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Loftus MJ, Young-Sharma T, Lee SJ, Wati S, Badoordeen GZ, Blakeway LV, Byers S, Cheng AC, Cooper BS, Cottingham H, Jenney A, Hawkey J, Macesic N, Naidu R, Prasad A, Prasad V, Tudravu L, Vakatawa T, van Gorp E, Wisniewski JA, Rafai E, Peleg AY, Stewardson AJ. Attributable Mortality and Excess Length of Stay associated with Third-Generation Cephalosporin Resistant Enterobacterales Bloodstream Infections - a prospective cohort study in Suva, Fiji. J Glob Antimicrob Resist 2022; 30:286-293. [PMID: 35738385 PMCID: PMC9452645 DOI: 10.1016/j.jgar.2022.06.016] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/11/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji. METHODS We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and multistate modelling to estimate the excess length of hospital stay. RESULTS From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs, 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio (aHR) 1.13, 95% CI 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission. CONCLUSION Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.
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Affiliation(s)
- M J Loftus
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | | | - S J Lee
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - S Wati
- Colonial War Memorial Hospital, Suva, Fiji
| | - G Z Badoordeen
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - L V Blakeway
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Smh Byers
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - B S Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, The United Kingdom; Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - H Cottingham
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Awj Jenney
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Fiji National University, Suva, Fiji
| | - J Hawkey
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - N Macesic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Centre to Impact AMR, Monash University, Melbourne, Australia
| | - R Naidu
- Colonial War Memorial Hospital, Suva, Fiji
| | - A Prasad
- Colonial War Memorial Hospital, Suva, Fiji
| | - V Prasad
- Colonial War Memorial Hospital, Suva, Fiji
| | - L Tudravu
- Colonial War Memorial Hospital, Suva, Fiji
| | - T Vakatawa
- Colonial War Memorial Hospital, Suva, Fiji
| | - E van Gorp
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - J A Wisniewski
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - E Rafai
- Fiji Ministry of Health and Medical Services, Suva, Fiji
| | - A Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia; Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia.
| | - A J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.
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Macesic N, Morrissey CO, Liew D, Bohensky MA, Chen SCA, Gilroy NM, Milliken ST, Szer J, Slavin MA. Is a biomarker-based diagnostic strategy for invasive aspergillosis cost effective in high-risk haematology patients? Med Mycol 2018; 55:705-712. [PMID: 28131991 DOI: 10.1093/mmy/myw141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 09/05/2016] [Accepted: 12/02/2016] [Indexed: 11/14/2022] Open
Abstract
Empirical antifungal therapy is frequently used in hematology patients at high risk of invasive aspergillosis (IA), with substantial cost and toxicity. Biomarkers for IA aim for earlier and more accurate diagnosis and targeted treatment. However, data on the cost-effectiveness of a biomarker-based diagnostic strategy (BDS) are limited. We evaluated the cost effectiveness of BDS using results from a randomized controlled trial (RCT) and individual patient costing data. Data inputs derived from a published RCT were used to construct a decision-analytic model to compare BDS (Aspergillus galactomannan and PCR on blood) with standard diagnostic strategy (SDS) of culture and histology in terms of total costs, length of stay, IA incidence, mortality, and years of life saved. Costs were estimated for each patient using hospital costing data to day 180 and follow-up for survival was modeled to five years using a Gompertz survival model. Treatment costs were determined for 137 adults undergoing allogeneic hematopoietic stem cell transplant or receiving chemotherapy for acute leukemia in four Australian centers (2005-2009). Median total costs at 180 days were similar between groups (US$78,774 for SDS [IQR US$50,808-123,476] and US$81,279 for BDS [IQR US$59,221-123,242], P = .49). All-cause mortality was 14.7% (10/68) for SDS and 10.1% (7/69) for BDS, (P = .573). The costs per life-year saved were US$325,448, US$81,966, and US$3,670 at 180 days, one year and five years, respectively. BDS is not cost-sparing but is cost-effective if a survival benefit is maintained over several years. An individualized institutional approach to diagnostic strategies may maximize utility and cost-effectiveness.
