also increase hypoxia and HIF-1α activity. In our recent clinical trial, treatment with the vascular endothelial growth factor A (VEGF-A) antibody, bevacizumab, followed by a combination of bevacizumab and radiation led to near complete necrosis in nearly half of sarcomas. Gene Set Enrichment Analysis of microarrays from pretreatment biopsies found that the Gene Ontology category “Response to hypoxia” was upregulated in poor responders and that the hierarchical clustering based on 140 hypoxia-responsive genes reliably separated poor responders from good responders. The most commonly used chemotherapeutic drug for sarcomas, doxorubicin (Dox), was recently found to block HIF-1α binding to DNA at low metronomic doses. In four sarcoma cell lines, HIF-1α shRNA or Dox at low concentrations blocked HIF-1α induction of VEGF-A by 84–97% and carbonic anhydrase 9 by 83–93%. HT1080 sarcoma xenografts had increased hypoxia and/or HIF-1α activity with increasing tumor size and with anti-VEGF receptor antibody (DC101) treatment. Combining DC101 with HIF-1α shRNA or metronomic Dox had a synergistic effect in suppressing growth of HT1080 xenografts, at least in part via induction of tumor endothelial cell apoptosis. In conclusion, sarcomas respond to increased hypoxia by expressing HIF-1α target genes that may promote resistance to antiangiogenic and other therapies. HIF-1α inhibition blocks this evasive resistance and augments destruction of the tumor vasculature.
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Affiliation(s)
- Yeo-Jung Kim
- Department of Cancer Biology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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24
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Kim YJ, Zhang AY, Karl D, Eisenger K, Simon MC, Yoon SS. Abstract 2851: Metronomic doxorubicin blocks hypoxia inducible factor-mediated responses to hypoxia in sarcomas and augments the effects of anti-VEGF therapy. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-2851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Levels of hypoxia and hypoxia inducible factors (HIFs) in human sarcomas correlate with tumor progression and metastasis. Prolonged anti-angiogenic therapy of sarcomas can inhibit tumor growth but may also increase hypoxia and HIF activation. The most commonly used chemotherapeutic drug for sarcomas, doxorubicin (dox), was recently found to block HIF binding to DNA at low metronomic doses.
Methods: 20 patients with soft tissue sarcomas were treated with anti-VEGF antibody (bevacizumab). The tumors, before and after treatment, were examined for changes in microvessel density using CD31 immunohistochemical staining and global gene expression using microarrays. Patients’ tumors were then treated with a combination of bevacizumab and radiation followed by surgical resection. Expression of specific HIF-target genes in the response to hypoxia and/or dox was examined in vitro in 4 sarcoma cell lines by q-RT-PCR. HT1080 human sarcoma xenografts and sarcomas in genetically engineered LSL-KrasG12D/+Trp53fl/fl mice were treated with anti-VEGF receptor antibody (DC101) and/or metronomic dox and analyzed for levels of hypoxia, HIFs, and HIF-target genes.
Results: Bevacizumab alone reduced microvessel density in sarcomas by a median of 53% (p<0.05). Gene set enrichment analysis of microarrays found the Gene Ontology category “Response to hypoxia” (which includes HIF-1a, HIF-2a, and ARNT) was upregulated in sarcomas with a poor response to combination therapy (bevacizumab plus radiation). Dox at 1-10 uM blocked HIF induction of VEGF and CA-9 in all 4 sarcoma cell lines by 83.7-97.0% and 88.6-97.6%, respectively, while inhibition of other HIF-target genes including c-MET and FOXM1 was variable. HT1080 sarcoma xenografts and LSL-KrasG12D/+Trp53fl/fl sarcomas demonstrated increasing hypoxia with larger tumor size and with treatment with an anti-VEGFR-2 antibody (DC101). Increasing hypoxia corresponded to greater nuclear expression of HIF-1α and HIF-2α, and metronomic Dox lowered expression of HIF-depended genes by up to 92.3%. Combining VEGFR-2 antibody and metronomic Dox therapies had a synergistic effect in suppressing tumor growth.
Conclusion: Human sarcomas respond to increased hypoxia by expressing HIF-target genes which promote compensatory responses. This hypoxic response may be exacerbated by anti-VEGF therapies and promote resistance to such therapies. Low metronomic doses of dox can block activation of HIF-target genes and works synergistically with anti-VEGF therapies to inhibit tumor growth.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2851. doi:10.1158/1538-7445.AM2011-2851
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Affiliation(s)
- Yeo-Jung Kim
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | - Karin Eisenger
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
| | - M. Celeste Simon
- 1University of Pennsylvania School of Medicine, Philadelphia, PA
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Abstract
Dupuytren's disease is characterised by nodular fibroblastic proliferation of the palmar fascia leading to contracture of the hand. Transforming growth factor beta (TGF-beta) is thought to play a role in its pathogenesis. We performed a cDNA microarray analysis of Dupuytren's diseased cord tissue with an emphasis on TGF-beta isoforms. Normal-appearing transverse ligament of the palmar fascia from adjacent to the diseased cord and palmar fascia from patients undergoing carpal tunnel release were used as controls. TGF-beta gene expression was confirmed by quantitative real-time polymerase chain reaction. Over 20 unique genes were found to be significantly up-regulated, including several previously reported genes. A dominant increase in TGF-beta2 expression was seen in the cord tissue, whereas TGF-beta1 and TGF-beta3 were found not to be significantly up-regulated. Quantitative real-time polymerase chain reaction confirmed these findings. This gene expression profile allows for further experiments that may eventually lead to gene therapy to block the development and progression of Dupuytren's disease clinically.
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Affiliation(s)
- A Y Zhang
- Division of Plastic Surgery, Stanford Hospital and Clinics, Stanford, CA, USA.
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Yi F, Zhang AY, Li N, Muh RW, Fillet M, Renert AF, Li PL. Inhibition of ceramide-redox signaling pathway blocks glomerular injury in hyperhomocysteinemic rats. Kidney Int 2006; 70:88-96. [PMID: 16688115 DOI: 10.1038/sj.ki.5001517] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ceramide-activated NAD(P)H oxidase has been reported to participate in homocysteine (Hcys)-induced abnormal metabolism of the extracellular matrix (ECM) in rat glomerular mesangial cells. However, it remains unknown whether this ceramide-redox signaling pathway contributes to glomerular injury induced by hyperhomocysteinemia (hHcys) in vivo. The present study was designed to address this question, defining the role of ceramide and activated NAD(P)H oxidase in the development of hHcys-induced glomerular injury. Uninephrectomized Sprague-Dawley rats were fed a folate-free diet for 8 weeks to produce hHcys and the de novo ceramide synthesis inhibitor myriocin or the NAD(P)H oxidase inhibitor apocynin was administrated. Rats with folate-free diet significantly increased plasma Hcys levels, renal ceramide levels, and NAD(P)H oxidase activity accompanied by marked glomerular injury. Treatment of rats with myriocin significantly reduced ceramide levels and improved glomerular injury, as shown by decreased urinary albumin excretion and reduced glomerular damage index. ECM components changed towards to normal levels with decreased tissue inhibitor of metalloproteinase-1 and increased matrix metalloproteinase-1 activity. NAD(P)H oxidase activity and Rac GTPase activity were reduced by 69 and 66%, respectively. In rats treated with apocynin, similar beneficial effects in protecting glomeruli from hHcys-induced injury were observed. These results support the view that de novo ceramide production is involved in Hcys-induced NAD(P)H oxidase activity in the kidney of hHcys rats and indicate the important role of ceramide-mediated redox signaling in hHcys-induced glomerular injury in rats.