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Affiliation(s)
- N Macesic
- Division of Infectious Diseases, Columbia University Medical Center, 161 Fort Washington Ave, New York, NY 10032, USA.,Department of Infectious Diseases, 145 Studley Rd, Heidelberg, VIC 3084, Australia
| | - C O Morrissey
- Department of Infectious Diseases, 55 Commercial Rd, Prahran, VIC 3181, Australia.,Department of Infectious Diseases, Central Clinical School, Monash University, 55 Commercial Rd, Prahran, VIC 3181, Australia
| | - D Liew
- School of Public Health and Preventive Medicine, Monash University, 40 Exhibition Walk, Clayton, VIC 3800, Australia
| | - M A Bohensky
- Melbourne EpiCentre, University of Melbourne, Level 7 East, 300 Grattan Street, Parkville, VIC 3052, Australia
| | - S C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Level 3, ICPMR, Westmead Hospital, Locked Bag 9001, Westmead, NSW 2145, Australia
| | - N M Gilroy
- Blood and Marrow Transplant Network, Agency for Clinical Innovation, 67 Albert Ave, Chatswood, NSW 2057, Australia
| | - S T Milliken
- Department of Clinical Haematology and Bone Marrow Transplantation, St. Vincent's Hospital, Sydney, 390 Victoria St, Darlinghurst, NSW 2010, Australia
| | - J Szer
- Department of Clinical Haematology and Bone Marrow Transplant Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia
| | - M A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, 2 St Andrews Pl, East Melbourne, VIC 3002, Australia.,Victorian Infectious Diseases Service, The Doherty Institute for Infection and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia
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Macesic N, Hall V, Mahony A, Hueston L, Ng G, Macdonell R, Hughes A, Fitt G, Grayson ML. Acute Flaccid Paralysis: The New, The Old, and The Preventable. Open Forum Infect Dis 2015; 3:ofv190. [PMID: 26788545 PMCID: PMC4716344 DOI: 10.1093/ofid/ofv190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/30/2015] [Indexed: 12/28/2022] Open
Abstract
Acute flaccid paralysis (AFP) has a changing epidemiology with ongoing polio outbreaks and emerging causes such as nonpolio enteroviruses and West Nile virus (WNV). We report a case of AFP from the Horn of Africa that was initially classified as probable polio but subsequently found to be due to WNV.
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Affiliation(s)
- N Macesic
- Departments of Infectious Diseases; Division of Infectious Diseases, Columbia University Medical Center, New York
| | | | - A Mahony
- Departments of Infectious Diseases
| | - L Hueston
- Arbovirus Emerging Diseases Unit , Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, Westmead Hospital , Sydney
| | | | - R Macdonell
- Neurology; Department of Medicine, University of Melbourne, Australia
| | | | - G Fitt
- Radiology, Austin Health, Melbourne , Australia
| | - M L Grayson
- Departments of Infectious Diseases; Department of Medicine, University of Melbourne, Australia
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Macesic N, Ameratunga M, Grayson M, Johnson D. Fever in melanoma: new drugs or bugs? Clin Microbiol Infect 2015; 21:e77-8. [DOI: 10.1016/j.cmi.2015.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 06/19/2015] [Indexed: 12/01/2022]
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Macesic N, Langsford D, Nicholls K, Hughes P, Gottlieb DJ, Clancy L, Blyth E, Micklethwaite K, Withers B, Majumdar S, Fleming S, Sasadeusz J. Adoptive T cell immunotherapy for treatment of ganciclovir-resistant cytomegalovirus disease in a renal transplant recipient. Am J Transplant 2015; 15:827-32. [PMID: 25648555 DOI: 10.1111/ajt.13023] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [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: 12/30/2013] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 01/25/2023]
Abstract
Cytomegalovirus (CMV) is a significant cause of morbidity, mortality and graft loss in solid organ transplantation (SOT). Treatment options for ganciclovir-resistant CMV are limited. We describe a case of ganciclovir-resistant CMV disease in a renal transplant recipient manifested by thrombotic microangiopathy-associated glomerulopathy. Adoptive T cell immunotherapy using CMV-specific T cells from a donor bank was used as salvage therapy. This report is a proof-of-concept of the clinical and logistical feasibility of this therapy in SOT recipients.
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Affiliation(s)
- N Macesic
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, Australia
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Morrissey CO, Gilroy NM, Macesic N, Walker P, Ananda-Rajah M, May M, Heath CH, Grigg A, Bardy PG, Kwan J, Kirsa SW, Slavin M, Gottlieb T, Chen S. Consensus guidelines for the use of empiric and diagnostic-driven antifungal treatment strategies in haematological malignancy, 2014. Intern Med J 2014; 44:1298-314. [DOI: 10.1111/imj.12596] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- C. O. Morrissey
- Department of Infectious Diseases; Alfred Health and Monash University; Prahran Victoria
- Department of Clinical Haematology; Alfred Health; Prahran Victoria
| | - N. M. Gilroy
- Blood and Marrow Transplant (BMT) Network; Agency for Clinical Innovation; Chatswood New South Wales
- Department of Infectious Diseases and Clinical Microbiology; St Vincent's Hospital; Darlinghurst New South Wales
| | - N. Macesic
- Departmentof Infectious Diseases; Austin Health; Heidelberg Victoria
| | - P. Walker
- Malignant Haematology and Stem Cell Transplantation Service; Alfred Health; Prahran Victoria
- Australian Centre for Blood Diseases; Monash University; Melbourne Victoria