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Affiliation(s)
- F Yi
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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28
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Abstract
This study examines self-perceived physical and mental health among 213 Chinese elderly who visited the Geriatric Outpatient Clinic of Beijing Hospital, the People's Republic of China. The study hypothesizes that cultural factors, specified by family relations, along with demographic factors, number of diseases, economic well-being, and living conditions have a significant impact on subjects self-perceived health status. Pearson correlation, linear and logistic regression analyses are performed. Results indicate that age, number of diseases, perceived family respect, neighborhood relations, and percentage of income spent on rent are significant predictors of self-perceived physical health. These same factors plus preference to live with a son and personal monthly income are significant predictors of self-perceived mental health. Socio-cultural implications of these findings are examined.
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Affiliation(s)
- L C Yu
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania 16802, USA.
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29
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Abstract
The present study examined correlates of life satisfaction among 350 Chinese elderly aged 65 or older. Subjects consisted of a clinic sample (n = 200) and a randomly selected community sample (n = 150) recruited from the same area in Beijing. Linear regression analysis was performed, using health, financial status, and family support as independent variables. Results showed that the regression model explained 38 percent of the variance in life satisfaction in the total sample, 34 percent and 43 percent of the variance respectively in the clinical and community samples. Life satisfaction was significantly predicted by health and financial status among community elderly and by health, financial status, as well as family support among outpatient elderly. Findings suggest that the socio-cultural context has exerted important impacts on the Chinese elderly's life satisfaction.
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Affiliation(s)
- A Y Zhang
- School of Public Health, University of California at Berkeley, 94720-7360, USA.
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30
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Abstract
This study investigated the essential feature and concomitant experiences of anthropophobia, a culturally specific phobic disorder in China and Japan. One hundred and fifty subjects, including 50 anthropophobic, 50 neurasthenic and 50 normal subjects, were recruited from hospitals and downtown residential areas in Beijing. Measures of anthropophobic symptoms and DSM-III-R depressive and anxiety symptoms were administered to all subjects. Nonparametric analysis of variance, analysis of variance (ANOVA and MANOVA) and Fisher's exact test were performed to examine group differences on each symptomatic item of the three measures. Results indicate that the core anthropophobic symptoms include a fear of making eye contact with others and a fear of being watched by others, which essentially express fears of others' judgement or opinion of oneself. Anxiety and depression are associated features of anthropophobia. However, these concomitants are experienced more cognitively and less somatically in the case of anthropophobia than neurasthenia.
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Affiliation(s)
- A Y Zhang
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4961, USA
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Abstract
BACKGROUND Anthropophobia, a subtype of social phobia, is prevalent in Chinese and Japanese societies. This study investigated sociocultural influences on the course of this culturally specific mental disorder. METHOD One hundred and fifty subjects, including 50 anthropophobic, 50 neurasthenic, and 50 community subjects, were interviewed in Beijing, China for the assessment of their early life experiences (child-parent relationships and sexual experiences), collectivism disposition, sexual attitudes, and communication behaviors. Logistic and linear regression analyses were performed to examine significant predictors of the occurrence and the symptom level of anthropophobia. RESULTS Regression models explained 69% of variance in the diagnosis and 57% of variance in the symptom level of anthropophobia among anthropophobic and community subjects. They also explained 48% and 47% of variance respectively in the diagnosis and the level of symptoms among anthropophobic and neurasthenic subjects. Anthropophobic subjects had more problematic relationships with parents than did community and neurasthenic subjects. They also exhibited significantly stronger characteristics of collectivism than did community subjects. Sexual contact with a non-family member prior to age 19 and a feeling of discomfort when interacting with the opposite sex were significantly associated with the diagnosis and symptom level of anthropophobia. CONCLUSIONS It was concluded that anthropophobic subjects' early sexual experiences and need for parental approval shaped their conformity to social norms and negative sexual attitudes, which were reinforced by the collective-orientated cultural environment, and contributed to the development of anthropophobia.
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Affiliation(s)
- A Y Zhang
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4961, USA
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32
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Abstract
The study examined the ethnic ratio of 16 DSM-III mental disorders among White, Black, Hispanic, and Asian Americans. A total of 18,126 residents from 5 sites and 2,939 residents from the Epidemiological Catchment Area's Los Angeles site were studied separately. Logistic regression analysis was performed. Results showed that Blacks were significantly less likely than Whites to have major depressive episode, major depression, dysthymia, obsessive-compulsive disorder, drug and alcohol abuse or dependence, antisocial personality, and anorexia nervosa, but they were significantly more likely than Whites to have phobia and somatization. Lifetime prevalence rates of schizophrenia, obsessive-compulsive disorder, panic, and drug abuse or dependence were significantly lower among Hispanics than among Whites. Asians also had significantly lower rates than Whites of schizophreniform, manic episode, bipolar disorder, panic, somatization, drug and alcohol abuse or dependence, and antisocial personality. Compared with the overall findings, ethnic differences at the Los Angeles site were lessened between Blacks and Whites, enhanced between Hispanics and Whites, and basically unchanged between Asians and Whites.
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Affiliation(s)
- A Y Zhang
- School of Public Health, University of California, Berkeley, USA.
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33
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Abstract
This study hypothesized that depressive experiences of the elderly could be aggravated by universal factors such as low social status, poor health, financial strain, and unhealthy lifestyle, as well as by factors specific to an indigenous socio-cultural environment (stressful family dynamics) of a given population. Three hundred and fifty Chinese subjects aged 65 or older were interviewed either at their homes or in the geriatric out-patient clinic of Beijing Hospital. Hierarchical logistic regression was used to examine significant predictors of depression. Results showed that certain social status, poor physical health, financial strain, unhealthy lifestyle, and stressful family situation explained 47 percent of the variance in depression. However, stressful family situation alone explained 13 percent of the variance in depression, indicating that family factors were important predictors of depression for Chinese elderly. Furthermore, this study demonstrated for the first time that verbal abuse within Chinese families is a significant correlate of depression among the elderly. Cultural implications of these findings are discussed.
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Affiliation(s)
- A Y Zhang
- Department of Health Policy and Research, School of Public Health, University of California, Berkeley 94720-7360, USA
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34
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Abstract
To explore the effects of diet and other factors on breast cancer development, a case-control study was conducted in Tianjin between 1986-87. After adjusting for confounding factors, it was found that factors associated with increased risk of breast cancer included --early age at menarche; late age at menopause; late age at first birth; high Qutelet's index; histories of breast wound, disease and benign tumor; and a family history of malignant tumor, high fat, high calorie, low vegetable intake; elevated serum cholesterol and LDL-cholesterol; and lower levels of serum HDL-cholesterol and whole blood selenium.
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Affiliation(s)
- X Y Qi
- Tianjin Medical University, People's Republic of China
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35
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Zhang AY. [Risk factors of breast cancer among women in Tianjin, China and Adelaide, Australia]. Zhonghua Zhong Liu Za Zhi 1988; 10:437-40. [PMID: 3250829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In order to study the possible explanation of the marked difference in the incidences of breast cancer between Chinese and Australian women, the authors have compared and analysed the results of two case-control studies completed recently in Tianjin, China and Adelaide, Australia. Of 9 potential risk factors studied, 8 are significantly higher in Adelaide (Ad) women than in Tianjin women. Women in Ad were much taller, heavier, more obese, earlier at menarche, later at first full-term pregnancy, more nulliparous, less parity, more in history of breast cancer in first degree relatives. In addition, they were well educated. The findings obtained by analysis of logistic regression model indicated that increased risk for breast cancer was associated with early menarche, late first full-term pregnancy, less parity, nulliparity, histories of benign breast diseases and breast cancer in first degree relatives in the Tianjin study, but not in Ad study. Late menopause and history of oral contraceptive were not associated with the increased risk in both studies. These factors being not associated with breast cancer in Ad women was unexpected. The explanation of the indefinite findings in Ad study was due to the fact that the level of the risk factor is higher, more uniform, and lack of stratum. The difference in the level of the risk factor will not appear among cases and controls in case-control study, and significance of the risk factor therefore may not be found. According to data on diet survey in these two cities, the amount of fat intake was significantly higher in Ad women than in Tianjin women.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Y Zhang
- Health Department, Tianjin Medical College
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