| | - M. Ananda-Rajah
- Department of Infectious Diseases; Alfred Health and Monash University; Prahran Victoria
- Department of General Medicine; Alfred Health; Prahran Victoria
| | - M. May
- Department of Microbiology; Sullivan Nicolaides Pathology; Brisbane Queensland
| | - C. H. Heath
- Department of Microbiology and Infectious Diseases; Royal Perth Hospital; Perth Western Australia
- School of Medicine and Pharmacology (RPH Unit); University of Western Australia; Perth Western Australia
| | - A. Grigg
- Department of Clinical Haematology; Austin Health; Heidelberg Victoria
- School of Medicine; The University of Melbourne; Melbourne Victoria
| | - P. G. Bardy
- Royal Adelaide Hospital Cancer Centre; Royal Adelaide Hospital; Adelaide South Australia
- Division of Medicine; The Queen Elizabeth Hospital; Woodville South South Australia
- Discipline of Medicine; School of Medicine; The University of Adelaide; Adelaide South Australia
| | - J. Kwan
- Department of Haematology and Bone Marrow Transplant; Westmead Hospital; Westmead New South Wales
| | - S. W. Kirsa
- Pharmacy Department; Peter MacCallum Cancer Centre; East Melbourne Victoria
| | - M. Slavin
- School of Medicine; The University of Melbourne; Melbourne Victoria
- Department of Infectious Diseases and Infection Control; Peter MacCallum Cancer Centre; East Melbourne Victoria
- Victorian Infectious Diseases Service; The Doherty Institute for Infection and Immunity; Parkville Victoria
| | - T. Gottlieb
- The Infectious Diseases and Microbiology Department; Concord Repatriation General Hospital; Concord New South Wales
| | - S. Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services; ICPMR - Pathology West; Westmead New South Wales
- Department of Infectious Diseases; Westmead Hospital; Westmead New South Wales
- Sydney Medical School; The University of Sydney; Sydney New South Wales
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Macesic N, Morrissey CO, Cheng AC, Spencer A, Peleg AY. Changing microbial epidemiology in hematopoietic stem cell transplant recipients: increasing resistance over a 9-year period. Transpl Infect Dis 2014; 16:887-96. [PMID: 25298044 DOI: 10.1111/tid.12298] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 06/03/2014] [Accepted: 07/12/2014] [Indexed: 11/30/2022]
Abstract
UNLABELLED Infections remain important contributors to mortality in hematopoietic stem cell transplantation (HSCT). METHOD We studied the evolving epidemiology and trends in susceptibility of bacterial and Candida isolates at an Australian HSCT center. A total of 528 HSCTs in 508 patients were performed from April 2001 to May 2010. A total of 605 isolates were eligible for study inclusion; 318 (53%) were gram-positive, 268 (44%) were gram-negative, and 19 (3%) were Candida species. RESULTS The most common site for isolates was blood (380 isolates, 63%). Staphylococcus aureus was the most common gram-positive organism (n = 107, 34%), but trends to increasing coagulase-negative staphylococci (P = 0.002) and vancomycin-resistant Enterococcus (P < 0.001) were observed. Escherichia coli was the most common gram-negative isolate (n = 74, 28%). Fluoroquinolone resistance increased with widespread use of protocol fluoroquinolone prophylaxis (P = 0.001). Carbapenem resistance was found in 44% of Pseudomonas or Acinetobacter isolates. Bloodstream infection with a multidrug-resistant organism (odds ratio 3.61, 95% confidence interval: 1.40-9.32, P = 0.008) was an independent predictor of mortality at 7 days after a positive blood culture. CONCLUSIONS Antimicrobial resistance is an increasing problem in this vulnerable patient population, and not only has an impact on choice of empiric therapy for febrile neutropenia but also on mortality.
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Affiliation(s)
- N Macesic
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia
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Macesic N, Fleming S, Kidd S, Madigan V, Chean R, Ritchie D, Slavin M. Protothecosis in hematopoietic stem cell transplantation: case report and review of previous cases. Transpl Infect Dis 2014; 16:490-5. [DOI: 10.1111/tid.12223] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/28/2013] [Accepted: 01/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- N. Macesic
- Victorian Infectious Diseases Service; Royal Melbourne Hospital; Parkville Victoria Australia
| | - S. Fleming
- Department of Clinical Haematology; Royal Melbourne Hospital; Parkville Victoria Australia
| | - S. Kidd
- Mycology Unit; SA Pathology; Adelaide South Australia Australia
| | - V. Madigan
- Department of Microbiology; Royal Melbourne Hospital; Parkville Victoria Australia
| | - R. Chean
- Department of Microbiology; Royal Melbourne Hospital; Parkville Victoria Australia
| | - D. Ritchie
- Department of Clinical Haematology; Royal Melbourne Hospital; Parkville Victoria Australia
- Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Parkville Victoria Australia
| | - M. Slavin
- Victorian Infectious Diseases Service; Royal Melbourne Hospital; Parkville Victoria Australia
- Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Medicine; University of Melbourne; Parkville Victoria Australia
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Macesic N, Chang C, Abbott IA, Trevillyan J, Pham A, Lewin SR. Pustular skin lesions in a patient with advanced HIV infection and pneumonia. Clin Infect Dis 2013; 57:1162-3; 1210-1. [PMID: 24068772 DOI: 10.1093/cid/cit485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N Macesic
- Infectious Diseases Unit, Alfred Hospital
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